Association between sleep disturbances, fear of hypoglycemia and psychological well-being in adults with type 1 diabetes mellitus, data from cross-sectional VARDIA study

AIM

To assess the relationship between sleep quality, fear of hypoglycemia, glycemic variability and psychological well-being in type 1 diabetes mellitus.

METHODS

Our data were provided by the VARDIA Study, a multicentric cross-sectional study conducted between June and December 2015. Sleep characteristics were assessed by the Pittsburgh Sleep Quality Index (PSQI). Fear of hypoglycemia and psychological well-being were measured with the Hypoglycemia Fear Survey version II (HFS-II) and the Hospital Anxiety and Depression Scale (HADS), respectively. Glycemic variability (GV) was determined using the CV of three 7-point self-monitoring blood glucose profiles and the mean amplitude of glycemic excursion (MAGE).

RESULTS

315 patients were eligible for PSQI questionnaire analysis: 54% women, mean age 47 ± 15, mean diabetes duration of 24 ± 13 years, HbA1c of 7.6 ± 0.9% (60 ± 7,5mmol/mol). Average PSQI score was 6.0 ± 3.3 and 59.8% of the patients had a PSQI score > 5. HFS-II score and HADS were significantly higher among "poor" sleepers (p < 0.0001) and PSQI score was positively associated with HADS (β = 0.22; 95% CI = 0.08;0.35). GV evaluated by CV or MAGE did not differ between "poor" and "good" sleepers (p = 0.28 and 0.54, respectively).

CONCLUSIONS

Adult patients with type 1 diabetes have sleep disturbances which correlate with psychological well-being. This study suggests that psychological management can be a target to improve sleep quality in adults with type 1 diabetes mellitus.

Perioperative management of adult diabetic patients. Preoperative period

In diabetic patients undergoing surgery, we recommend assessing glycaemic control preoperatively by assessing glycated haemoglobin (HbA1c) levels and recent capillary blood sugar (glucose) levels, and to adjust any treatments accordingly before surgery, paying particular attention to specific complications of diabetes. Gastroparesis creates a risk of stasis and aspiration of gastric content at induction of anaesthesia requiring the use of a rapid sequence induction technique. Cardiac involvement can be divided into several types. Coronary disease is characterised by silent myocardial ischaemia, present in 30-50% of T2D patients. Diabetic cardiomyopathy is a real cause of heart failure. Finally, cardiac autonomic neuropathy (CAN), although rarely symptomatic, should be investigated because it causes an increased risk of cardiovascular events and a risk of sudden death. Several signs are suggestive of CAN, and confirmation calls for close perioperative surveillance. Chronic diabetic kidney disease (diabetic nephropathy) aggravates the risk of perioperative acute renal failure, and we recommend measurement of the glomerular filtration rate preoperatively. The final step of the consultation concerns the management of antidiabetic therapy. Preoperative glucose infusion is not necessary if the patient is not receiving insulin. Non-insulin drugs are not administered on the morning of the intervention except for metformin, which is not administered from the evening before. The insulins are injected at the usual dose the evening before. The insulin pump is maintained until the patient arrives in the surgical unit. It should be remembered that insulin deficiency in a T1D patient leads to ketoacidosis within a few hours.

Perioperative management of adult diabetic patients. Intraoperative period

Perioperative hyperglycaemia (>1.80g/L or 10mmol/L) increases morbidity (particularly due to infection) and mortality. Hypoglycaemia can be managed in the perioperative period by decreasing blood sugar levels with insulin between 0.90 and 1.80g/L but it may occur more frequently when the goal is strict normoglycaemia. We propose continuous administration of insulin therapy via an electronic syringe (IVES) in type-1 diabetes (T1D) and type-2 diabetes (T2D) patients if required or in cases of stress hyperglycaemia. Stopping a personal insulin pump requires immediate follow on with IVES insulin. We recommend 4mg dexamethasone for the prophylaxis of nausea and vomiting, rather than 8mg, combined with another antiemetic drug. The use of regional anaesthesia (RA), when possible, allows for better control of postoperative pain and should be prioritised. Analgesic requirements are higher in patients with poorly controlled blood sugar levels than in those with HbA1c<6.5%. The struggle to prevent hypothermia, the use of RA and multimodal analgesia (which allow for a more rapid recovery of bowel movements), limitation of blood loss, early ambulation and minimally invasive surgery are the preferred measures to regulate perioperative insulin resistance. Finally, diabetes does not change the usual rules of fasting or of antibiotic prophylaxis.

