Real time continuous glucose monitoring in neonatal intensive care

Hypoglycaemia and hyperglycaemia are common in infants requiring intensive care and are associated with worse clinical outcomes. However, glucose levels are taken infrequently, and there remains controversy regarding optimal management. In adults and children continuous glucose monitoring (CGM) is now established as an important adjunct to caring for patients at risk from dysglycaemia. This technology is also increasingly providing insights into glucose regulation in the newborn, demonstrating significant periods of clinically silent hypoglycaemia and hyperglycaemia. This baseline data will be important to allow the significance of glucose dysregulation on long-term outcomes to be assessed. Small studies have also shown the potential for CGM to safely support targeting of glucose control in preterm infants, and a large multicentre trial is ongoing. Current technology is not specifically designed for use in NICU, but with rapid technological developments, CGM holds promise for the future care of babies in NICU.

Importance of gestational hypoglycaemia for foetal malformations and skeletal development in rats

The aim was to investigate embryo-foetal effects of continuous maternal insulin-induced hypoglycaemia extending throughout gestation or until gestation day (GD)17 (typical last day of dosing during pre-clinical evaluation) providing comparator data for safety assessment of longer-acting insulin analogues in non-diabetic rats. Pregnant rats received human insulin (HI)-infusion during gestation until either GD20 or GD17 (HI-GD20; HI-GD17). On GD20, foetal abnormalities and skeletal ossification/mineralisation were evaluated. HI-infusion induced continuous hypoglycaemia. Foetal skeletal and eye malformations (e.g. bent ribs, microphthalmia) were common in both groups. Foetal size and skeletal ossification/mineralisation decreased, particularly with infusion throughout gestation. Concluding, insulin-induced hypoglycaemia during gestation in non-diabetic rats is damaging to embryo-foetal growth and skeletal development, particularly after GD17. Three days without HI-infusion after GD17 allows for some developmental catch-up. Eye development is sensitive to HI-infusion before GD17. These results should serve as a benchmark during pre-clinical safety assessment of longer-acting insulin analogues tested in rats.

Cardiogenic shock triggered by phaeochromocytoma crisis after an oral glucose tolerance test: a case report

Background

Phaeochromocytomas are rare catecholamine-producing tumours which typically present with comparatively benign symptoms such as headache, palpitations, sweating, hypertension, and insulin resistance. In rare cases, severe cardiac manifestations have been reported. We describe a patient who developed severe hypoglycaemia after an oral glucose tolerance test (OGTT), potentially triggering a phaeochromocytoma crisis and cardiogenic shock. To the best of our knowledge, only four other cases of hypoglycaemia after OGTT have been reported in patients with phaeochromocytoma, of which none developed a phaeochromocytoma crisis.

Case summary

A 53-year-old woman with hypertension, dyslipidaemia, and prediabetes presented to the Emergency Department with hypoxia, hyperglycaemia, lactic acidosis, severe left ventricular dysfunction, and pulmonary oedema followed by cardiogenic shock. Onset of symptoms was only few hours after an OGTT during which she had developed severe transient hypoglycaemia. Angiography was performed due to elevated troponin levels and showed a midventricular contraction pattern typical of takotsubo. This was subsequently confirmed by cardiac magnetic resonance imaging. The patient’s condition improved during the first 36 h and she was discharged home on Day 7. A positive catecholamine test prompted readmission to the Endocrinology Unit, where computer tomography confirmed the diagnosis of phaeochromocytoma. An adrenalectomy was performed, and the diagnosis was verified histopathologically.

Discussion

The possibility of a phaeochromocytoma must be considered as a potential triggering factor in patients presenting with takotsubo cardiomyopathy, in particular, when blood glucose levels fluctuate between severe hypo- and hyperglycaemia.

Refinement of the critical genomic region for hypoglycaemia in the Chromosome 9p deletion syndrome

Background: Large contiguous gene deletions at the distal end of the short arm of chromosome 9 result in the complex multi-organ condition chromosome 9p deletion syndrome.  A range of clinical features can result from these deletions with the most common being facial dysmorphisms and neurological impairment. Congenital hyperinsulinism is a rarely reported feature of the syndrome with the genetic mechanism for the dysregulated insulin secretion being unknown.  Methods: We studied the clinical and genetic characteristics of 12 individuals with chromosome 9p deletions who had a history of neonatal hypoglycaemia. Using off-target reads generated from targeted next-generation sequencing of the genes known to cause hyperinsulinaemic hypoglycaemia (n=9), or microarray analysis (n=3), we mapped the minimal shared deleted region on chromosome 9 in this cohort. Targeted sequencing was performed in three patients to search for a recessive mutation unmasked by the deletion. Results: In 10/12 patients with hypoglycaemia, hyperinsulinism was confirmed biochemically. A range of extra-pancreatic features were also reported in these patients consistent with the diagnosis of the Chromosome 9p deletion syndrome. The minimal deleted region was mapped to 7.2 Mb, encompassing 38 protein-coding genes. In silico analysis of these genes highlighted SMARCA2 and RFX3 as potential candidates for the hypoglycaemia. Targeted sequencing performed on three of the patients did not identify a second disease-causing variant within the minimal deleted region. Conclusions: This study identifies 9p deletions as an important cause of hyperinsulinaemic hypoglycaemia and increases the number of cases reported with 9p deletions and hypoglycaemia to 15 making this a more common feature of the syndrome than previously appreciated.  Whilst the precise genetic mechanism of the dysregulated insulin secretion could not be determined in these patients, mapping the deletion breakpoints highlighted potential candidate genes for hypoglycaemia within the deleted region.

