Flash glucose monitoring: Impact on markers of glycaemic control and patient-reported outcomes in individuals with type 1 diabetes mellitus in the real-world setting

AIMS

We aimed to evaluate both glycaemic parameters and patient-reported outcomes in patients prescribed FGM based on the local criteria at our institution.

METHODS

This retrospective observational study included patients aged > 18 years with a diagnosis of type 1 diabetes mellitus (T1DM) who were prescribed FreeStyle Libre FGM (n = 90). Quantitative data on glycaemic parameters was collected pre- and post-initiation of FGM in addition to patient-reported outcome measures (PROMs). The primary outcome was change in pre- and post-FGM levels of glycosylated haemoglobin (HbA1C).

RESULTS

There was a mean reduction in HbA_1c of -7.29 ± 10.76 mmol/mol (p < 0.001, CI_95% 4.94-9.64) sustained to the latest reading. There was also a mean reduction in the number of hypoglycaemic episodes per week of 3.20 (percentage reduction 51.86%, p < 0.001, CI_95% 1.64-4.77). A significant improvement in quality of life scores was noted in all five domains of the abbreviated DDS between before and after starting FGM (p < 0.001). Key themes highlighted in inductive content analysis include 'life-changing', 'positive experience', and 'convenient'.

CONCLUSION

Flash glucose monitoring is associated with significant improvement in HbA_1c to a mean follow-up of 4.6 months. Additionally, patients reported positive experiences of FGM with significant improvement in all aspects of a focussed Diabetes Distress Scale.

Reconstructive options in the treatment of osteoradionecrosis of the craniomaxillofacial skeleton

Osteoradionecrosis (ORN) of the craniomaxillofacial skeleton is a serious and debilitating complication that can occur following radiation therapy in the head and neck. Patients require effective treatment, which eradicates diseased tissue and restores function with minimal additional morbidity in a single stage, a requirement fulfilled in many cases by free tissue transfer. In a 6-year period from 1994 to 1999, 21 patients with ORN were treated by wide resection and free-flap reconstruction. The median interval between radiation therapy and ORN was 4 years (range: 1-33 years). The median radiation dose was 6000cGy. The affected areas were the mandible (15 patients), the temporal bone (three patients), the maxilla (one patient), the cervical vertebrae (one patient) and the frontal bone (one patient). Clinical symptoms included pain, ulceration, a persistent draining fistula, exposure of bone or hardware, and pathological fracture or non-union of bone. Six patients had had previous unsuccessful attempts at conservative surgical resection. Ten patients had preoperative hyperbaric oxygen (HBO) therapy. A number of different flaps were used for reconstruction in these patients. These included free fibula flaps (13 patients), iliac crest flaps (two patients), scapula flaps (three patients) and rectus abdominis flaps (three patients). All patients achieved relief from their presenting symptoms and primary bone or wound healing. One flap (4.8%) was lost. This was successfully reconstructed in a subsequent procedure. There were three flap re-explorations, two for arterial thrombosis and one for venous thrombosis. Conservative measures, such as limited debridement and HBO therapy, may be effective in preventing the progression of ORN. However, they fail to eradicate established ORN, which requires radical surgical resection followed by functional reconstruction with well-vascularised tissue.

Induction of nuclear factor-kappaB in nucleus accumbens by chronic cocaine administration

DeltaFosB is a Fos family transcription factor that is induced by chronic exposure to cocaine and other drugs of abuse in the nucleus accumbens and related striatal regions, brain regions that are important for the behavioral effects of these drugs. To better understand the mechanisms by which DeltaFosB contributes to the effects of chronic drug treatment, we used DNA microarray analysis to identify genes that are regulated in the nucleus accumbens upon DeltaFosB expression in inducible bitransgenic mice. One of the most highly regulated genes was that encoding a subunit of another transcription factor, nuclear factor-kappaB (NF-kappaB). Subsequent experiments confirmed the induction of NF-kappaB in the nucleus accumbens of mice overexpressing DeltaFosB as well as in wild-type mice treated chronically, but not acutely, with cocaine. These results establish NF-kappaB as a putative target for DeltaFosB and implicate NF-kappaB signaling pathways in the long-term adaptations of nucleus accumbens neurons to cocaine.

Early changes in respiratory compliance and resistance during the development of bronchopulmonary dysplasia in the era of surfactant therapy

