DiaTrend: A dataset from advanced diabetes technology to enable development of novel analytic solutions

Objective digital data is scarce yet needed in many domains to enable research that can transform the standard of healthcare. While data from consumer-grade wearables and smartphones is more accessible, there is critical need for similar data from clinical-grade devices used by patients with a diagnosed condition. The prevalence of wearable medical devices in the diabetes domain sets the stage for unique research and development within this field and beyond. However, the scarcity of open-source datasets presents a major barrier to progress. To facilitate broader research on diabetes-relevant problems and accelerate development of robust computational solutions, we provide the DiaTrend dataset. The DiaTrend dataset is composed of intensive longitudinal data from wearable medical devices, including a total of 27,561 days of continuous glucose monitor data and 8,220 days of insulin pump data from 54 patients with diabetes. This dataset is useful for developing novel analytic solutions that can reduce the disease burden for people living with diabetes and increase knowledge on chronic condition management in outpatient settings.

MON-409 Ectopic ACTH Syndrome with a Pituitary Mass

Background: The ectopic ACTH syndrome comprises 10% of Cushing’s syndrome cases. It is associated with an array of both highly malignant and more indolent tumors. Clinical features develop rapidly in ectopic ACTH syndrome. Distinguishing ectopic ACTH production from pituitary ACTH secretion is essential in determining appropriate management and may be challenging in the case of an occult neuroendocrine tumor. Clinical Case: A 46 year-old male presented to the ER after his PCP identified hypokalemia to 1.6 mmol/L (3.5- 5.0 mmol/L). He endorsed two weeks of proximal muscle weakness, lower extremity edema, a retro-orbital headache, and 10lb weight loss. Exam revealed mild facial fullness and pitting edema to the knees. No supraclavicular or dorsal cervical adiposity, violaceous abdominal striae or hyperpigmentation was observed. His blood pressure was elevated at 177/92 and an EKG revealed sinus bradycardia at a rate of 44 bpm. An 8AM cortisol was elevated at 67.4 mcg/dL (2.5-19.5 mcg/dL). ICU admission for blood pressure control and IV potassium supplementation was required. There was concern for Cushing’s disease given an inappropriately elevated ACTH level of 159.3 pg/mL (6-50 pg/mL). However, ectopic ACTH was highly suspected given the rapid development of symptoms and a smoking history of roughly 60 pack yrs. A CT of the chest, abdomen, and pelvis revealed no findings suspicious for malignancy. An MRI brain revealed a 19mm sellar and suprasellar mass atop the pituitary extending superiorly in the supra-diaphragmatic region adjacent to the pituitary stalk with a thickened, enhancing infundibulum. The patient required 60meq TID of oral KCl at discharge. Insulin dependent DMII rapidly developed in the weeks following discharge. An 8mg dexamethasone suppression test was performed with a baseline 8AM cortisol of 88 mcg/dL. Post dexamethasone, 8AM cortisol was 62 mcg/dL. Although these results were not consistent with the 50% reduction in cortisol levels expected by a pituitary adenoma in response to high dose dexamethasone administration, a trans-sphenoidal hypophysectomy was undertaken per patient preference. A pale discohesive tissue was identified intra-operatively which stained for ACTH, consistent with a corticotroph macroadenoma. An Indium-111 pentetreotide scan was negative for evidence of a somatostatin receptor expressing neoplasm. Two months after surgery, early-afternoon cortisol decreased to 7.5 mcg/dL. The patient’s insulin dependence gradually resolved as did his hypokalemia, edema, weakness, and weight loss. Conclusion: We describe an unusual case wherein clinical features of the ectopic ACTH syndrome developed over the course of two weeks in a lifelong smoker. Despite failing an 8mg dexamethasone test, a corticotroph macroadenoma was discovered. There was no identifiable source of ectopic ACTH on an octreotide scan despite a highly suggestible presentation.