Experimental non-severe hypoglycaemia substantially impairs cognitive function in type 2 diabetes: a randomised crossover trial

AIMS/HYPOTHESIS

Previous studies have demonstrated a relationship between cognitive impairment and hypoglycaemia (<3 mmol/l). This study hypothesised that non-severe insulin-induced hypoglycaemia reduces cognitive function in individuals with type 2 diabetes.

METHODS

In this randomised crossover study, 25 participants with type 2 diabetes attended two experimental visits with hyperinsulinaemic glucose clamping: one hypoglycaemic clamp (plasma glucose 3.0 ± 0.2 mmol/l) and one euglycaemic clamp (plasma glucose 6.0 ± 0.2 mmol/l). Participants were eligible if their diabetes was treated with diet or glucose-lowering medications (except sulfonylureas or insulin), age was 35-70 years, BMI was 23-35 kg/m² and HbA_1c was below 75 mmol/mol (9%). Cognitive function was assessed with a neurocognitive test battery measuring verbal memory, executive function, sustained attention and psychomotor speed. From the examined cognitive domains, a global cognition score was constructed estimating global cognition. A measurement for psychomotor speed was selected as the primary outcome. Participants and people assessing the outcomes were blinded to group assignment.

RESULTS

Cognitive performance was impaired during hypoglycaemia with a mean score in the primary outcome test, Symbol Digit Modalities Test measuring psychomotor speed, of 48.7 ± 9.8 (hypoglycaemia) vs 56.6 ± 12.0 (euglycaemia); i.e. a change of -7.9 points (95% CI -10.9, -4.9; p < 0.0001). In addition, hypoglycaemia reduced global cognitive score by -0.7 (95% CI -0.9, -0.6; p < 0.0001). A stable glucose plateau was achieved during both experimental visits. For the hypoglycaemic clamp, mean plasma glucose concentration (± SD) during neurocognitive testing was 3.1 (± 0.3) mmol/l. Age, sex, fasting C-peptide, counter-regulatory hormones and the severity of hypoglycaemic symptoms did not influence cognitive function.

CONCLUSIONS/INTERPRETATION

Acute non-severe hypoglycaemia (mean plasma glucose 3.1 mmol/l) has a substantial negative impact on cognitive function in individuals with type 2 diabetes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03014011.

FUNDING

The study was supported in part by a research grant from the Investigator Initiated Studies Program of Merck Sharp & Dohme Corp (MSD-MA-NORD-007-01). The opinions expressed in this paper are those of the authors and do not necessarily represent those of Merck Sharp & Dohme Corp. Funding was also received from Skibsreder Per Henriksen, R. og hustrus Foundation, The Danish Alzheimer Foundation and Savværksejer Jeppe Juhl og hustrus Foundation.

Incretin-based medications (GLP-1 receptor agonists, DPP-4 inhibitors) as a means to avoid hypoglycaemic episodes

Hypoglycaemia is common in both type 1 and type 2 diabetes and has both acute and long-term consequences. Therefore, a key to proper glucose-lowering therapy in diabetes is to avoid or prevent hypoglycaemia. Incretin therapy (DPP-4 inhibitors and GLP-1 receptor agonists) offers an advantage in this respect, because it reduces glucose with a low risk of hypoglycaemia, both in monotherapy and in combination with other therapies. The reason for this low risk of hypoglycaemia is the glucose dependency of action of incretin therapy and the sustainment of glucose counter-regulatory hormone responses to hypoglycaemia, in particular the glucagon response. Incretin therapy is also associated with a low risk of hypoglycaemia in patient groups which are especially vulnerable and susceptible for hypoglycaemia, e.g., subjects with renal impairment, elderly subjects and subjects with on-going insulin therapy. This review summarizes how incretin therapy may meet the challenges of hypoglycaemia and suggests that incretin therapy is a therapy of choice to avoid hypoglycaemia, both in the general diabetes population and in subjects with increased risk or vulnerability for hypoglycaemia.