Perioperative management of adult diabetic patients. The role of the diabetologist

A patient should be referred to a diabetologist perioperatively in several circumstances: preoperative recognition of a previously unknown diabetes or detection of glycaemic imbalance (HbA1c <5% or >8%); during hospitalisation, recognition of a previously unknown diabetes, persisting glycaemic imbalance despite treatment or difficulty resuming previously used chronic treatment; postoperatively and after discharge from hospital, for all diabetic patients in whom HbA1c is >8%.

Assessment of patient-led or physician-driven continuous glucose monitoring in patients with poorly controlled type 1 diabetes using basal-bolus insulin regimens: a 1-year multicenter study

OBJECTIVE

The benefits of real-time continuous glucose monitoring (CGM) have been demonstrated in patients with type 1 diabetes. Our aim was to compare the effect of two modes of use of CGM, patient led or physician driven, for 1 year in subjects with poorly controlled type 1 diabetes.

RESEARCH DESIGN AND METHODS

Patients with type 1 diabetes aged 8-60 years with HbA(1c) ≥ 8% were randomly assigned to three groups (1:1:1). Outcomes for glucose control were assessed at 1 year for two modes of CGM (group 1: patient led; group 2: physician driven) versus conventional self-monitoring of blood glucose (group 3: control).

RESULTS

A total of 257 subjects with type 1 diabetes underwent screening. Of these, 197 were randomized, with 178 patients completing the study (age: 36 ± 14 years; HbA(1c): 8.9 ± 0.9%). HbA(1c) improved similarly in both CGM groups and was reduced compared with the control group (group 1 vs. group 3: -0.52%, P = 0.0006; group 2 vs. group 3: -0.47%, P = 0.0008; groups 1 + 2 vs. group 3: -0.50%, P < 0.0001). The incidence of hypoglycemia was similar in the three groups. Patient SF-36 questionnaire physical health score improved in both experimental CGM groups (P = 0.004). Sensor consumption was 34% lower in group 2 than in group 1 (median [Q1-Q3] consumption: group 1: 3.42/month [2.20-3.91] vs. group 2: 2.25/month [1.27-2.99], P = 0.001).

CONCLUSIONS

Both patient-led and physician-driven CGM provide similar long-term improvement in glucose control in patients with poorly controlled type 1 diabetes, but the physician-driven CGM mode used fewer sensors.

Lower rate of initial failures and reduced occurrence of adverse events with a new catheter model for continuous subcutaneous insulin infusion: prospective, two-period, observational, multicenter study

BACKGROUND

No recent clinical data on the incidence of catheter-related adverse events under insulin pump therapy have been reported.

METHODS

This was a prospective, two-period, observational, multicenter study in 45 diabetes outpatients (mean continuous subcutaneous insulin infusion [CSII] use, 6 years; mean hemoglobin A1c, 7.7%, at baseline). During the initial 1-month period (P1), the patients used their current catheter model, including a soft cannula in 98% of cases. They moved then to the new Accu-Chek FlexLink catheter model (Disetronic Medical Systems AG, Burgdorf, Switzerland) for a 3-month period. The primary end point, including insertion failures and unexplained hyperglycemia within the first 6h after catheter placement, was assessed from logbook records during P1 and the last month of the second period (P2). Secondary end points were catheter replacements for unexplained hyperglycemia and/or events at risk for immediate insulin delivery failure after the first 6h.

RESULTS

Forty-five initial infusion failures occurred in 14 patients among 507 catheter insertions (8.9% of cases) during P1, whereas 15 similar events were seen in nine patients during P2 among 488 catheter insertions (3.1% of cases) (P<0.001). Catheters were replaced for later infusion troubles in 8% of cases during both P1 and P2. The overall rate of late cumulative events was, however, 113 of 507 (P1) versus 66 of 488 (P2) (P<0.001). The occurrence of pain, skin reaction, or redness at the infusion site was lower during P2.

CONCLUSION

Incidences both of initial failures and of premature catheter replacements were 8–9% with current CSII catheters. Significantly reduced failures after insertion and adverse events at the infusion site were observed with the new catheter model.

Technical risks with subcutaneous insulin infusion

The popularity of continuous subcutaneous insulin infusion (CSII), as a way for achieving long term strict glycaemic control in diabetic patients, has increased over the last ten years. Most reports on technical faults, often leading to metabolic emergencies, mainly ketoacidosis, have been published in the 1980s. Obstruction of infusion set and infection of infusion site are the most frequent events. Insulin precipitation or aggregation is thought to be one of the precipitating factors. Few data are available about failures of the pump itself. We report our experience of pump malfunctions recorded between 2001 and 2004 in 376 pumps used by patients treated with CSII therapy in Brittany. Recent studies indicate a decrease of metabolic complication frequency during CSII. This suggests technical improvements and/or a greater experience of physicians in selecting and educating patients. We report instructions for monitoring insulin pump therapy that should be included in a formal educational program for pump users. Clinical studies using newly available devices should reassess technical risks associated with CSII.

