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Bandari E, Beuzen T, Habashy L, Raza J, Yang X, Kapeluto J, Meneilly G, Madden K. Machine Learning Decision Support for Bedside Ultrasound to Detect Lipohypertrophy. JMIR Form Res 2022; 6:e34830. [PMID: 35404833 PMCID: PMC9123536 DOI: 10.2196/34830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 03/14/2022] [Accepted: 04/09/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The most common dermatological complication of insulin therapy is lipohypertrophy. OBJECTIVE As a proof-of-concept, we built and tested an automated model using a convolutional neural network (CNN) to detect the presence of lipohypertrophy in ultrasound images. METHODS Ultrasound images were obtained in a blinded fashion using a portable GE LOGIQe machine with an L8-18i-D probe (5-18 MHz; GE Healthcare, Frankfurt, Germany). The data was split into train, validation and test splits of 70%, 15%, and 15% respectively. Given the small size of the dataset, image augmentation techniques were used to expand the size of the training set and improve the model's generalizability. To compare the performance of the different architectures, the team considered the accuracy and recall of the models when tested on our test set. RESULTS The DenseNet CNN architecture was found to have the highest accuracy (76%) and recall (76%) in detecting lipohypertrophy in ultrasound images, when compared to other CNN architectures. Additional work showed that the YOLOv5m object detection model could be used to help identify the approximate location of lipohypertrophy in ultrasound images identified as containing lipohypertrophy by the DenseNet CNN. CONCLUSIONS We were able to demonstrate the ability of machine learning approaches to automate the process of detecting and locating lipohypertrophy. CLINICALTRIAL
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Affiliation(s)
- Ela Bandari
- Master's in Data Science Program, University of British Columbia, Vancouver, CA
| | - Tomas Beuzen
- Master's in Data Science Program, University of British Columbia, Vancouver, CA
| | - Lara Habashy
- Master's in Data Science Program, University of British Columbia, Vancouver, CA
| | - Javairia Raza
- Master's in Data Science Program, University of British Columbia, Vancouver, CA
| | - Xudong Yang
- Master's in Data Science Program, University of British Columbia, Vancouver, CA
| | - Jordanna Kapeluto
- Gerontology and Diabetes Research Laboratory, University of British Columbia, 828 West 10th Avenue, Vancouver, CA.,Division of Endocrinology, Department of Medicine, University of British Columbia, Vancouver, CA
| | - Graydon Meneilly
- Gerontology and Diabetes Research Laboratory, University of British Columbia, 828 West 10th Avenue, Vancouver, CA.,Division of Geriatric Medicine, Department of Medicine, University of British Columbia, Gordon and Leslie Diamond Health Care Centre2775 Laurel Street, Vancouver, CA
| | - Kenneth Madden
- Gerontology and Diabetes Research Laboratory, University of British Columbia, 828 West 10th Avenue, Vancouver, CA.,Division of Geriatric Medicine, Department of Medicine, University of British Columbia, Gordon and Leslie Diamond Health Care Centre2775 Laurel Street, Vancouver, CA.,Centre for Hip Health and Mobility, Vancouver, CA
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Xatzipsalti M, Alvertis H, Kourousi G, Patouni K, Konstantakopoulos S, Delis D, Vazeou A. Lipoatrophy, a rare complication of diabetes: a single-center experience. Hormones (Athens) 2022; 21:61-69. [PMID: 34671939 DOI: 10.1007/s42000-021-00324-z] [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] [Received: 01/25/2021] [Accepted: 09/09/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Lipoatrophy (LA), a rare skin complication in patients with type 1 diabetes (T1D), has decreased dramatically over the past decades due to the use of human purified insulin preparations. METHODS We collected data from the records of T1D patients with LA. Types of insulin and insulin regimen, presence of eosinophilia, anti-insulin (IAA), anti-GAD, anti-IA2 autoantibodies, other autoimmune disorders, site of atrophy and its relationship to catheter, HbA1c at LA onset and after resolution, and different treatment modalities (i.e., change of insulin type or site, sodium cromoglycate (SCG) cream, cortisone cream or percutaneous injections, and laser treatment) were recorded. RESULTS Thirteen out of 1200 T1D subjects (1%) presented with LA. The majority were on insulin pump using rapid-acting analogs. Twelve out of 13 patients had changed the type of insulin, and most of them had switched injection sites. Ten out of 13 patients used SCG cream and 7/10 showed complete/partial improvement. One patient used dexamethasone injection with improvement. Five patients showed self-improvement. In 3/7 patients who were receiving SCG, treatment was combined with change of insulin type (glulisine); however, in 1/3, the result should be attributed to concomitant laser treatment. In 4/7 patients, there was a clear, beneficial effect of SCG. In 1/4 with partial resolution of LA, laser treatment was used after SCG, which further improved the result. CONCLUSIONS LA is a rare skin complication seen even today with the use of insulin analogs. SCG alone or combined with change of insulin type seems to be the most effective treatment. Laser treatment is a promising new therapy.