Spurious HbA1c results in patients with diabetes treated with dapsone

SUMMARY

Measurement of glycated haemoglobin (HbA1c) has been utilised in assessing long-term control of blood glucose in patients with diabetes, as well as diagnosing diabetes and identifying patients at increased risk of developing diabetes in the future. HbA1c reflects the level of blood glucose to which the erythrocyte has been exposed during its lifespan, and there are a number of clinical situations affecting the erythrocyte life span in which HbA1c values may be spuriously high or low and therefore not reflective of the true level of glucose control. In the present case series, we describe the particulars of three patients with diabetes who had spuriously low HbA1c levels as a result of dapsone usage. Furthermore, we discuss the limitations of HbA1c testing and the mechanisms by which it may be affected by dapsone in particular.

LEARNING POINTS

Various conditions and medications can result in falsely low HbA1c. Dapsone can lead to falsely low HbA1c by inducing haemolysis and by forming methaemoglobin. Capillary glucose measurement, urine glucose measurements and fructosamine levels should be used as alternatives to HbA1c for monitoring glycaemic control if it was falsely low or high.

Fulminant hepatitis and elevated levels of sIL-2R in thyroid storm

SUMMARY

We report the case of a 48-year-old man with thyroid storm associated with fulminant hepatitis and elevated levels of soluble interleukin-2 receptor (sIL-2R). Fatigue, low-grade fever, shortness of breath, and weight loss developed over several months. The patient was admitted to the hospital because of tachycardia-induced heart failure and liver dysfunction. Graves' disease with heart failure was diagnosed. He was treated with methimazole, inorganic iodide, and a β-blocker. On the day after admission, he became unconscious with a high fever and was transferred to the intensive care unit. Cardiogenic shock with atrial flutter was treated with intra-aortic balloon pumping and cardioversion. Hyperthyroidism decreased over 10 days, but hepatic failure developed. He was diagnosed with thyroid storm accompanied by fulminant hepatitis. Laboratory investigations revealed elevated levels of sIL-2R (9770 U/mL). The fulminant hepatitis was refractory to plasma exchange and plasma filtration with dialysis, and no donors for liver transplantation were available. He died of hemoperitoneum and gastrointestinal hemorrhage due to fulminant hepatitis 62 days after admission. Elevated circulating levels of sIL-2R might be a marker of poor prognosis in thyroid storm with fulminant hepatitis.

LEARNING POINTS

The prognosis of thyroid storm when fulminant hepatitis occurs is poor. Liver transplantation is the preferred treatment for fulminant hepatitis induced by thyroid storm refractory to plasma exchange. Elevated levels of soluble interleukin-2 receptor might be a marker of poor prognosis in patients with thyroid storm.

Prolonged acidosis is a feature of SGLT2i-induced euglycaemic diabetic ketoacidosis

SUMMARY

We describe two cases of SGLT2i-induced euglycaemic diabetic ketoacidosis, which took longer than we anticipated to treat despite initiation of our DKA protocol. Both patients had an unequivocal diagnosis of type 2 diabetes, had poor glycaemic control with a history of metformin intolerance and presented with relatively vague symptoms post-operatively. Neither patient had stopped their SGLT2i pre-operatively, but ought to have by current treatment guidelines.

LEARNING POINTS

SGLT2i-induced EDKA is a more protracted and prolonged metabolic derangement and takes approximately twice as long to treat as hyperglycaemic ketoacidosis. Surgical patients ought to stop SGLT2i medications routinely pre-operatively and only resume them after they have made a full recovery from the operation. While the mechanistic basis for EDKA remains unclear, our observation of marked ketonuria in both patients suggests that impaired ketone excretion may not be the predominant metabolic lesion in every case. Measurement of insulin, C-Peptide, blood and urine ketones as well as glucagon and renal function at the time of initial presentation with EDKA may help to establish why this problem occurs in specific patients.

An on-line support tool to reduce exercise-related hypoglycaemia and improve confidence to exercise in type 1 diabetes

OBJECTIVE

Hypoglycaemia related to exercise and lack of confidence to exercise, are common in T1DM. An online educational exercise tool (ExT1D) was tested to determine whether these parameters can be improved.

RESEARCH DESIGN AND METHODS

Thirty two adults with T1DM (50%M, age 35.8 ± 9.5 yr diabetes duration 12.3 ± 9.9 yr, median HbA1c 7.1%[ICR 6.4-7.7] NGSPU) exercising ≥ 60 min/week enrolled in a RCT utilising ExT1D, with partial cross-over design. The primary end-point was Exercise-related hypoglycaemia (ErH) number corrected for exercise session number, with ErH defined as CGM episodes < 4.0 mM occurring within 24 h of exercise. Secondary RCT endpoints were total ErH duration, and ErH duration/episode. A pre-defined longitudinal analysis with each subject compared with their baseline was also undertaken, for the three ErH parameters, and using fear of hypoglycaemia questionnaires.

RESEARCH

In the RCT a 50% lower median ErH number (P = 0.6) (37% lower ErH number per exercise session (P = 0.06, NS primary endpoint) occurred in the Intervention vs Control group. A 49% lower ErH duration per episode (P = 0.2), and 80% less ErH duration (P = 0.3), were also observed in the Intervention vs Control group. In the longitudinal study, ErH number reduced by 43% (P = 0.088), ErH duration per episode by 52% (P = 0.157) and total duration of ErH fell by 71% (P = 0.015). Confidence to prevent glucose lowering by exercise also improved (P = 0.039). Post-hoc analysis showed those with the greatest ErH events at baseline benefited most. Fructosamine and HbA1c levels were unchanged from baseline.

