1
|
Urakami T, Terada H, Tanabe S, Mine Y, Aoki M, Aoki R, Suzuki J, Morioka I. Clinical significance of coefficient of variation in continuous glucose monitoring for glycemic management in children and adolescents with type 1 diabetes. J Diabetes Investig 2024. [PMID: 39230367 DOI: 10.1111/jdi.14303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 08/03/2024] [Accepted: 08/20/2024] [Indexed: 09/05/2024] Open
Abstract
AIMS/INTRODUCTION Coefficient of variation (CV) is an indicator for glucose variability in continuous glucose monitoring (CGM), and the target threshold of %CV in type 1 diabetes is proposed to be ≤36%. This study aimed to evaluate the clinical significance of CV in children and adolescents with type 1 diabetes. MATERIALS AND METHODS Participants included 66 children with type 1 diabetes. A total of 48 participants were treated with multiple daily injections of insulin, and 18 with continues subcutaneous insulin infusion, using intermittently scanned CGM. The frequencies of the CGM metrics and glycosylated hemoglobin values were examined, and the significance of a threshold %CV of 36% was evaluated. RESULTS The mean frequencies in time in range (TIR), time below range, %CV and the mean glycosylated hemoglobin value were 59.3 ± 16.1, 4.0 ± 3.5, 39.3 ± 6.2 and 7.3 ± 0.8%, respectively. The frequencies of participants who achieved a TIR >70% and a %CV of ≤36% were 24.1 and 27.3%, respectively. A total of 18 participants with a %CV of ≤36% had significantly higher TIR, lower time below range and lower glycosylated hemoglobin than the 48 with a %CV of >36% (72.6 ± 12.6 vs 52.4 ± 13.6, 2.4 ± 1.9 vs 4.6 ± 3.6, 6.9 ± 0.8 vs 7.4 ± 0.7%, respectively). CONCLUSIONS Children and adolescents with type 1 diabetes using intermittently scanned CGM had difficulties in achieving the recommended targets of TIR and CV. However, the target %CV of ≤36% seems to be an appropriate indicator for assessing glycemic control and risk of hypoglycemia in pediatric patients with type 1 diabetes with any treatment.
Collapse
Affiliation(s)
- Tatsuhiko Urakami
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
- Urakami Pediatric Endocrinology and Diabetes Clinic, Tokyo, Japan
| | - Hiroki Terada
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Satomi Tanabe
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Yusuke Mine
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Masako Aoki
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Ryoji Aoki
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Junichi Suzuki
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Ichiro Morioka
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| |
Collapse
|
2
|
Zhou Y, Sardana D, Kuroko S, Haszard JJ, de Block MI, Weng J, Jefferies C, Wheeler BJ. Comparing the glycaemic outcomes between real-time continuous glucose monitoring (rt-CGM) and intermittently scanned continuous glucose monitoring (isCGM) among adults and children with type 1 diabetes: A systematic review and meta-analysis of randomized controlled trials. Diabet Med 2024; 41:e15280. [PMID: 38197238 DOI: 10.1111/dme.15280] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 12/12/2023] [Accepted: 12/22/2023] [Indexed: 01/11/2024]
Abstract
AIM To conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing the effectiveness of real-time continuous glucose monitoring (rtCGM) versus intermittently scanned continuous glucose monitoring (isCGM) on key glycaemic metrics (co-primary outcomes HbA1c and time-in-range [TIR] 70-180 mg/dL, 3.9-10.0 mmol/L) among people with type 1 diabetes (T1D). METHODS Medline, PubMed, Scopus, Web of Science and Cochrane Central Register of clinical trials were searched. Inclusion criteria were RCTs; T1D populations of any age and insulin regimen; comparing any type of rtCGM with isCGM (only the first generation had been compared to date); and reporting the glycaemic outcomes. Glycaemic outcomes were extracted post-intervention and expressed as mean differences and 95% CIs between the two comparators. Results were pooled using a random-effect meta-analysis. The risk of bias was assessed using the Cochrane RoB2 tool. The quality of evidence was assessed by the GRADE approach. RESULTS Five RCTs met the inclusion criteria (4 parallel and 1 crossover design; 4 with CGM use <8 weeks), involving 446 participants (354 adults; 92 children and adolescents). Overall, meta-analysis showed rtCGM compared to isCGM improved absolute TIR by +7.0% (95% CI: 5.8%-8.3%, I2 = 0%, p < 0.01) accompanied by a favorable effect on time-below-range <70 mg/dL (3.9 mmol/L) - 1.7% (95%CI: -3.0% to -0.4%; p = 0.03). No differences were seen regarding HbA1c. CONCLUSIONS This meta-analysis highlights that for people with T1D, rtCGM confers benefits over isCGM primarily related to increased TIR, with improvements in hypo- and hyperglycaemia.