Multicenter randomized evaluation of a nutritional education software in obese patients

OBJECTIVE

To study the efficacy of the nutritional education software, Nutri-Expert, in the management of obese adult patients.

MATERIAL AND METHODS

Two groups of obese patients were followed up over one year in a randomized study: the first group received close traditional management (seven nutritional visits over the year, with physicians and dietitians conjointly) and the second one also used at home by Minitel the Nutri-Expert system. 557 patients were enrolled in the study by 16 French centers of diabetology and nutrition. Body mass index (BMI), tests of dietetic knowledge, dietary records and centralized biological measurements were assessed at inclusion, 6 and 12 months. 341 patients were evaluable at the end of the year.

RESULTS

The group using Nutri-Expert scored significantly better in the tests of dietetic knowledge than the control group. For all patients, nutritional education led to a significant improvement in BMI, dietary records and biological measurements, without significant difference between the two groups. Five years after the end of the study, the weight of 148 patients was recorded; mean BMI was significantly lower than the initial value but there was no significant difference between the two groups.

CONCLUSION

In the management of obese patients, Nutri-Expert system has a role to play in reinforcing nutritional knowledge; if regular follow-up is not possible, or if a large series of obese patients is to be treated, Nutri-Expert could partly replace traditional management, for example between visits.

[Anti-TPO antibodies and screening of thyroid dysfunction in type 1 diabetic patients]

The diagnosis of thyroid dysfunction is often late in type 1 diabetic population. So, the aims of this study were 1) to evaluate the prevalences of thyroperoxydase (TPO) and thyroglobulin (Tg) autoantibodies detected by highly sensitive radioimmunological method in a cohort of 258 adult type 1 diabetic patients without evidence of clinical thyroid disease; 2) to determine whether or not measurement of TPO and/or Tg antibodies can identify subjects at risk of clinical or infraclinical thyroid dysfunction by measuring TSH in the entire group. TPO antibodies were found in 45 of the 258 diabetic patients (17%). The prevalence of TPO antibodies was not influenced by the following factors: gender, duration of disease, age at screening and at diabetes diagnosis, positivity of familial history. Tg antibodies were found in 19 patients (7%), including 13 cases with TPO antibodies. All patients without TPO antibody (n=213), including Tg-positive patients displayed TSH values in normal range. Among the 45 TPO-positive patients, 11 patients displayed infraclinical thyroid dysfunction. At the end of the 5-year follow-up, only 2/45 patients became anti-TPO negative. Thirteen of the 45 patients developed subclinical or clinical thyroid diseases (4 Graves'disease and 9 thyroiditis with hypothyroidism). By contrast, none of 45 TPO negative patients, sex and age matched with the TPO-positive patients, developed during follow-up anti-TPO positivity and/or infraclinical thyroid dysfunction. In conclusion, the determination of TPO antibodies by a highly sensitive method allows identifying diabetic patients with thyroid autoimmunity and at risk of subsequent impaired thyroid function, whatever age at diagnosis and diabetes duration. By contrast, anti-Tg determination did not give further information about subsequent thyroid dysfunction. In TPO antibody positive patients repeated thyroid clinical examination and TSH determination could be recommended to detect infraclinical thyroid dysfunction.

[Synthetic antithyroid drugs and Basedow's disease or the choice of a therapeutic strategy]

We present the conclusions of two prospective studies of patients examined at their first manifestation of Graves' disease and treated with antithyroid drugs (ATD). The purpose of the first study was to investigate the effects of long-term treatment: the patients were given carbimazole in degressive doses without hormone replacement for 18 months, the followed up for 2 to 6 years after drug withdrawal. The second study was designed to determine the effect of treatment duration on the prognosis: the patients were given an ATD according to the same protocol for a duration randomly set at either 6 or 18 months, then seen again 2 years after ATD withdrawal. The results showed that after 18 months of treatment at least 50 percent of the patients could be expected to remain in remission for 6 years. Remissions were less frequent when treatment was shorter (41.7 percent after the 6 month treatment versus 61.8 percent after the 18 month treatment, with a 2 years' follow-up; P less than 0.05). The relapses that occurred came early: 70 percent of them took place within the first post-treatment month. This article also provides evidence of high T3 and/or T4 levels without signs of thyrotoxicosis during the post-treatment clinical course; these exclusively biochemical relapses spontaneously disappeared and may have been expressing epidoses of active thyroiditis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Gastric bypass in the treatment of major obesity. 15 cases]