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Affiliation(s)
- Maria Xatzipsalti
- Diabetes Center, A' Department of Pediatrics, P&A Kyriakou Children's Hospital, Athens, Greece.
| | | | - Giannoula Kourousi
- Diabetes Center, A' Department of Pediatrics, P&A Kyriakou Children's Hospital, Athens, Greece
| | - Konstantina Patouni
- Diabetes Center, A' Department of Pediatrics, P&A Kyriakou Children's Hospital, Athens, Greece
| | | | - Dimitris Delis
- Diabetes Center, A' Department of Pediatrics, P&A Kyriakou Children's Hospital, Athens, Greece
| | - Andriani Vazeou
- Diabetes Center, A' Department of Pediatrics, P&A Kyriakou Children's Hospital, Athens, Greece
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Hanif N, Wu H, Xu P, Li Y, Bibi A, Zulfiqar A, Iqbal MZ, Tahir M, Zhang X, Ali A. Proteomic Changes to the Updated Discovery of Engineered Insulin and Its Analogs: Pros and Cons. Curr Issues Mol Biol 2022; 44:867-888. [PMID: 35723344 PMCID: PMC8929101 DOI: 10.3390/cimb44020059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 02/04/2022] [Accepted: 02/07/2022] [Indexed: 11/17/2022] Open
Abstract
The destruction of β-cells of the pancreas leads to either insulin shortage or the complete absence of insulin, which in turn causes diabetes Mellitus. For treating diabetes, many trials have been conducted since the 19th century until now. In ancient times, insulin from an animal's extract was taken to treat human beings. However, this resulted in some serious allergic reactions. Therefore, scientists and researchers have tried their best to find alternative ways for managing diabetes with progressive advancements in biotechnology. However, a lot of research trials have been conducted, and they discovered more progressed strategies and approaches to treat type I and II diabetes with satisfaction. Still, investigators are finding more appropriate ways to treat diabetes accurately. They formulated insulin analogs that mimic the naturally produced human insulin through recombinant DNA technology and devised many methods for appropriate delivery of insulin. This review will address the following questions: What is insulin preparation? How were these devised and what are the impacts (both positive and negative) of such insulin analogs against TIDM (type-I diabetes mellitus) and TIIDM (type-II diabetes mellitus)? This review article will also demonstrate approaches for the delivery of insulin analogs into the human body and some future directions for further improvement of insulin treatment.
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Affiliation(s)
- Naeema Hanif
- State Key Laboratory of Crop Gene Exploration and Utilization in Southwest China, Rice Research Institute, Sichuan Agricultural University, Chengdu 611130, China; (N.H.); (P.X.)