CONCLUSIONS

ExT1D can reduce exercise-related hypoglycaemia and provide greater confidence to exercise.

Initial management of diabetic ketoacidosis and prognosis according to diabetes type: a French multicentre observational retrospective study

Background

Guidelines for the management of diabetic ketoacidosis (DKA) do not consider the type of underlying diabetes. We aimed to compare the occurrence of metabolic adverse events and the recovery time for DKA according to diabetes type.

Methods

Multicentre retrospective study conducted at five adult intermediate and intensive care units in Paris and its suburbs, France. All patients admitted for DKA between 2013 and 2014 were included. Patients were grouped and compared according to the underlying type of diabetes into three groups: type 1 diabetes, type 2 or secondary diabetes, and DKA as the first presentation of diabetes. Outcomes of interest were the rate of metabolic complications (hypoglycaemia or hypokalaemia) and the recovery time.

Results

Of 122 patients, 60 (49.2%) had type 1 diabetes, 28 (22.9%) had type 2 or secondary diabetes and 34 (27.9%) presented with DKA as the first presentation of diabetes (newly diagnosed diabetes). Despite having received lower insulin doses, hypoglycaemia was more frequent in patients with type 1 diabetes (76.9%) than in patients with type 2 or secondary diabetes (50.0%) and in patients with newly diagnosed diabetes (54.6%) (p = 0.026). In contrast, hypokalaemia was more frequent in the latter group (82.4%) than in patients with type 1 diabetes (57.6%) and type 2 or secondary diabetes (51.9%) (p = 0.022). The median recovery times were not significantly different between groups.

Conclusions

Rates of metabolic complications associated with DKA treatment differ significantly according to underlying type of diabetes. Decreasing insulin dose may limit those complications. DKA treatment recommendations should take into account the type of diabetes.

Electronic supplementary material

The online version of this article (10.1186/s13613-019-0567-y) contains supplementary material, which is available to authorized users.

Hypoglycaemia and type 1 diabetes are associated with an increased risk of fractures

People with diabetes have an increased risk of fractures, and in this study, the effect of hypoglycaemia and insulin on this risk was investigated. Type 1 diabetes and hypoglycaemia did increase the fracture risk, and prevention of hypoglycaemia is thus an important focus area in the prevention of fractures.

INTRODUCTION

Studies have shown that type 1 diabetes (T1D) and type 2 diabetes (T2D) are associated with increased risk of fractures. Especially, subjects with T1D have an increased risk of fractures. The purpose of this study was to investigate the association of T1D, hypoglycaemia and insulin on fracture risk.

METHODS

A cohort study with T1D subjects (n = 19,896) and T2D subjects (n = 312,188) matched with subjects from the general populated (n = 996,252) and a nested case-control study with T1D subjects with fracture (n = 895) as cases and T1D subjects without (n = 2685) as controls were conducted based on subjects from the Danish National Patient Registry (DNPR).

RESULTS

T1D (HR = 2.47, 95% CI 2.37 to 2.59), age (HR = 1.05, 95% CI 1.05 to 1.05), previous fracture (HR = 1.95, 95% CI 1.92 to 1.99) and being female (HR = 2.06, 95% CI 2.04 to 2.09) increased the risk of fractures. Also, T2D (HR = 1.14, 95% CI 1.11 to 1.18) increased the risk of proximal upper arm and shoulder fractures. T1D (HR = 2.41, 95% CI 2.20 to 2.65) increased the risk of hip and femoral region fractures. Hypoglycaemia (OR = 1.58, 95% CI 1.27 to 1.97) increased the risk of fractures, whereas insulin use did not change the risk.

CONCLUSIONS

Hypoglycaemic episodes are associated with increased fracture risk, and the frequency of hypoglycaemic episodes leading to hospital admission was above 16% for T1D subjects. Prevention of hypoglycaemia is thus an important focus area in the prevention of fractures.

Factors influencing safe glucose-lowering in older adults with type 2 diabetes: A PeRsOn-centred ApproaCh To IndiVidualisEd (PROACTIVE) Glycemic Goals for older people: A position statement of Primary Care Diabetes Europe

Diabetes in later life is associated with a range of factors increasing the complexity of glycaemic management. This position statement, developed from an extensive literature review of the subject area, represents a consensus opinion of primary care clinicians and diabetes specialists. It highlights many challenges facing older people living with type 2 diabetes and aims to support primary care clinicians in advocating a comprehensive, holistic approach. It emphasises the importance of the wishes of the individual and their carers when determining glycaemic goals, as well as the need to balance intended benefits of treatment against the risk of adverse treatment effects. Its ultimate aim is to promote consistent high-quality care for older people with diabetes.