MON-002 Perspective of Graduating Endocrinology, Diabetes, and Metabolism Fellows on the Benefits of Wearing a Continuous Glucose Monitor and Insulin Pump for Their Education

*RC and RC contribute equally as senior authors. Introduction:Diabetes management technologies are rapidly evolving and devices such as Continuous Glucose Monitors (CGM’s) and insulin pumps are becoming more sophisticated. These technologies are being covered by insurance companies and, in the near future more patients are expected to use these devices. Therefore, endocrinologists and endocrinology fellows need to feel competent in the indications, use and interpretation of output from these devices. Objectives: To our knowledge, no prior research has explored the prevalence of wearing CGM’s and/or insulin pumps among in-training fellows and their perception of doing so as part of their education. Our objectives therefore are: to estimate the frequency with which wearing a CGM and/or insulin pump is used as a learning opportunity and to explore the main motivators and perception on its value. Methods: Amultiple-choice survey that addressed fellow’s level of training, type of fellowship training program, and use of CGM and/or insulin pump among fellows was sent to all ACGME endocrinology, diabetes and metabolism program coordinators or programs directors. We asked them to forward this survey to their graduating fellows. Their perception on the value of wearing these devices was addressed. Results: 51 graduating fellows responded to the survey. 78.43% and 62.5% of them wore a CGM and insulin pump respectively. 89.48% and 90% of those who wore a CGM and insulin pump respectively thought it was above average value for their education and the most common reasons were to learn the technical aspects and understand what patients with diabetes go through. Conclusions: Wearing a CGM and/or insulin pump is perceived by endocrinology graduating fellows as valuable to their education specifically to learn the technical aspects, understand the patient’s experience and develop empathy.

Consistency of Hemoglobin A1c Testing and Cardiovascular Outcomes in Medicare Patients With Diabetes

Background

Annual hemoglobin A1c testing is recommended for patients with diabetes mellitus. However, it is unknown how consistently patients with diabetes mellitus receive hemoglobin A1c testing over time, or whether testing consistency is associated with adverse cardiovascular outcomes.

Methods and Results

We identified 1 574 415 Medicare patients (2002–2012) with diabetes mellitus over the age of 65. We followed each patient for a minimum of 3 years to determine their consistency in hemoglobin A1C testing, using 3 categories: low (testing in 0 or 1 of 3 years), medium (testing in 2 of 3 years), and high (testing in all 3 years). In unweighted and inverse propensity‐weighted cohorts, we examined associations between testing consistency and major adverse cardiovascular events, defined as death, myocardial infarction, stroke, amputation, or the need for leg revascularization. Overall, 70.2% of patients received high‐consistency testing, 17.6% of patients received medium‐consistency testing, and 12.2% of patients received low‐consistency testing. When compared to high‐consistency testing, low‐consistency testing was associated with a higher risk of adverse cardiovascular events or death in unweighted analyses (hazard ratio [HR]=1.21; 95% CI, 1.20–1.23; P<0.001), inverse propensity‐weighted analyses (HR=1.16; 95% CI, 1.15–1.17; P<0.001), and weighted analyses limited to patients who had at least 4 physician visits annually (HR=1.15; 95% CI, 1.15–1.16; P<0.001). Less‐consistent testing was associated with worse results for each cardiovascular outcome and in analyses using all years as the exposure.

Conclusions

Consistent annual hemoglobin A1c testing is associated with fewer adverse cardiovascular outcomes in this observational cohort of Medicare patients of diabetes mellitus.

Use of a glucose management service improves glycemic control following vascular surgery: an interrupted time-series study

BACKGROUND

The optimal method for obtaining good blood glucose control in noncritically ill patients undergoing peripheral vascular surgery remains a topic of debate for surgeons, endocrinologists, and others involved in the care of patients with peripheral arterial disease and diabetes. A prospective trial was performed to evaluate the impact of routine use of a glucose management service (GMS) on glycemic control within 24 hours of lower-extremity revascularization (LER).

METHODS

In an interrupted time-series design (May 1, 2011-April 30, 2012), surgeon-directed diabetic care (Baseline phase) to routine GMS involvement (Intervention phase) was compared following LER. GMS assumed responsibility for glucose management through discharge. The main outcome measure was glycemic control, assessed by (1) mean hospitalization glucose and (2) the percentage of recorded glucose values within target range. Statistical process control charts were used to assess the impact of the intervention.

