Continuous glucose monitoring and metrics for clinical trials: an international consensus statement

Randomised controlled trials and other prospective clinical studies for novel medical interventions in people with diabetes have traditionally reported HbA1c as the measure of average blood glucose levels for the 3 months preceding the HbA1c test date. The use of this measure highlights the long-established correlation between HbA1c and relative risk of diabetes complications; the change in the measure, before and after the therapeutic intervention, is used by regulators for the approval of medications for diabetes. However, with the increasing use of continuous glucose monitoring (CGM) in clinical practice, prospective clinical studies are also increasingly using CGM devices to collect data and evaluate glucose profiles among study participants, complementing HbA1c findings, and further assess the effects of therapeutic interventions on HbA1c. Data is collected by CGM devices at 1-5 min intervals, which obtains data on glycaemic excursions and periods of asymptomatic hypoglycaemia or hyperglycaemia (ie, details of glycaemic control that are not provided by HbA1c concentrations alone that are measured continuously and can be analysed in daily, weekly, or monthly timeframes). These CGM-derived metrics are the subject of standardised, internationally agreed reporting formats and should, therefore, be considered for use in all clinical studies in diabetes. The purpose of this consensus statement is to recommend the ways CGM data might be used in prospective clinical studies, either as a specified study endpoint or as supportive complementary glucose metrics, to provide clinical information that can be considered by investigators, regulators, companies, clinicians, and individuals with diabetes who are stakeholders in trial outcomes. In this consensus statement, we provide recommendations on how to optimise CGM-derived glucose data collection in clinical studies, including the specific glucose metrics and specific glucose metrics that should be evaluated. These recommendations have been endorsed by the American Association of Clinical Endocrinologists, the American Diabetes Association, the Association of Diabetes Care and Education Specialists, DiabetesIndia, the European Association for the Study of Diabetes, the International Society for Pediatric and Adolescent Diabetes, the Japanese Diabetes Society, and the Juvenile Diabetes Research Foundation. A standardised approach to CGM data collection and reporting in clinical trials will encourage the use of these metrics and enhance the interpretability of CGM data, which could provide useful information other than HbA1c for informing therapeutic and treatment decisions, particularly related to hypoglycaemia, postprandial hyperglycaemia, and glucose variability.

Automated Insulin Delivery: Easy Enough to Use in Primary Care?

There are three automated insulin delivery devices on the U.S. market, two of which are currently approved by the U.S. Food and Drug Administration. These systems have already made a significant impact for the people who use them in improving diabetes outcomes, including glycemic control and hypoglycemia prevention. This article aims to help primary care and endocrinology providers better understand the components, differences, limitations, and potential fit of these systems into clinical practice.

SAT-636 The Fast-Evolving Connected Diabetes Care Landscape: Transforming Diabetes Care with Telehealth and Technology

Background and Aims

Recent years have brought about a new form of “connected diabetes care,” defined as digital diabetes management systems based around (1) smartphone apps, (2) devices with built-in connectivity, and (3) remote human and automated coaching and support. Given their potential to help improve health outcomes, the rapid pace of innovation, and the dearth of information about them to guide patients, providers, and payers, we provide an update on the landscape of and trends in connected diabetes care offerings.

Methods

Prominent connected diabetes care providers that have published results are categorized and characterized. Similarities and differences are identified and the state of available evidence is evaluated.

Results

Connected diabetes care offerings were analyzed for items including: health conditions managed, care team composition, connected medical devices, and evidence. We expect these players will further expand offerings across chronic conditions, strive to integrate more deeply with the traditional healthcare system, deploy greater automation to promote scalability, and find clever ways to promote and support the use of continuous glucose monitoring in type 2 diabetes. Future evidence generation for this field should have more standardized methodology.

Conclusions

The field of connected diabetes care has tremendous potential to improve outcomes, but it is in its infancy in terms of awareness, uptake, and effectiveness. Further, questions regarding offerings’ abilities to support most people with diabetes sustainably remain. However, existing evidence is sufficient to support further exploration and refinement of the model as the next step in team-based diabetes care.

Implementation of Oral Health Screening and Referral Guidelines in Primary Health Care

Objectives:

To determine the oral health screening and referral practices of pediatric providers, their adherence to American Academy of Pediatrics oral health guidelines, and barriers to adherence.

Methods:

Providers in 10 pediatric practices participating in the North Carolina Quality Improvement Initiative, funded by the Child Health Insurance Program Reauthorization Act of 2009, were asked to complete a 91-item questionnaire. Questions on risk assessment and referral practices were based on those recommended by the American Academy of Pediatrics. Adherence to oral health guidelines was assessed by practitioners’ evaluation of 4 vignettes presenting screening results for an 18-mo-old child with different levels of risk and caries status. Respondents chose referral recommendations assuming adequate and inadequate dentist workforces. Logit models determined the association between barriers specified in Cabana’s framework and adherence (count of 6 to 8 adherent vignettes vs. 0 to 5).