Collapse
Affiliation(s)
- Yongwen Zhou
- Department of Women's and Children's Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
- Department of Endocrinology, Institute of Endocrine and Metabolic Diseases, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, Clinical Research Hospital of Chinese Academy of Sciences (Hefei), University of Science and Technology of China, Hefei, Anhui, China
| | - Divesh Sardana
- Division of Pediatric Dentistry, Department of Developmental Sciences, Oklahoma University Health Sciences Center, Oklahoma, USA
| | - Sarahmarie Kuroko
- Department of Women's and Children's Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | | | - Martin I de Block
- Department of Paediatrics, University of Otago, Christchurch, New Zealand
- Department of Paediatrics, Te Whatu Ora -Waitaha, New Zealand
| | - Jianping Weng
- Department of Endocrinology, Institute of Endocrine and Metabolic Diseases, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, Clinical Research Hospital of Chinese Academy of Sciences (Hefei), University of Science and Technology of China, Hefei, Anhui, China
| | - Craig Jefferies
- Starship Child Health, Te Whatu Ora - Health New Zealand, Te Toka Tumai Auckland
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Benjamin John Wheeler
- Department of Women's and Children's Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
- Paediatric Endocrinology, Te Whatu Ora/Health New Zealand - Southern, Dunedin, New Zealand
| |
Collapse
|
3
|
Jabari M. Efficacy and safety of closed-loop control system for type one diabetes in adolescents a meta analysis. Sci Rep 2023; 13:13165. [PMID: 37574494 PMCID: PMC10423718 DOI: 10.1038/s41598-023-40423-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 08/10/2023] [Indexed: 08/15/2023] Open
Abstract
This meta-analysis compares the efficacy and safety of Closed-Loop Control (CLC) to Sensor-Augmented Insulin Pump (SAP) for adolescent patients with Type 1 Diabetes Mellitus (T1DM). Eleven randomized-controlled trials were included with a total of 570 patients, from a total of 869 articles found adhering to PRISMA guidelines. The efficacy of the therapies were evaluated from the day, night and during physical activities monitoring of the of the mean blood glucose (BG), Time In Range (TIR), and Standard Deviation (SD) of the glucose variability. The safety measure of the therapies, was assessed from the day and night recording of the hypoglycemic and hyperglycemic events occurred. Pooled results of comparison of mean BG values for day, night and physical activities, - 4.33 [- 6.70, - 1.96] (P = 0.0003), - 16.61 [- 31.68, - 1.54] (P = 0.03) and - 8.27 [- 19.52, 2.99] (P = 0.15). The monitoring for day, night and physical activities for TIR - 13.18 [- 19.18, - 7.17] (P < 0.0001), - 15.36 [- 26.81, - 3.92] (P = 0.009) and - 7.39 [- 17.65, 2.87] (P = 0.16). The day and night results of SD of glucose variability was - 0.40 [- 0.79, - 0.00] (P = 0.05) and - 0.86 [- 2.67, 0.95] (P = 0.35). These values shows the superiority of CLC system in terms of efficacy. The safety evaluation, of the day, night and physical activities observations of average blood glucose goal hypoglycemic events - 0.54 [- 1.86, 0.79] (P = 0.43), 0.04 [- 0.20, 0.27] (P = 0.77) and 0.00 [- 0.25, 0.25] (P = 1.00) and hyperglycemic events - 0.04 [- 0.20, 0.27] (P = 0.77), - 7.11 [- 12.77, - 1.45] (P = 0.01) and - 0.00 [- 0.10, 0.10] (P = 0.97), highlights the commendable safety factor of CLC. The CLC systems can be considered as an ideal preference in the management of adolescents with type 1 diabetes to be used during a 24 h basis.