Marked improvement in HbA1c following commencement of flash glucose monitoring in people with type 1 diabetes

AIMS/HYPOTHESIS

Minimal evidence supports the efficacy of flash monitoring in lowering HbA_1c. We sought to assess the impact of introducing flash monitoring in our centre.

METHODS

We undertook a prospective observational study to assess change in HbA_1c in 900 individuals with type 1 diabetes following flash monitoring (comparator group of 518 with no flash monitoring). Secondary outcomes included changes in hypoglycaemia, quality of life, flash monitoring data and hospital admissions.

RESULTS

Those with baseline HbA_1c ≥58 mmol/mol (7.5%) achieved a median -7 mmol/mol (interquartile range [IQR] -13 to -1) (0.6% [-1.2 to -0.1]%) change in HbA_1c (p < 0.001). The percentage achieving HbA_1c <58 mmol/mol rose from 34.2% to 50.9% (p < 0.001). Median follow-up was 245 days (IQR 182 to 330). Individuals not using flash monitoring experienced no change in HbA_1c across a similar timescale (p = 0.508). Higher HbA_1c (p < 0.001), younger age at diagnosis (p = 0.003) and lower social deprivation (p = 0.024) were independently associated with an HbA_1c fall of ≥5 mmol/mol (0.5%). More symptomatic (OR 1.9, p < 0.001) and asymptomatic (OR 1.4, p < 0.001) hypoglycaemia was reported after flash monitoring. Following flash monitoring, regimen-related and emotional components of the diabetes distress scale improved although the proportion with elevated anxiety (OR 1.2, p = 0.028) and depression (OR 2.0, p < 0.001) scores increased. Blood glucose test strip use fell from 3.8 to 0.6 per day (p < 0.001). Diabetic ketoacidosis admissions fell significantly following flash monitoring (p = 0.043).

CONCLUSIONS/INTERPRETATION

Flash monitoring is associated with significant improvements in HbA_1c and fewer diabetic ketoacidosis admissions. Higher rates of hypoglycaemia may relate to greater recognition of hitherto unrecognised events. Impact upon quality of life parameters was mixed but overall treatment satisfaction was overwhelmingly positive.

Prepregnancy care in women with type 1 diabetes improves HbA1c and glucose variability without worsening hypoglycaemia time and awareness: Glycaemic variability during prepregnancy care

AIMS

To evaluate the impact of a prepregnancy care (PPC) programme, beyond HbA_1c, on hypoglycaemia awareness and glycaemic variability (GV).

METHODS

Prospective pilot study. We selected women with Type 1 diabetes who initiated a PPC programme with normal hypoglycaemia awareness (n = 24). Hypoglycaemia awareness, hypoglycaemic events and GV derived from masked-continuous glucose monitoring were evaluated in the first visit and within 2 weeks after pregnancy confirmation.

RESULTS

The duration was 16.5 ± 13.0 months. HbA_1c significantly decreased (-0.8 ± 0.7; p < 0.001). The Clarke score increased (0[0-1] vs. 1[0-2] points, p = 0.164), 2 out of 24 were reclassified as having impaired awareness of hypoglycaemia and 2 presented severe hypoglycaemia. GV decreased: standard deviation (p = 0.008), coefficient of variation (p = 0.021), mean amplitude of glycaemic excursions (p = 0.007), average daily risk range (p < 0.001), J-index (p = 0.010), high blood glucose index (HBGI) (p = 0.004), continuous overall net glycaemic action (CONGA) (p = 0.018), mean of daily differences (p = 0.045) and glycaemic risk assessment diabetes equation (p = 0.012). Final HbA_1c was associated with baseline J-index, CONGA and HBGI (β = 0.535, β = 0.466, β = 0.534, respectively; p < 0.05).

CONCLUSIONS

A PPC programme improved HbA_1c as well as GV with no significant impact on hypoglycaemia awareness. Moreover, GV could help to identify women less likely to achieve glycaemic targets. Larger studies are needed to confirm these results.

Outcomes of Long Pouch Gastric Bypass (LPGB): 4-Year Experience in Primary and Revision Cases

BACKGROUND

One of the most important complications of the one anastomosis gastric bypass (OAGB) is enterobilio acid reflux (EBAR). We report the concept of the long pouch Roux-en-Y gastric bypass (LPRYGB) meaning a Roux-en-Y with a long pouch and a 100-cm alimentary limb to avoid EBAR, with a long biliopancreatic limb to increase metabolic effects.

METHODS

A total of 300 LPRYGB cases in a 4-year period, with a 90% follow-up rate, were analysed. Anthropometric, technical feasibility, morbidity, weight loss and comorbidity outcomes were analysed.

RESULTS

The percentage total weight loss (%TWL) was 30.5% at 4 years of follow-up (32.3% in primary and 28.3% in revisions). Six intra-operative (2%) and 28 postoperative complications (9.3%) were seen. Out of this 28 complications, 11 (3.6%) were late complications. Reoperations were performed in 15 patients (5.0%). Clinically relevant EBAR was present in 3 cases only (1%) 4 years after the operation.