Gastro-jejunal bypass, as derived from Mason's technique, consists of excluding most of the stomach, leaving only a 60 ml fundic pouch anastomosed with a Y-shaped jejunal loop. Fifteen patients (11 women and 4 men), aged from 21 to 51 years, were operated upon by this technique. In 3 of them, a jejuno-ileal bypass was transformed into a gastric bypass. The amount of weight lost by each individual patient was unpredictable and varied, in fact, from 1 to 50 kg (mean :30 kg). This was obtained within the 6 months following surgery, after which weight remained stable. All but one of the patients failed to attain their ideal weight. The only post-operative complication observed was abscess of the abdominal wall in 3 cases. Digestive disorders were constant during the first 3 months, but rapidly subsided thereafter. In view of the overall satisfactory loss of weight and low incidence of complications, this treatment can be considered useful. However, it should only be applied after strict selection and provided the patient's nutritional status can be regularly supervised.

HLA and Graves' disease: an association with HLA-DRw3

HLA-A, -B, and -C antigens were tested by a standard lymphocyte microcytotoxicity technique in 86 Caucasians patients from western France with Graves' disease, and the data were compared with findings in 356 healthy controls. For HLA-DR antigen typing performed by lymphocyte microcytotoxicity testing using a long incubation time, the data were compared to findings in 100 healthy controls. An increase was found in the frequency of HLA-DRw3 [51.16% of patients vs. 20% of controls, corrected P (Pc) < 0.0003; relative risk (rr), 4.19) associated with an increased frequency of HLA-B8 (44.19% of patients vs. 22.47% of controls; Pc < 0.001; rr, 2.73) and HLA-A1 (40.7% of patients vs. 28.93% of controls; Pc < 0.03; rr, 1.71). In contrast, a diminished frequency was found for HLA-B12 (12.79% vs. 31.74%; Pc < 0.01). The antigen combination B8-DRw3 was noted in 37 of the 86 Graves' disease patients compared with 13 of 100 controls (Pc < 0.00003). No association was observed between HLA antigens and the different manifestations of the disease, such as the presence of goiter and/or exophthalmos, or the severity of clinical or biochemical signs. The present findings confirm the reported increase in the frequency of HLA-B8 in patients with Graves' disease. The most striking finding was the prevalence of HLA-DRw3, which, together with recent reports on lymphocyte-defined D locus determinants pointing to an increase frequency of HLA-Dw3, suggests that the gene or genes conferring susceptibility to Graves' disease may be located close to the HLA-D (DR) region of the sixth chromosome.

[Graves' disease. Predominance of the DRw3 antigen (author's transl)]

HLA-A, B, C antigens were studied in 86 white european patients with Graves' disease, using a lymphocyte toxicity microtechnique and the results were compared with those obtained in 356 healthy subjects. HLA-D (DR) antigens were studied by the same technique after prolonged incubation and the results were compared with those of 100 healthy controls. The incidence of DRw3 was 51.16% in the patients as against 20% in controls, the difference being highly significant (pc--PC less than 0.0003) - corrected p = p multiplied by the number of antigens tested. There was also a significant (pc less than 0.001) increase in HLA-BB: 44.19% against 22.47%, and in HLA-A1: 40.7% against 28.93% (pc less than 0.03). Conversely, there was a decrease in the incidence of HLA-B12: 12.79% against 31.74% (pc less than 0.01). B8 was found to be associated with DRw3 in 37 of the 86 patients, but in only 13 of the 100 controls (p less than 0.00003). There was no correlation between the HLA antigens and the clinical features of the disease (presence or absence of goitre and exophthalmos, severity of clinical or biological symptoms). These results are in agreement with those of other studies reporting an increase in HLA-B8. The increase in HLA-A1 is probably due to an accentuation of the unbalanced linkage with B8. The major finding was the predominance of the DRw3 antigen, also found by other authors working with a mixed lymphocyte culture. It seems therefore possible that the putative Graves' disease susceptibility antigen is present on the sixth chromosome, near to HLA-D (DR).

[HLA DRW3 and Graves' disease (author's transl)]

HLA A, B, C antigens were studied in 86 caucasians with Graves' disease, using the lymphocytotoxicity microtechnique. Results were compared to those obtained in 336 healthy controls. HLA DR antigens were studied by the technique of microlymphocytotoxicity after long incubation and results compared to those of 100 healthy controls. There is an increased incidence of DRW3: 51.6% as compared to 20% in controls with a high degree of statistical significance pc less than 0,0003. There is also an increased incidence of B8: 44,19% in Graves' disease against 22,47% in controls pc less than 0,001. These results agree with the conclusions of two recent studies where the incidence of DW3 analyzed by a lymphocytic mixed culture was greater than incidence of the B8 antigen.