- Department of Biomedical Sciences, National University of Science and Technology, Islamabad 44000, Pakistan
| | - Hezhou Wu
- Hunan Taohuayuan Agricultural Technologies Co., Ltd., Yueyang 415000, China;
| | - Peizhou Xu
- State Key Laboratory of Crop Gene Exploration and Utilization in Southwest China, Rice Research Institute, Sichuan Agricultural University, Chengdu 611130, China; (N.H.); (P.X.)
| | - Yun Li
- Chengdu Academy of Agricultural and Forestry Sciences, Chengdu 611130, China;
| | - Amir Bibi
- Department of Plant Breeding and Genetics, University of Agriculture, Faisalabad 38000, Pakistan;
| | - Asma Zulfiqar
- Department of Botany, Quaid-e-Azam Campus, University of Punjab, Lahore 05422, Pakistan;
| | - Muhammad Zafar Iqbal
- College of Grassland Science and Technology, Sichuan Agricultural University, Chengdu 611130, China; (M.Z.I.); (M.T.)
| | - Muhammad Tahir
- College of Grassland Science and Technology, Sichuan Agricultural University, Chengdu 611130, China; (M.Z.I.); (M.T.)
| | - Xiangyang Zhang
- Branch of China National Hybrid Rice Research and Development Centre, Sichuan Tiland Huizhi Biology Science and Technology Co., Ltd., Chengdu 611130, China
| | - Asif Ali
- State Key Laboratory of Crop Gene Exploration and Utilization in Southwest China, Rice Research Institute, Sichuan Agricultural University, Chengdu 611130, China; (N.H.); (P.X.)
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Passanisi S, Salzano G, Lombardo F. Skin Involvement in Paediatric Patients with Type 1 Diabetes. Curr Diabetes Rev 2022; 18:e030921196145. [PMID: 34477525 DOI: 10.2174/1573399817666210903153837] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 07/05/2021] [Accepted: 07/08/2021] [Indexed: 11/22/2022]
Abstract
Skin involvement is an overlooked aspect in the management of paediatric patients with type 1 diabetes. A comprehensive search of published literature using the PubMed database was carried out using the following key terms: "children," "pediatric/paediatric patients," "skin," "skin disorders," "type 1 diabetes." Dermatological side effects are frequently observed among diabetic children and adolescents. Insulin-induced lipodystrophies and allergic contact dermatitis caused by insulin pumps or glycaemic sensors are the most common skin reactions in these patients. Furthermore, several diabetes-associated skin diseases such as necrobiosis lipoidica, granuloma annulare, vitiligo, and bullosis diabeticorum may already be present in paediatric patients. Paediatric diabetes specialists should pay attention to their patients' skin to recognize these disorders, identify the potential causes, and choose the most suitable treatment. Finally, the evaluation of skin concentrations of advanced glycation end-products using non-invasive diagnostic techniques may be used to assess the risk of chronic complications of diabetes as early as adolescence.
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Affiliation(s)
- Stefano Passanisi
- Department of Human Pathology in Adult and Developmental Age, University of Messina, Messina, Italy
| | - Giuseppina Salzano
- Department of Human Pathology in Adult and Developmental Age, University of Messina, Messina, Italy
| | - Fortunato Lombardo
- Department of Human Pathology in Adult and Developmental Age, University of Messina, Messina, Italy
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Yang AJ, Magill SB. Visual Vignette. Endocr Pract 2020; 26:1230. [PMID: 33471725 DOI: 10.4158/ep-2019-0592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Almira J Yang
- From the Medical College of Wisconsin, Division of Endocrinology and Molecular Medicine, Department of Medicine, Milwaukee, Wisconsin..
| | - Steven B Magill
- From the Medical College of Wisconsin, Division of Endocrinology and Molecular Medicine, Department of Medicine, Milwaukee, Wisconsin
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6
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Insulin analogs: Glimpse on contemporary facts and future prospective. Life Sci 2019; 219:90-99. [DOI: 10.1016/j.lfs.2019.01.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 01/05/2019] [Accepted: 01/09/2019] [Indexed: 01/20/2023]
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Kapeluto JE, Paty BW, Chang SD, Meneilly GS. Ultrasound detection of insulin-induced lipohypertrophy in Type 1 and Type 2 diabetes. Diabet Med 2018; 35:1383-1390. [PMID: 29908078 DOI: 10.1111/dme.13764] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/14/2018] [Indexed: 11/26/2022]
Abstract
AIMS To define standard criteria for the detection of lipohypertrophy using ultrasonography and to determine the accuracy of this method. METHOD Individuals using insulin therapy for ≥2 years with unknown lipohypertrophy status were enrolled at a diabetes education centre. A team of diabetes educator nurses performed a clinical examination for evidence of lipohypertrophy and a separate team of ultrasonographers examined participants in a blinded fashion. RESULTS The echo signature for lipohypertrophy consisted of location in the subcutaneous layer and lesions that were 1) well circumscribed either by hyperechoic foci with defined borders or a nodular shape with a hypoechoic halo, 2) heterogeneous in echotexture compared with surrounding tissue, 3) associated with distortion of surrounding connective tissue with 4) absence of vascularity and 5) absence of capsule. Ultrasonography identified individuals with lipohypertrophy significantly more frequently than inspection or palpation (P<0.0001). Inter-observer agreement was moderate (κ=0.50) and limited by the presence of subclinical lesions in 73% of the participants. CONCLUSIONS The ultrasound detection of lipohypertrophy is consistent with clinical examination and is reproducible using a defined echo signature. (ClinicalTrials.gov registration no: NCT02348099).