CONCLUSIONS

The LPRYGB combines the main advantages of the OAGB (light restriction and moderate malabsorption) with the anti-reflux effect from the Roux-en-Y diversion.

Glucose controls glucagon secretion by directly modulating cAMP in alpha cells

AIMS/HYPOTHESIS

Glucagon is critical for normal glucose homeostasis and aberrant secretion of the hormone aggravates dysregulated glucose control in diabetes. However, the mechanisms by which glucose controls glucagon secretion from pancreatic alpha cells remain elusive. The aim of this study was to investigate the role of the intracellular messenger cAMP in alpha-cell-intrinsic glucose regulation of glucagon release.

METHODS

Subplasmalemmal cAMP and Ca²⁺ concentrations were recorded in isolated and islet-located alpha cells using fluorescent reporters and total internal reflection microscopy. Glucagon secretion from mouse islets was measured using ELISA.

RESULTS

Glucose induced Ca²⁺-independent alterations of the subplasmalemmal cAMP concentration in alpha cells that correlated with changes in glucagon release. Glucose-lowering-induced stimulation of glucagon secretion thus corresponded to an elevation in cAMP that was independent of paracrine signalling from insulin or somatostatin. Imposed cAMP elevations stimulated glucagon secretion and abolished inhibition by glucose elevation, while protein kinase A inhibition mimicked glucose suppression of glucagon release.

CONCLUSIONS/INTERPRETATION

Glucose concentrations in the hypoglycaemic range control glucagon secretion by directly modulating the cAMP concentration in alpha cells independently of paracrine influences. These findings define a novel mechanism for glucose regulation of glucagon release that underlies recovery from hypoglycaemia and may be disturbed in diabetes.

Resources to Guide Exercise Specialists Managing Adults with Diabetes

Exercise is an important element to optimize health and well-being, though navigating exercise safely can be challenging for exercise specialists working with people with diabetes. Measuring glucose levels before an exercise session assists in the determination of whether exercise is safe for a person with diabetes. A number of organizations have recently developed guidelines to provide exercise and diabetes recommendations based on glucose levels and other relevant factors. However, there are limited easy-to-use resources to assist exercise specialists to determine whether exercise should be started and continued by people with diabetes. The type of diabetes, pre-exercise glucose level, medications and their timing, recent food intake and general sense of wellness all warrant consideration when determining the approach to each exercise session. An expert group was convened to review the published literature and develop resources to guide exercise specialists in assessing the safety of an adult with diabetes starting exercise, and indications to cease exercise, based upon glucose levels and other factors. Contraindications to people with diabetes starting or continuing exercise are (1) glucose < 4.0 mmol/L; (2) glucose > 15.0 mmol/L with symptoms of weakness/tiredness, or with ketosis; (3) hypoglycaemic event within the previous 24 h that required assistance from another person to treat and (4) feeling unwell. To optimize diabetes and exercise safety, recommendations (stratified by pre-exercise glucose level) are provided regarding carbohydrate ingestion, glucose monitoring and medication adjustment.

Timing of insulin basal rate reduction to reduce hypoglycemia during late post-prandial exercise in adults with type 1 diabetes using insulin pump therapy: A randomized crossover trial

AIMS

To compare the efficacy of three timings to decrease basal insulin infusion rate to reduce exercise-induced hypoglycaemia in patients with type 1 diabetes (T1D) using pump therapy.

METHODS

A single-blinded, randomized, 3-way crossover study in 22 adults that had T1D > 1 year and using insulin pump > 3 months (age, 40 ± 15 years; HbA_1c, 56.3 ± 10.2 mmol/mol). Participants practiced three 45-min exercise sessions (ergocyle) at 60% VO_2peak 3 hours after lunch comparing an 80% reduction of basal insulin applied 40 minutes before (T-40), 20 minutes before (T-20) or at exercise onset (T0).

RESULTS

No significant difference was observed for percentage of time spent < 4.0 mmol/L (T-40: 16 ± 25%; T-20: 26 ± 27%; T0: 24 ± 29%) (main outcome) and time spent in target range 4.0-10.0 mmol/L (T-40: 63 ± 37%; T-20: 66 ± 25%; T0: 65 ± 31%). With T-40 strategy, although not significant, starting blood glucose (BG) was higher (T-40: 8.6 ± 3.6 mmol/L; T-20: 7.4 ± 2.5 mmol/L ; T0: 7.4 ± 2.7 mmol/L), fewer patients needed extra carbohydrates consumption prior to exercise for BG < 5.0 mmol/L (T-40: n = 3; T-20: n = 5; T0: n = 6) as well as during exercise for BG < 3.3 mmol/L [T-40: n = 6 (27%); T-20: n = 12 (55%); T0: n = 11 (50%)] while time to first hypoglycaemic episode was delayed (T-40: 28 ± 14 min; T-20: 24 ± 10 min; T0: 22 ± 11 min).