RESULTS

Clinically important differences in patient demographics were noted between groups; the 19 patients in the Intervention arm had worse peripheral vascular disease than the 19 patients in the Baseline arm (74% critical limb ischemia versus 58%; p = .63). Routine use of GMS significantly reduced mean hospitalization glucose (191 mg/dL Baseline versus 150 mg/dL Intervention, p < .001). Further, the proportion of glucose values in target range increased (48% Baseline versus 78% Intervention, p = .05). Following removal of GMS involvement, measures of glycemic control did not significantly decrease for the 19 postintervention patients.

CONCLUSIONS

Routine involvement of GMS improved glycemic control in patients undergoing LER. Future work is needed to examine the impact of improved glycemic control on clinical outcomes following LER.

Metabolic and hormonal effects of caffeine: randomized, double-blind, placebo-controlled crossover trial

In short-term studies, caffeine has been shown to increase insulin levels, reduce insulin sensitivity, and increase cortisol levels. However, epidemiological studies have indicated that long-term consumption of beverages containing caffeine such as coffee and green tea is associated with a reduced risk of type 2 diabetes mellitus. There is a paucity of randomized studies addressing the metabolic and hormonal effects of consuming caffeine over periods of more than 1 day. We evaluated the effect of oral intake of 200 mg of caffeine taken twice a day for 7 days on glucose metabolism, as well as on serum cortisol, dehydroepiandrosterone (DHEA), and androstenedione, and on nighttime salivary melatonin. A double-blind, randomized, placebo-controlled crossover study with periods of 7 days and washouts of 5 days comparing caffeine with placebo capsules was conducted. Participants were 16 healthy adults aged 18 to 22 years with a history of caffeine consumption. Blood samples from each subject were assayed for glucose, insulin, serum cortisol, DHEA, and androstenedione on the eighth day of each period after an overnight fast. Nighttime salivary melatonin was also measured. Insulin levels were significantly higher (by 1.80 microU/mL; 95% confidence interval, 0.33-3.28) after caffeine intake than after placebo. The homeostasis model assessment index of insulin sensitivity was reduced by 35% (95% confidence interval, 7%-62%) by caffeine. There were no differences in glucose, DHEA, androstenedione, and melatonin between treatment periods. This study provides evidence that daily caffeine intake reduces insulin sensitivity; the effect persists for at least a week and is evident up to 12 hours after administration.

EPR spectrometer for clinical applications

This article describes an EPR spectrometer specifically designed and constructed for EPR spectroscopy in humans. The spectrometer is based on a permanent magnet, suitable for measurements at 1200 MHz. The magnet has a full 50 cm gap between the poles, which facilitates accurate and comfortable placement of the subject for the EPR measurement at any location on the human body. The bridge includes features to facilitate clinical operations, including an indicator for phasing of the reference arm and a 2 level RF amplifier. Resonators with holders for each type and site of measurement have been developed that comfortably position the resonator and the patient and prevent artifacts due to motion. The initial applications for which the spectrometer has been designed are for oximetry using loops on the surface, oximetry using implanted resonators for measuring deep sites, and measurements in the teeth for determination of exposures to clinically significant doses of ionizing radiation.

IVM – the first choice for IVF in Italy

In March 2004, a new law was introduced in Italy to regulate assisted reproduction; at present it is impossible to use more than a maximum of three oocytes per IVF cycle, nor can embryos or prezygotes (2PN cells) be selected or cryopreserved. The prohibitions introduced by the new law have, on the one hand, reduced the expectations of success of current techniques and, on the other hand, stimulated clinicians and embryologists to work on new therapeutic strategies so as to offer the highest chances of success with the lowest risks. In-vitro maturation (IVM) of oocytes fits very well with these new requirements: ovarian stimulation is avoided and the handling of spare oocytes is facilitated. The IVM protocol is an intriguing alternative to conventional IVF techniques, since it removes the side-effects of drug stimulation, especially ovarian hyperstimulation syndrome, and it also reduces the costs of the entire procedure, both in terms of 'time consumption' and 'patient/society costs for drugs'. In the authors' IVF centre the IVM technique has been used for more than a year, with significant success in terms of maturation and fertilization rates, percentage of embryo transfers, number of pregnancies and, finally, healthy babies born.