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Affiliation(s)
- J E Kapeluto
- Division of Endocrinology, Department of Medicine, Vancouver General Hospital and University of British Columbia, Vancouver, Canada
| | - B W Paty
- Division of Endocrinology, Department of Medicine, Vancouver General Hospital and University of British Columbia, Vancouver, Canada
| | - S D Chang
- Department of Radiology, Vancouver General Hospital and University of British Columbia, Vancouver, Canada
| | - G S Meneilly
- Division of Geriatric Medicine, Department of Medicine, Vancouver General Hospital and University of British Columbia, Vancouver, Canada
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Singha A, Bari R, Bhattacharjee R, Saha S, Biswas D, Ghosh S, Chakravarti HN, Chowdhury S. Insulin Aspart–Induced Lipoatrophy Treated Successfully With Glucocorticoid Injection. AACE Clin Case Rep 2017. [DOI: 10.4158/ep161492.cr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Singha A, Bhattarcharjee R, Ghosh S, Chakrabarti SK, Baidya A, Chowdhury S. Concurrence of Lipoatrophy and Lipohypertrophy in Children With Type 1 Diabetes Using Recombinant Human Insulin: Two Case Reports. Clin Diabetes 2016; 34:51-3. [PMID: 26807009 PMCID: PMC4714723 DOI: 10.2337/diaclin.34.1.51] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Arijit Singha
- Department of Endocrinology and Metabolism, Institute of Postgraduate Medical Education & Research/SSKM Hospital. Kolkata, West Bengal, India
| | - Rana Bhattarcharjee
- Department of Endocrinology and Metabolism, Institute of Postgraduate Medical Education & Research/SSKM Hospital. Kolkata, West Bengal, India
| | - Sujoy Ghosh
- Department of Endocrinology and Metabolism, Institute of Postgraduate Medical Education & Research/SSKM Hospital. Kolkata, West Bengal, India
| | - Sumit Kumar Chakrabarti
- Department of Endocrinology and Metabolism, Institute of Postgraduate Medical Education & Research/SSKM Hospital. Kolkata, West Bengal, India
| | - Arjun Baidya
- Department of Endocrinology and Metabolism, Institute of Postgraduate Medical Education & Research/SSKM Hospital. Kolkata, West Bengal, India
| | - Subhankar Chowdhury
- Department of Endocrinology and Metabolism, Institute of Postgraduate Medical Education & Research/SSKM Hospital. Kolkata, West Bengal, India
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Saberi S, Esfandiari NH, MacEachern MP, Tan MH. Detemir plus aspart and glulisine induced lipoatrophy: 2015 literature review and report of a new case. Clin Diabetes Endocrinol 2015; 1:10. [PMID: 28702229 PMCID: PMC5471683 DOI: 10.1186/s40842-015-0013-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Accepted: 07/20/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In the first and only literature review, conducted in 2009, of human insulin analog- induced lipoatrophy, there were 12 published cases, including 1 with aspart, 1 with detemir, 1 with NovoMix 30 and none with detemir plus aspart. It is perceived that insulin analog induced-lipoatrophy is increasing. We conducted a 2015 literature review of published reports of lipoatrophy induced by aspart, detemir, detemir plus aspart, and NovoMix30. We also report a new case of detemir plus aspart and glulisine induced lipoatrophy. METHODS Our focused literature searches (limited to 1995-2014) in PubMed, Embase, and Web of Science, using a combination of insulin analog and lipoatrophy terminology, was conducted in early January 2015. RESULTS From the 520 unique citations there were 33 (from 13 papers and 9 abstracts) lipoatrophy cases induced by detemir (n = 5), aspart (n = 21), detemir plus aspart (n = 4) and NovoMix 30 (n = 3), representing 30 new cases since 2009. Many of these reported cases were females (76 %), had