CONCLUSION

Decreasing basal insulin infusion rate by 80% up to 40 minutes before exercise onset is insufficient to reduce exercise-induced hypoglycaemia.

Exceptional diazoxide sensitivity in hyperinsulinaemic hypoglycaemia due to a novel HNF4A mutation

Diazoxide is the first-line treatment for patients with hyperinsulinaemic hypoglycaemia (HH). Approximately 50% of patients with HH are diazoxide resistant. However, marked diazoxide sensitivity resulting in severe hyperglycaemia is extremely uncommon and not reported previously in the context of HH due to HNF4A mutation. We report a novel observation of exceptional diazoxide sensitivity in a patient with HH due to HNF4A mutation. A female infant presented with severe persistent neonatal hypoglycaemia and was diagnosed with HH. Standard doses of diazoxide (5 mg/kg/day) resulted in marked hyperglycaemia (maximum blood glucose 21.6 mmol/L) necessitating discontinuation of diazoxide. Lower dose of diazoxide (1.5 mg/kg/day) successfully controlled HH in the proband, which was subsequently confirmed to be due to a novel HNF4A mutation. At 3 years of age, the patient maintains age appropriate fasting tolerance on low dose diazoxide (1.8 mg/kg/day) and has normal development. Diagnosis in proband's mother and maternal aunt, both of whom carried HNF4A mutation and had been diagnosed with presumed type 1 and type 2 diabetes mellitus, respectively, was revised to maturity-onset diabetes of young (MODY). Proband's 5-year-old maternal cousin, also carrier of HNF4A mutation, had transient neonatal hypoglycaemia. To conclude, patients with HH due to HNF4A mutation may require lower diazoxide than other group of patients with HH. Educating the families about the risk of marked hyperglycaemia with diazoxide is essential. The clinical phenotype of HNF4A mutation can be extremely variable. Learning points: Awareness of risk of severe hyperglycaemia with diazoxide is important and patients/families should be accordingly educated. Some patients with HH due to HNF4A mutations may require lower than standard doses of diazoxide. The clinical phenotype of HNF4A mutation can be extremely variable.

Risk of diabetic ketoacidosis during Ramadan fasting: A critical reappraisal

OBJECTIVES

To evaluate the validity of the perceived increased risk and the actual occurrence of DKA observed during fasting in Ramadan.

METHODS

This is a non-systematic narrative review of the literature on the occurrence of DKA during Ramadan. Online databases (PubMed, Google Scholar, Cochrane Database, Medline OVID and CINAHL EBSCO) were searched. Three research questions are addressed 1. What is the basis of the expert opinion on the risk for DKA? 2. What is the likelihood that DKA is precipitated by Ramadan fast? and 3. What is the frequency of observed DKA during Ramadan?

RESULTS

The expert opinion suggesting a risk of DKA during Ramadan fasting was proposed with no evidence in the early writing on Ramadan fasting and has been reiterated and propagated since then. However, from first principles, DKA is not readily precipitated by the usual stress-free metabolic environment induced by Ramadan fasting with the exception of cases involved in the usual risk factors for metabolic decompensation. Furthermore, recent studies could not document any increase in observed DKA during Ramadan fasting in retrospective, prospective and database studies.

CONCLUSIONS

The current state of knowledge and evidence suggests the risk of DKA is not increased during Ramadan fasting.

Reduction of serum albumin in non-critically ill patients during hospitalization is associated with incident hypoglycaemia

AIM

Our study looked at the association between changes in serum albumin (SA) levels during hospitalization and incidence of hypoglycaemia among non-critically ill patients.

METHODS

Included were patients discharged from internal medicine units with hospital stays ≤ 14 days. Patients were allocated to three groups: (1) admission SA > 3.5 g/dL with no decrease during hospitalization; (2) admission SA < 3.5 g/dL with no decrease during hospitalization; and (3) decrease in SA regardless of admission SA level. Incident hypoglycaemia (glucose ≤ 70 mg/dL) was predicted by applying regression analysis, using hypoglycaemia as a dependent variable. Mortality studies were performed using Cox regression.

RESULTS

Included were 7718 patients (mean age 71.8 ± 17.4 years, 49.9% males, 27.1% with diabetes). Of these patients, 12.7% had at least one documented hypoglycaemia episode during hospitalization. Patients with decreases in SA levels during hospitalization (group 3) had higher rates of incident hypoglycaemia compared with patients in groups 1 and 2 (21.0% vs. 6.0% and 16.3%, respectively; P < 0.001 for both). Results remained significant after controlling for admission SA. Strong negative correlations were observed between SA and serum osmolarity (r = -0.204, P < 0.0001) and, separately, between changes in SA with changes in serum osmolarity (r = -0.157, P < 0.001), indicating that SA changes were not due to haemodilution. Overall 1-year mortality was 16.7%, and Cox regression analysis showed an increased 1-year mortality in patients in group 3 (27.9%) compared with those in groups 1 and 2 (15.2% and 13.8%, respectively).