Clinical applications of EPR: overview and perspectives

The development and use of in vivo techniques for strictly experimental applications in animals has been very successful, and these results now have made possible some very attractive potential clinical applications. The area with the most obvious immediate, effective and widespread clinical use is oximetry, where EPR almost uniquely can make repeated and accurate measurements of pO2 in tissues. Such measurements can provide clinicians with information that can impact directly on diagnosis and therapy, especially for oncology, peripheral vascular disease and wound healing. The other area of immediate and timely importance is the unique ability of in vivo EPR to measure clinically significant exposures to ionizing radiation 'after-the-fact', such as may occur due to accidents, terrorism or nuclear war. There are a number of other capabilities of in vivo EPR that also potentially could become extensively used in human subjects. In pharmacology the unique capabilities of in vivo EPR to detect and characterize free radicals could be applied to measure free radical intermediates from drugs and oxidative process. A closely related area of potential widespread applications is the use of EPR to measure nitric oxide. These often unique capabilities, combined with the sensitivity of EPR spectra to the immediate environment (e.g. pH, molecular motion, charge) have already resulted in some very productive applications in animals and these are likely to expand substantially in the near future. They should provide a continually developing base for extending clinical uses of in vivo EPR. The challenges for achieving full implementation include adapting the spectrometer for safe and comfortable measurements in human subjects, achieving sufficient sensitivity for measurements at the sites of the pathophysiological processes that are being measured, and establishing a consensus on the clinical value of the measurements.

[Ocular diseases in public health]

The renewed sensibility towards the quality of life of disability has moved the authors to undertake a review to assess the low vision-blindness phenomenon as a public health problem. Particular attention has been paid to the aetiology and to the geographic distribution worldwide and in Italy. The prevention aspects of the main ocular diseases widespread in the industrialized countries, including the interventions focused on the patient and on the rehabilitation, have been analysed.

[Noise and communal dining facilities]

Noise is a sound which is unwanted, either because of its effect on humans, its effect on fatigue or multifunctions of physical equipment, or its interference with the perception or detection of other sounds. It is a part of environmental pollution which can, in certain circumstances, reach worrying levels for the population (130 dB cause pain). Unsuitable exposure to noise for even short periods of time is responsible for symptomology involving the hearing organs (hypoacusis) and other parts of the body such as the cardiovascular, muscular and digestive systems via the connection between the central and the autonomous nervous systems. Noise in communal eating areas can be classed as coming from 3 sources: 1) operation of cooking machinery; 2) banging of pans and equipment; 3) voices of both staff and diners. The intensity of noise on these premises varies generally between 60 and 80 dB (discomfort threshold). The Regulations governing this subject are D.Lgs n.277 of 15/8/1991 regarding the protection of employees, D.P.C.M. of 1/3/1991 which establishes the maximum levels of noise both in the home and outside, and the more recent D.P.C.M. of 21/5/1999 referring to noise in public places, which includes restaurants. To contain the exposure to noise in public eating places, we believe that action should be taken at legal levels with stricter limits than the recently passed level of 105 dB, in the building planning departments and also with technological intervention in order to reduce the effects that noise has on the auditive and extra-auditive organs and thus limit possible sublimal messages which certainly do not benefit the psycho-physical well-being of the diners.

[The food poisoning problem in communal restaurant facilities]

In view of the considerable development during the last few years of communal feeding facilities (factory, school, and university canteens, hospital kitchens, self service, fast food, and restaurants) in our country as well as elsewhere, the authors wish to supply detailed information on the incidence of food poisoning in Italy from 1979 to 1988 in such facilities. They report the findings of an epidemiological study they carried out in Rome and Lazio [correction of Latium] covering this period and which by and large confirmed the trend observed at the national level. As to prevention, the most recent techniques for food conservation are described.