type 1 diabetes mellitus (T1DM) (94 %) and were in young persons (61 %). A 41-year-old T1DM woman developed lipoatrophy on her upper thighs, arms and abdomen 14 months after injecting detemir plus aspart at the same sites. Later on, after a year on continuous subcutaneous insulin infusion (CSII) using aspart and then glulisine, she developed lipoatrophy at the infusion sites. When CSII insulin was switched to lispro she did not develop lipoatrophy after 10 months. Meanwhile, the original lipoatrophy sites significantly improved. CONCLUSIONS Our literature review uncovered 30 new published cases of aspart, detemir, aspart plus detemir and NovoMix 30-induced lipoatrophy since 2009. The largest increase in cases was in aspart- induced lipoatrophy. Recent surveys showed most rapid acting insulin analog-induced lipoatrophy were associated with CSII. In our review of the reported cases, 85.7 % cases of aspart-induced lipoatrophy were associated with CSII. As in previous reports, we showed lipoatrophy was more common in females, T1DM and young persons. Our patient may be the 5th published case of detemir plus aspart-induced lipoatrophy and possibly the first case report of glulisine induced lipoatrophy. She believed both detemir plus aspart and glulisine induced the lipoatrophy.
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Affiliation(s)
- Sima Saberi
- Ann Arbor Endocrinology and Diabetes, PC, Ypsilanti, Michigan USA
| | - Nazanene H Esfandiari
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Lobby C, 24 Frank Lloyd Wright Drive, Ann Arbor, MI 48106 USA
| | - Mark P MacEachern
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, Michigan USA
| | - Meng H Tan
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Lobby C, 24 Frank Lloyd Wright Drive, Ann Arbor, MI 48106 USA
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Salgin B, Meissner T, Beyer P, Haberland H, Borkenstein M, Fussenegger J, Brand U, Hauffa BP, Hungele A, Holl RW. Lipoatrophy is associated with an increased risk of Hashimoto's thyroiditis and coeliac disease in female patients with type 1 diabetes. Horm Res Paediatr 2014; 79:368-72. [PMID: 23796529 DOI: 10.1159/000351708] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 04/28/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Lipoatrophy (LA) is a rare, possibly under-recognised side effect of insulin treatment of unclear aetiology. The aim of this study was to describe the characteristics of patients with type 1 diabetes (T1D) who have LA and to explore the relationship between LA and other autoimmune diseases based on the hypothesis that additional autoimmune phenomena are more prevalent in T1D patients with LA. METHODS This was a cross-sectional observational study of T1D patients with LA in comparison to T1D patients without LA who are registered with the Diabetes Patienten-Verlaufsdokumentationssystem database of 241,650 patients in Germany and Austria. RESULTS Hashimoto's thyroiditis and coeliac disease were more prevalent in patients with LA (p < 0.001 for both). LA was associated with an increased risk of Hashimoto's thyroiditis and coeliac disease in female patients [odds ratio (OR) 2.5, p = 0.003, and OR 3.1, p = 0.02, respectively]. This relationship persisted after adjustment for current age, duration of diabetes and calendar year of treatment (OR 2.7, p = 0.002, and OR 3.5, p = 0.01, respectively). CONCLUSION These findings support the hypothesis that an immune complex-mediated inflammatory process may be important in the development of LA.
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Affiliation(s)
- Burak Salgin
- Department of General Paediatrics, Neonatology and Paediatric Cardiology, University Children's Hospital Düsseldorf, Düsseldorf, Germany.