Collapse
Affiliation(s)
- Mosleh Jabari
- Department of Pediatrics, Imam Mohammed Ibn Saud Islamic University, An Nada, 13317, Riyadh, Saudi Arabia.
| |
Collapse
|
4
|
Wilkie G, Melnik V, Brainard L, Antonioli S, Baltich Nelson B, Leung K, Leftwich H. Continuous glucose monitor use in type 2 diabetes mellitus in pregnancy and perinatal outcomes: a systematic review and meta-analysis. Am J Obstet Gynecol MFM 2023; 5:100969. [PMID: 37061044 DOI: 10.1016/j.ajogmf.2023.100969] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/03/2023] [Accepted: 04/09/2023] [Indexed: 04/17/2023]
Abstract
OBJECTIVE This study aimed to assess whether continuous glucose monitor use in type 2 diabetes mellitus in pregnancy is associated with improved perinatal outcomes. DATA SOURCES We searched Ovid MEDLINE, Scopus, ClinicalTrials.gov, and Cochrane library from inception through May 9, 2022. STUDY ELIGIBILITY CRITERIA We included all studies that compared continuous glucose monitor use with fingerstick glucose monitoring in women with type 2 diabetes mellitus. METHODS The initial search yielded 2463 unique citations that were screened in Covidence by 2 independent reviewers. Study types included randomized controlled trials, cohort studies, and cross-sectional studies. Our outcomes of interest were macrosomia or large-for-gestational-age infants, hemoglobin A1c, cesarean delivery, hypertensive disorders of pregnancy including preeclampsia, gestational age at delivery, and neonatal hypoglycemia. RESULTS Three randomized controlled trials met the inclusion criteria. We performed random-effects meta-analyses of estimates from 2 studies without risk of significant bias and reported summary adjusted odds ratios and 95% confidence intervals. Meta-analysis of 56 women with continuous glucose monitor use and 53 control women without continuous glucose monitor use showed that there was no difference in the incidence of large-for-gestational-age infants between continuous glucose monitor users and standard-of-care controls (odds ratio, 0.78; 95% confidence interval, 0.34-1.78) with an I2 of 0%. In addition, there was no difference in the development of preeclampsia between continuous glucose monitor users and standard-of-care controls (odds ratio, 1.63; 95% confidence interval, 0.34-7.22) with an I2 of 0%. CONCLUSION Continuous glucose monitor use was not associated with improved perinatal outcomes as assessed by large-for-gestational-age infants and preeclampsia. This review is limited by the small amount of data available for this population, and further research is needed.
Collapse
Affiliation(s)
- Gianna Wilkie
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Massachusetts Chan Medical School, Worcester, MA (Dr Wilkie, Ms Leung, and Dr Leftwich).
| | - Veronika Melnik
- University of Massachusetts Chan Medical School, Worcester, MA (Ms. Melnik, Ms. Brainard, Ms. Antonioli, and Ms. Nelson)
| | - Lydia Brainard
- University of Massachusetts Chan Medical School, Worcester, MA (Ms. Melnik, Ms. Brainard, Ms. Antonioli, and Ms. Nelson)
| | - Sophia Antonioli
- University of Massachusetts Chan Medical School, Worcester, MA (Ms. Melnik, Ms. Brainard, Ms. Antonioli, and Ms. Nelson)
| | - Becky Baltich Nelson
- University of Massachusetts Chan Medical School, Worcester, MA (Ms. Melnik, Ms. Brainard, Ms. Antonioli, and Ms. Nelson)
| | - Katherine Leung
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Massachusetts Chan Medical School, Worcester, MA (Dr Wilkie, Ms Leung, and Dr Leftwich)
| | - Heidi Leftwich
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Massachusetts Chan Medical School, Worcester, MA (Dr Wilkie, Ms Leung, and Dr Leftwich)
| |
Collapse
|
5
|
March CA, Nanni M, Lutz J, Kavanaugh M, Jeong K, Siminerio LM, Rothenberger S, Miller E, Libman IM. Comparisons of school-day glycemia in different settings for children with type 1 diabetes using continuous glucose monitoring. Pediatr Diabetes 2023; 2023:8176606. [PMID: 37929231 PMCID: PMC10623999 DOI: 10.1155/2023/8176606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Abstract
Objective Using continuous glucose monitoring (CGM), we examined patterns in glycemia during school hours for children with type 1 diabetes, exploring differences between school and non-school time. Methods We conducted a retrospective analysis of CGM metrics in children 7-12 years (n=217, diabetes duration 3.5±2.5 years, hemoglobin A1c 7.5±0.8%). Metrics were obtained for weekday school hours (8 AM to 3 PM) during four weeks in fall 2019. Two comparison settings included weekend (fall 2019) and weekday (spring 2020) data when children had transitioned to virtual school due to COVID-19. We used multilevel mixed models to examine factors associated with time in range (TIR) and compare glycemia between in-school, weekends, and virtual school. Results Though CGM metrics were clinically similar across settings, TIR was statistically higher, and time above range (TAR), mean glucose, and standard deviation (SD) lower, for weekends and virtual school (p<0.001). Hour and setting exhibited a significant interaction for several metrics (p<0.001). TIR in-school improved from a mean of 40.9% at the start of the school day to 58.0% later in school, with a corresponding decrease in TAR. TIR decreased on weekends (60.8 to 50.7%) and virtual school (62.2 to 47.8%) during the same interval. Mean glucose exhibited a similar pattern, though there was little change in SD. Younger age (p=0.006), lower hemoglobin A1c (p<0.001), and insulin pump use (p=0.02) were associated with higher TIR in-school. Conclusion Although TIR was higher for weekends and virtual school, glycemic metrics improve while in-school, possibly related to beneficial school day routines.