[Minor salmonellosis in childhood: epidemiological and preventive considerations]

The diffusion of so-called minor salmonellosis in Italy, 18,135 isolates in 1985 -and the serious illness that they may induce in correlation to age and state of health have moved the Authors to consider their epidemiology and discuss their prevention. The morbidity per 100,000 population, from about 10 in the early '70s, has grown to a peak of 22.22 in 1976 and, after having irregularly reduced to a value of 16.76 in 1984, has grown again to 22.23 in 1986. Travelling abroad, modern breeding technologies, animals and raw food trade among States are frequently indicated as the most important factors in spreading salmonellas. The rise of morbidity in Italy has indeed occurred in concomitance with the renewal of breeding activity realized by means of animals imported from abroad, and moreover, presence of strains of S. typhimurium identical to those which caused serious epidemic outbreaks in bovine and humans in Great Britain and other Countries of North Europe is now ascertained. Recently, cooked ham prepared with raw meat contaminated with two serotypes uncommon in Italy (S. corvallis and S. mbandaka), imported from Rumania and Holland, has been the cause of two foodborne outbreaks each showing both of the above contaminants. At present, salmonellosis is quite common in large urban areas and is supported by person-to-person spread; more than 50% of the yearly isolates occurs in childhood Number of cases, their ages, sex distribution, and relative morbidity, have been calculated in Tab. 1, 2, 3, 4. From 1976 to 1986 the withdraw of S. wien, the research of excretors, and the improvement of quality of life, are all factors that may have favoured the lowering of morbidity at age zero, while the increasing of the same index at the ages 1-5 and 6-10 may correlate to the high number of serotypes of Salmonella now endemic in Italy. The diffusion of fast-food and the habit, recently acquired in our Country, to buy at shop cooked foods ready to eat, may be involved too. Age distribution shows a highest number of isolates at age zero and a still high number at ages 1, 2, and 3. Throughout childhood morbidity is lower in females. From 1975 on, the percentage increase of number of children admitted for minor salmonellosis is also indicated by surveys held at many Hospitals in Italy.(ABSTRACT TRUNCATED AT 400 WORDS)

Expression of peptide hormone genes in human islet cell tumors

The embryogenesis of the pancreas suggests the existence of a common stem cell progenitor of the four islet cell types (insulin, glucagon, somatostatin, and pancreatic polypeptide). We investigated whether neoplastic islet tumors express multiple hormone-specific cellular phenotypes of the islets. By analyses of RNA transcripts and immunoreactive peptides in four human insulinomas and one glucagonoma, we found that the insulin, somatostatin, and glucagon genes were coexpressed in all tumors. The expression of the three hormone genes in a lymph node metastasis of a glucagonoma reduced the possibility that contamination of tumor tissue by normal islets occurred. These observations lend further support to the hypothesis of the multipotentiality of neoplastic islet cells for the expression of genes encoding several different islet hormones.

Intraoperative ultrasonographic localization of islet cell tumors. A prospective comparison to palpation

The purpose of the present study was to evaluate prospectively the value of intraoperative ultrasound scanning (IOUS) in localizing islet cell tumors by comparing results of IOUS to those of palpation during 44 consecutive laparotomies for gastrinoma (36) or insulinoma (8). All patients had preoperative radiographic imaging studies and selective venous sampling for hormones, which guided the subsequent laparotomy. Any suspicious finding by palpation and/or IOUS was resected. Pathologic evidence of islet cell neoplasm served as the reference standard. Five patients were excluded from analysis because neither palpation nor IOUS had suspicious findings and no islet cell tumor was found. Seven pancreatic insulinomas were found in seven patients. IOUS was as sensitive as palpation at localizing insulinomas. Twenty-three pancreatic gastrinomas were found in 19 patients. IOUS was equal to palpation in the ability to localize gastrinomas. Gastrinomas that were successfully imaged by IOUS were significantly larger than gastrinomas that were not imaged. Twelve extrapancreatic gastrinomas were found in nine patients, and palpation was more sensitive than IOUS at localizing these small duodenal wall tumors. Five patients (11%) had their surgical management changed by IOUS. Two patients had pancreatic tumors (one gastrinoma and insulinoma) enucleated that would not have been found without IOUS, and three patients had resections of pathologically proven malignant islet cell tumors based on sonographic findings. All five patients were cured with short follow-up. The present results demonstrate that palpation and IOUS are complementary because IOUS can image tumors that are not palpable and IOUS can provide additional information concerning malignant potential not detected by palpation.