Results:

Of 72 eligible providers, 53 (74%) responded. Almost everyone (98.1%) screened for dental problems; 45.2% referred in at least half of well-child visits. Respondents were aware of oral health guidelines, expressed strong agreement with them, and reported confidence in providing preventive oral health services. Yet they underreferred by an average of 42% per vignette for the 7 clinical vignette-workforce scenarios requiring an immediate referral. Frequently cited barriers were providers’ beliefs that 1) parents are poorly motivated to seek dental care, 2) oral health counseling has a small effect on parent behaviors, 3) there is a shortage of dentists in their community who will see infants and toddlers, and 4) information systems to support referrals are insufficient.

Conclusion:

Pediatric clinicians’ beliefs lead to a conscious decision not to refer many patients, even when children should be referred.

Knowledge Transfer Statement:

Evidence suggests that the primary care–dental referral process needs improvement. This study identifies barriers to delivering recommended preventive oral health services in pediatrics. The information can be used to improve the screening and referral process and, thus, the quality of preventive oral health services provided in primary care. Results also can guide researchers on the selection of interventions that need testing and might close gaps in the referral process and improve access to dental care.

Challenges in Diabetes Care: Can Digital Health Help Address Them?

In Brief There is great enthusiasm for the potential of digital health solutions in medicine and diabetes to address key care challenges: patient and provider burden, lack of data to inform therapeutic decision-making, poor access to care, and costs. However, the field is still in its nascent days; many patients and providers do not currently engage with digital health tools, and for those who do, the burden is still often high. Over time, digital health has excellent potential to collect data more seamlessly, make collected data more useful, and drive better outcomes at lower costs in less time. But there is still much to prove. This review offers key background information on the current state of digital health in diabetes, six of the most promising digital health technologies and services, and the challenges that remain.

PsychDT Working Group: Report Psychosocial Aspects of Artificial Pancreas Systems

BACKGROUND

Diabetes technology is a cornerstone of diabetes management in the 21st century, with advances in available devices over recent years playing a central role in the way that health care has progressed. Psychosocial interventions have been shown to have a positive impact on glycemic control, reduce psychological distress and reduce costs of health care. Addressing and improving psychosocial outcomes that complement biomedical improvements and looking to the future are crucial to enhance patient acceptance of artificial pancreas (AP) systems.

METHODS

To achieve closer collaboration and comparability across different AP research trials, a working group was established.

RESULTS

Existing measures fail to adequately capture the extent to which human and psychological factors play a role in the uptake and efficient use of AP systems. Understanding these factors will ultimately lead to the most benefit for users. Reliable measures of the psychosocial impact of AP systems for users is crucial to ensure that (1) regulatory authorities are able to robustly consider these aspects as part of their approval process, (2) government and private payers are able to factor these aspects into their decisions regarding reimbursement, and (3) persons with diabetes maximize benefits in terms of both glycemic control and quality of life to minimize the burden of diabetes in everyday life.

CONCLUSIONS

This working group will serve as a platform to foster exchange, identify research needs, and guide and initiate collaborative research laying the groundwork for optimal utilization of diabetes technology in clinical diabetes care. A close collaboration among all key stakeholders is crucial to ensure that devices are designed, trialed, approved, and provided with minimal user burden and maximum beneficial effect.

Pediatricians' assessments of caries risk and need for a dental evaluation in preschool aged children

BACKGROUND

Risk-based prioritization of dental referrals during well-child visits might improve dental access for infants and toddlers. This study identifies pediatrician-assessed risk factors for early childhood caries (ECC) and their association with the need for a dentist's evaluation.

METHODS

A priority oral health risk assessment and referral tool (PORRT) for children < 36 months was developed collaboratively by physicians and dentists and used by 10 pediatricians during well-child visits. PORRT documented behavioral, clinical, and child health risks for ECC. Pediatricians also assessed overall ECC risk on an 11-point scale and determined the need for a dental evaluation. Logistic regression models calculated the odds for evaluation need for each risk factor and according to a 3-level risk classification.

RESULTS

In total 1,288 PORRT forms were completed; 6.8% of children were identified as needing a dentist evaluation. Behavioral risk factors were prevalent but not strong predictors of the need for an evaluation. The child's overall caries risk was the strongest predictor of the need for an evaluation. Cavitated (OR = 17.5; 95% CI = 8.08, 37.97) and non-cavitated (OR = 6.9; 95% CI = 4.47, 10.82) lesions were the strongest predictors when the caries risk scale was excluded from the analysis. Few patients (6.3%) were classified as high risk, but their probability of needing an evaluation was only 0.36.

CONCLUSIONS

Low referral rates for children with disease and prior to disease onset but at elevated risk, indicate interventions are needed to help improve the dental referral rates of physicians.