Collapse
Affiliation(s)
| | - Michelle Nanni
- School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - James Lutz
- School of Arts and Sciences, University of Pittsburgh, Pittsburgh, PA
| | - Madison Kavanaugh
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Kwonho Jeong
- Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, PA
| | | | - Scott Rothenberger
- Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, PA
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Elizabeth Miller
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA
| | - Ingrid M Libman
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA
| |
Collapse
|
6
|
The Advanced Diabetes Technologies for Reduction of the Frequency of Hypoglycemia and Minimizing the Occurrence of Severe Hypoglycemia in Children and Adolescents with Type 1 Diabetes. J Clin Med 2023; 12:jcm12030781. [PMID: 36769430 PMCID: PMC9917934 DOI: 10.3390/jcm12030781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 01/09/2023] [Accepted: 01/17/2023] [Indexed: 01/20/2023] Open
Abstract
Hypoglycemia is an often-observed acute complication in the management of children and adolescents with type 1 diabetes. It causes inappropriate glycemic outcomes and may impair the quality of life in the patients. Severe hypoglycemia with cognitive impairment, such as a convulsion and coma, is a lethal condition and is associated with later-onset cognitive impairment and brain-structural abnormalities, especially in young children. Therefore, reducing the frequency of hypoglycemia and minimizing the occurrence of severe hypoglycemia are critical issues in the management of children and adolescents with type 1 diabetes. Advanced diabetes technologies, including continuous glucose monitoring and sensor-augmented insulin pumps with low-glucose suspension systems, can reduce the frequency of hypoglycemia and the occurrence of severe hypoglycemia without aggravating glycemic control. The hybrid closed-loop system, an automated insulin delivery system, must be the most promising means to achieve appropriate glycemic control with preventing severe hypoglycemia. The use of these advanced diabetes technologies could improve glycemic outcomes and the quality of life in children and adolescents with type 1 diabetes.
Collapse
|
7
|
Time in Range in Children with Type 1 Diabetes before and during a Diabetes Camp-A Ceiling Effect? CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9121951. [PMID: 36553394 PMCID: PMC9777517 DOI: 10.3390/children9121951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 12/03/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022]
Abstract
Background: The aim of this study was to assess and compare the time in range (TIR) of children with type 1 diabetes (T1D) before and during a diabetes summer camp using different therapy modalities. Methods: A retrospective analysis of continuous glucose monitoring (CGM) data collected from 26 children with T1D (mean age: 11.0 ± 1.4 years; 62% female; 62% on insulin pump; Hb1Ac 7.3 ± 0.8% (56.3 ± 8.7 mmol/mol) before and during a 14-day summer camp. CGM methods: 50% intermittently scanned CGM (isCGM) and 50% real-time CGM (rtCGM). No child was using a hybrid closed loop system. Results: Mean TIR during camp was significantly higher than before camp ((67.0 ± 10.7%) vs. 58.2% ± 17.4%, p = 0.004). There was a significant reduction in time above range (TAR) (p = 0.001) and increase in time below range (TBR) (p < 0.001), Children using isCGM showed a more pronounced improvement in TIR during camp compared to rtCGM-users (p = 0.025). The increase in TIR strongly correlated with numbers of scans per day in isCGM-users (r = 0.751, p = 0.003). Compared to isCGM-users, rtCGM-users showed significantly less TBR. The TIR target was met by 30.8% of participants during camp. Conclusion: Glycemic control improved significantly during the camp. However, on average, the therapy goal (TIR > 70%) could not be achieved despite great professional effort.