Despite the availability of surfactant treatment, extremely low birth weight (ELBW) infants continue to be at high risk of developing bronchopulmonray dysplasia (BPD). Evidence suggests that pathologic changes occur within the first few days of life. We hypothesized that the changes in early respiratory system compliance and resistance in ELBW infants with or without hyaline membrane disease (HMD) would correlate with BPD severity and aid in its prediction. Respiratory system compliance (Crs) and resistance (Rrs) were measured at the end of weeks 1, 2, 3, and 4 in 46 infants weighing 1,000 g or less at birth, using the single breath airway occlusion method. Twenty-four infants had HMD and 22 did not. Fifteen infants with and 10 infants without HMD developed BPD with radiological changes and oxygen needs at 28 days. Twelve BPD infants required supplemental oxygen beyond 36 weeks, defined as chronic lung disease (CLD). Irrespective of whether the infant initially had HMD, the week 1 results showed that infants who subsequently developed BPD had a significantly higher respiratory system resistance than those who did not (P = 0.0014). Though week 1 compliance was lower, it was not statistical significant. Multiple logistic models consisting of simple neonatal variables and week 1 respiratory mechanics showed that Rrs was independently associated with subsequent BPD (P = 0.026) and CLD (P = 0.016), while compliance was not. Prediction of CLD improved with the inclusion of Rrs results as compared to prediction using clinical variables alone. Throughout the 4-week study period, Rrs was significantly higher in BPD infants than in those without BPD, and resistance was particularly abnormal in those who had CLD or subsequently required corticosteroid treatment. These observations provide rationale for interventions to prevent BPD within the first week of life. Respiratory mechanics measurements could be useful in the assessment of therapeutics in the current surfactant era.

Fas-induced apoptosis of alveolar epithelial cells requires ANG II generation and receptor interaction

Recent works from this laboratory demonstrated potent inhibition of Fas-induced apoptosis in alveolar epithelial cells (AECs) by the angiotensin-converting enzyme (ACE) inhibitor captopril [B. D. Uhal, C. Gidea, R. Bargout, A. Bifero, O. Ibarra-Sunga, M. Papp, K. Flynn, and G. Filippatos. Am. J. Physiol. 275 (Lung Cell. Mol. Physiol. 19): L1013-L1017, 1998] and induction of dose-dependent apoptosis in AECs by purified angiotensin (ANG) II [R. Wang, A. Zagariya, O. Ibarra-Sunga, C. Gidea, E. Ang, S. Deshmukh, G. Chaudhary, J. Baraboutis, G. Filippatos and B. D. Uhal. Am. J. Physiol. 276 (Lung Cell. Mol. Physiol. 20): L885-L889, 1999]. These findings led us to hypothesize that the synthesis and binding of ANG II to its receptor might be involved in the induction of AEC apoptosis by Fas. Apoptosis was induced in the AEC-derived human lung carcinoma cell line A549 or in primary AECs isolated from adult rats with receptor-activating anti-Fas antibodies or purified recombinant Fas ligand, respectively. Apoptosis in response to either Fas activator was inhibited in a dose-dependent manner by the nonthiol ACE inhibitor lisinopril or the nonselective ANG II receptor antagonist saralasin, with maximal inhibitions of 82 and 93% at doses of 0.5 and 5 microg/ml, respectively. In both cell types, activation of Fas caused a significant increase in the abundance of mRNA for angiotensinogen (ANGEN) that was unaffected by saralasin. Transfection with antisense oligonucleotides against ANGEN mRNA inhibited the subsequent induction of Fas-stimulated apoptosis by 70% in A549 cells and 87% in primary AECs (both P < 0.01). Activation of Fas increased the concentration of ANG II in the serum-free extracellular medium 3-fold in primary AECs and 10-fold in A549 cells. Apoptosis in response to either Fas activator was completely abrogated by neutralizing antibodies specific for ANG II (P < 0.01), but isotype-matched nonimmune immunoglobulins had no significant effect. These data indicate that the induction of AEC apoptosis by Fas requires a functional renin-angiotensin system in the target cell. They also suggest that therapeutic control of AEC apoptosis is feasible through pharmacological manipulation of the local renin-angiotensin system.

Angiotensin II induces apoptosis in human and rat alveolar epithelial cells

Recent work from this laboratory demonstrated potent inhibition of apoptosis in human alveolar epithelial cells (AECs) by the angiotensin-converting enzyme inhibitor captopril [B. D. Uhal, C. Gidea, R. Bargout, A. Bifero, O. Ibarra-Sunga, M. Papp, K. Flynn, and G. Filippatos. Am. J. Physiol. 275 (Lung Cell. Mol. Physiol. 19): L1013-L1017, 1998]. On this basis, we hypothesized that apoptosis in this cell type might be induced by angiotensin II (ANG II) through its interaction with the ANG II receptor. Purified ANG II induced dose-dependent apoptosis in both the human AEC-derived A549 cell line and in primary type II pneumocytes isolated from adult Wistar rats as detected by nuclear and chromatin morphology, caspase-3 activity, and increased binding of annexin V. Apoptosis also was induced in primary rat AECs by purified angiotensinogen. The nonselective ANG II-receptor antagonist saralasin completely abrogated both ANG II- and angiotensinogen-induced apoptosis at a concentration of 50 microgram/ml. With RT-PCR, both cell types expressed the ANG II-receptor subtypes 1 and 2 and angiotensin-converting enzyme (ACE). The nonthiol ACE inhibitor lisinopril blocked apoptosis induced by angiotensinogen, but not apoptosis induced by purified ANG II. These data demonstrate the presence of a functional ANG II-dependent pathway for apoptosis in human and rat AECs and suggest a role for the ANG II receptor and ACE in the induction of AEC apoptosis in vivo.