CONCLUSION

Changes in SA during hospitalization are associated with an increased risk of hypoglycaemia during hospitalization of non-critically ill patients.

Diabetic hypoglycaemia during Ramadan fasting: A trans-national observational real-world study

OBJECTIVES

To describe the risk of hypoglycaemia during Ramadan and determine its risk factors, and the impact of hypoglycaemia on patients' behaviour.

METHODS

A cross-sectional multi-country observational study, with data captured within 6 weeks after Ramadan 2015. Patients' and disease characteristics and its management, the risk of hypoglycaemia and patients' response to hypoglycaemia were recorded.

RESULTS

A cohort of 1759 patients; majority with type 2 diabetes mellitus from North Africa, Arabian Gulf, Saudi Arabia, and the Indian subcontinent. Hypoglycaemia was reported by 290 patients (16.8%); particularly affecting type 1 diabetes patients and in insulin-treated patients in general. Age was significantly younger in the hypoglycaemia group (P < 0.001). The commonest responses were reducing the dose or frequency of medications (42%), attending primary care providers (24.5%) or increasing monitoring (20.7%). Fasting was interrupted by 67% only of those who experienced hypoglycaemia and recourse to emergency services was pursued by less than a quarter of patients with hypoglycaemia. The country-wise analysis of the rates of hypoglycaemia was greatest in Egypt (51.3%) and lowest in Pakistan (3.5%).

CONCLUSIONS

Hypoglycaemia is a significant complication of fasting during Ramadan. It may be predicted by type of diabetes, and use of insulin. Patients' responses are varied and call for more formal pre-Ramadan education.

A novel PHKA2 mutation in a Chinese child with glycogen storage disease type IXa: a case report and literature review

Background

PHKA2 gene mutations can cause liver phosphorylase kinase (PhK) deficiency, resulting in glycogen storage disease type IXa (GSD IXa). Elevated liver transaminase levels and liver enlargement are the most frequent phenotypes of GSD IXa. However, whether the phenotypes are applicable to Chinese patients remains unclear.

Case report

A boy aged 2 years and 8 months with a history of episodic fatigue and weakness since he was 2 years old was referred to our endocrinology clinic. Apart from symptomatic ketotic hypoglycemic episodes (palpitation, hand shaking, sweating, etc.), no abnormalities of liver transaminase levels or liver size were found. To identify the aetiology of his clinically diagnosed hypoglycaemia, the proband and his parents were screened for PHKA2 gene mutations by next-generation sequencing. A heterozygous mutation (c.2972C > G, p.G991A) in PHKA2 was found in the proband and his mother. Twenty-one Chinese cases with GSD IXa have been reported in the literature to date, and elevated liver transaminase levels (95%) and liver enlargement (91%) are the most frequent phenotypes of GSD IXa in Chinese patients. Hypoglycaemia may be one of the early onset symptoms in infants with GSD IXa.

Conclusions

This study enriches our knowledge of the PHKA2 gene mutation spectrum and provides further information about the phenotypic characteristics of Chinese GSD IXa patients.

Impaired EIF2S3 function associated with a novel phenotype of X-linked hypopituitarism with glucose dysregulation

Background

The heterotrimeric GTP-binding protein eIF2 forms a ternary complex with initiator methionyl-tRNA and recruits it to the 40S ribosomal subunit for start codon selection and thereby initiates protein synthesis. Mutations in EIF2S3, encoding the eIF2γ subunit, are associated with severe intellectual disability and microcephaly, usually as part of MEHMO syndrome.

Methods

Exome sequencing of the X chromosome was performed on three related males with normal head circumferences and mild learning difficulties, hypopituitarism (GH and TSH deficiencies), and an unusual form of glucose dysregulation. In situ hybridisation on human embryonic tissue, EIF2S3-knockdown studies in a human pancreatic cell line, and yeast assays on the mutated corresponding eIF2γ protein, were performed in this study.

Findings

We report a novel hemizygous EIF2S3 variant, p.Pro432Ser, in the three boys (heterozygous in their mothers). EIF2S3 expression was detectable in the developing pituitary gland and pancreatic islets of Langerhans. Cells lacking EIF2S3 had increased caspase activity/cell death. Impaired protein synthesis and relaxed start codon selection stringency was observed in mutated yeast.

Interpretation

Our data suggest that the p.Pro432Ser mutation impairs eIF2γ function leading to a relatively mild novel phenotype compared with previous EIF2S3 mutations. Our studies support a critical role for EIF2S3 in human hypothalamo-pituitary development and function, and glucose regulation, expanding the range of phenotypes associated with EIF2S3 mutations beyond classical MEHMO syndrome. Untreated hypoglycaemia in previous cases may have contributed to their more severe neurological impairment and seizures in association with impaired EIF2S3.

Fund

GOSH, MRF, BRC, MRC/Wellcome Trust and NIGMS funded this study.