Barriers to the adoption and implementation of preventive dental services in primary medical care

OBJECTIVE

To determine the barriers to adopting preventive oral health procedures in medical primary care.

METHODS

Medical providers who participated in a Medicaid demonstration in North Carolina completed questionnaires reporting their experiences with providing preventive dental services for children from birth to 3 years of age. Eleven factors were established as possible obstacles to the adoption of an oral health program. After 12 months of participation in the Into the Mouths of Babes training program, providers (N = 231) from 49 pediatric practices and 28 family physician practices reported if any of the 11 factors had been an obstacle to adoption and, if so, whether these obstacles were overcome. Program adoption and implementation, defined as providing all of the services on a regular basis, were predicted by using logistic regression to analyze the responses from providers who reported 1 or more barriers, the number of barriers identified (knowledge, attitudes, and external factors), and the number that were overcome.

RESULTS

Program-adoption rates were high, with 70.3% of the participants providing dental services on a routine basis. Attitude and external factors were positively associated with adoption, particularly with difficulty in applying the varnish, integration of the dental procedures into practice, resistance among staff and colleagues, and dentist referral difficulties. From 40.4% to 61.5% of providers overcame these 4 most common barriers. Those who reported external barriers and were unable to overcome them were less likely to provide the services, compared with those providers who reported no barriers (odds ratio: 0.08 [95% confidence interval: 0.01-0.44]).

CONCLUSIONS

The number of barriers to adopting preventive dental procedures in primary care medical practices is associated with implementation. A large proportion of these barriers can be overcome, leading to high adoption rates in a short amount of time. The barriers to adoption are similar to those identified in the literature on changing patient care, with the unique aspects of fluoride application to teeth. Interventions to promote preventive dental care in medical settings should rely heavily on empirical literature. Training physicians in preventive dentistry should identify and target potential barriers with information and options for introducing office-based systems to improve the chances of adoption.

Morphine inhibits the release of tumor necrosis factor in human peripheral blood mononuclear cell cultures

Opiates modulate a variety of immune responses of peripheral blood mononuclear cells (PBMC). When PBMC were treated with morphine for 24 h, cells released less (P < 0.05) bioactive TNF, a cytokine important in host defense, in the following 24-h incubation period when stimulated with lipopolysaccharide and phytohemagglutinin. Morphine alone did not significantly alter the release of TNF from PBMC cultures. Pretreatment of PBMC cultures for 1 h with naloxone blocked (P < 0.05) the inhibitory effect of morphine on the release of TNF upon stimulation with phytohemagglutinin, but not with lipopolysaccharide, suggesting the involvement of an opioid receptor. The mechanism of morphine-induced suppression of TNF release appears to be counteracted by the effect of this opiate on the release of transforming growth factor (TGF)-beta, since antibodies to this immunoregulatory cytokine further enhanced morphine-related inhibition of TNF release. Taken together, these findings indicate that morphine suppresses the release of bioactive TNF from PBMC and that TGF-beta plays a modulatory role in this inhibitory process.

Cytokine release from microglia: differential inhibition by pentoxifylline and dexamethasone

Cytokines have been implicated in the pathogenesis of gram-negative bacterial meningitis. The effects of pentoxifylline and dexamethasone on the release of tumor necrosis factor (TNF), interleukin (IL)-1, and IL-6 from primary murine microglial cell cultures were explored using bioassays. When added concomitantly with lipopolysaccharide, pentoxifylline blocked the release of TNF and IL-1 but not IL-6, while dexamethasone inhibited the release of TNF and IL-6. After a 2-h exposure of microglia to lipopolysaccharide, pentoxifylline but not dexamethasone still inhibited the release of TNF. Release of TNF was enhanced 20-fold by priming of the microglia with interferon-gamma; only pentoxifylline blocked the priming effect of interferon-gamma on TNF release. These results demonstrate that pentoxifylline and dexamethasone differentially regulate the release of cytokines in microglial cell cultures and provide potential insight into their role in the treatment of gram-negative bacterial meningitis.

Immunologically mediated fatigue: a murine model

Chronic fatigue syndrome (CFS) is an idiopathic disorder in which the chief symptoms is profound fatigue. To explore the relationship between immune stimulation and fatigue, we developed a murine model for quantifying fatigue: reduction in voluntary running and delayed initiation of grooming after swimming. Inoculation of female BALB/c mice with Corynebacterium parvum antigen or the relatively avirulent Me49 strain of Toxoplasma gondii induced fatigue: baseline running reduced to less than 50 and 30% for 8 and 14 days, respectively, and delayed initiation of grooming after swimming in both immunologically stimulated groups. A threefold evaluation of serum transforming growth factor-beta levels, a cytokine increased in CFS patients, was found in fatigued C. parvum- and T. gondii-inoculated mice. This murine model appears promising for investigation of the pathogenesis of immunologically mediated fatigue.