Collapse
|
8
|
Urakami T. Significance of the CGM metric of time in range in children and adolescents with type 1 diabetes. Endocr J 2022; 69:1035-1042. [PMID: 36002301 DOI: 10.1507/endocrj.ej22-0257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Continuous glucose monitoring (CGM) has been widely used in children and adolescents as well as adults with type 1 diabetes. CGM metrics include three key measurements of target glucose: time in range (TIR: 70-180 mg/dL), time below range (TBR: <70 mg/dL), and time above range (TAR: >180 mg/dL). The primary goal of optimal glycemic control is to increase TIR to more than 70%, while simultaneously reducing TBR to less than 4%, while minimizing severe hypoglycemia to less than 1%, as proposed by the Advanced Technologies and Treatments for Diabetes (ATTD) panel. However, several studies have indicated that the TIR goal is quite difficult to achieve in pediatric patients who have remarkable interindividual and day-to-day glycemic variation due to their irregular lifestyles. Previous studies have demonstrated that patients without an automated insulin delivery system are unlikely to attain the recommended glycemic goals. On the other hand, reduction of hypoglycemia, particularly minimizing severe hypoglycemia, is a critical issue in the effective management of children with type 1 diabetes. Frequent episodes of severe hypoglycemia and hypoglycemia can cause lasting neurological damage. Accordingly, we propose reducing the TBR to less than 5%, rather than just targeting the TIR to more than 70%. In CGM metrics this should be the cardinal glycemic goal for pediatric patients who are either being treated with multiple daily injections of insulin or a conventional insulin pump, but who are not using an automated insulin delivery system.
Collapse
Affiliation(s)
- Tatsuhiko Urakami
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo 173-8610, Japan
| |
Collapse
|
9
|
Sakurai T, Kubota S, Kato T, Yabe D. Advances in insulin therapy from discovery to β-cell replacement. J Diabetes Investig 2022; 14:15-18. [PMID: 36074333 PMCID: PMC9807147 DOI: 10.1111/jdi.13902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 08/18/2022] [Accepted: 08/21/2022] [Indexed: 01/07/2023] Open
Abstract
Insulin therapy using insulin purified from porcine or bovine pancreas revolutionized diabetes therapy in the 1920s. A series of advances including cloning human insulin cDNA enabled the development of recombinant human insulin with improved features. Insulin treatment for diabetes may well be upended by β-cell replacement therapy in the coming decades.
Collapse
Affiliation(s)
- Teruaki Sakurai
- Department of Diabetes, Endocrinology and MetabolismGifu University Graduate School of MedicineGifuJapan,Department of Rheumatology and Clinical ImmunologyGifu University Graduate School of MedicineGifuJapan
| | - Sodai Kubota
- Department of Diabetes, Endocrinology and MetabolismGifu University Graduate School of MedicineGifuJapan,Department of Rheumatology and Clinical ImmunologyGifu University Graduate School of MedicineGifuJapan,Yutaka Seino Distinguished Center for Diabetes ResearchKansai Electric Power Medical Research InstituteKyotoJapan
| | - Takehiro Kato
- Department of Diabetes, Endocrinology and MetabolismGifu University Graduate School of MedicineGifuJapan,Department of Rheumatology and Clinical ImmunologyGifu University Graduate School of MedicineGifuJapan
| | - Daisuke Yabe
- Department of Diabetes, Endocrinology and MetabolismGifu University Graduate School of MedicineGifuJapan,Department of Rheumatology and Clinical ImmunologyGifu University Graduate School of MedicineGifuJapan,Yutaka Seino Distinguished Center for Diabetes ResearchKansai Electric Power Medical Research InstituteKyotoJapan,Center for Healthcare Information TechnologyTokai National Higher Education and Research SystemNagoyaJapan,Preemptive Food Research CenterGifu University Institute of Advanced StudyGifuJapan
| |
Collapse
|