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Agha A, Duffield E, Elrishi M. Detemir insulin related lipoatrophy: a case series. PRACTICAL DIABETES 2013. [DOI: 10.1002/pdi.1799] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Anbarasi K, Sathasivasubramanian S, Krithika CL, Venkatasai PM. Focal lipoatrophy of face: a rare esthetic complaint. J Clin Imaging Sci 2012; 2:14. [PMID: 22530185 PMCID: PMC3329066 DOI: 10.4103/2156-7514.94229] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Accepted: 02/15/2012] [Indexed: 11/22/2022] Open
Abstract
A well-proportioned face combines features that are balanced and symmetrical. Any structural alteration that leads to facial asymmetry causes esthetical and psychological disturbances. Lipoatrophy is one such condition, which results in loss of subcutaneous fat layer and manifests as a depression. Although many subtypes with varying clinical and etiological backgrounds exist, the idiopathic form is rare and facial involvement is the rarest. Computed tomography is one of the accepted diagnostic tools to determine the atrophic layer of facial anatomy. This report presents the clinical types, diagnosis, and management of a case of facial lipoatrophy.
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Affiliation(s)
- K Anbarasi
- Division of Oral Medicine and Radiology, Faculty of Dental Sciences, Sri Ramachandra University, Porur, Chennai, India
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Swelheim HT, Westerlaken C, van Pinxteren-Nagler E, Bocca G. Lipoatrophy in a girl with type 1 diabetes: beneficial effects of treatment with a glucocorticoid added to an insulin analog. Diabetes Care 2012; 35:e22. [PMID: 22355025 PMCID: PMC3322699 DOI: 10.2337/dc11-2135] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Hester T. Swelheim
- Department of Pediatrics, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Ciska Westerlaken
- Department of Pediatrics, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | | | - Gianni Bocca
- Department of Pediatric Endocrinology, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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Abstract
BACKGROUND Insulin allergy is a rare complication of insulin use. Localized lipoatrophy is also known to occur following subcutaneous injections of insulin. CASE REPORT A 53-year-old non-obese female patient with Type 2 diabetes displayed local allergic-type symptoms to all available insulin preparations. This was complicated by the development of severe lipoatrophy on her abdominal and thigh injection sites and subsequently resulted in suboptimal glycaemic control. CONCLUSIONS Whilst uncommon, insulin allergy and lipoatrophy can cause major problems in diabetic management. Potential pathophysiological mechanisms and a stepwise approach to management are discussed.
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Affiliation(s)
- A N Tavare
- Department of Diabetes and Endocrinology, The Hillingdon Hospital, Uxbridge, UK.
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Milan G, Murano I, Costa S, Pianta A, Tiengo C, Zulato E, Centobene C, Bruttomesso D, Cinti S, Vettor R. Lipoatrophy induced by subcutaneous insulin infusion: ultrastructural analysis and gene expression profiling. J Clin Endocrinol Metab 2010; 95:3126-32. [PMID: 20484470 DOI: 10.1210/jc.2009-2773] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT AND OBJECTIVE Subcutaneous adipose tissue (SAT) lipoatrophy (LA) is a rare complication of insulin therapy. We aimed to analyze the ultrastructural and molecular aspects of LA lesions. SETTING AND PATIENTS Macroscopic and microscopic morphology of SAT beneath the LA areas from patients with type 1 diabetes treated with Lispro insulin by continuous sc insulin infusion was studied using magnetic resonance imaging, immunohistochemistry, electron microscopy, and quantitative PCR for adipose tissue-specific genes. RESULTS SAT was present in LA lesions characterized by: 1) smaller, unilocular perilipin-positive adipocytes, with lipofuscin granules; 2) some "slimmed cells" losing lipid droplets as those we observed during starvation; and 3) numerous perivascular preadipocytes. We did not identify inflammatory cells. SAT in LA areas displayed a strong leptin down-regulation and an increase of AEBP1, a preadipocyte marker. CONCLUSIONS Our results clearly indicate that the remarkable reduction in fat cell lipid droplets and adipocyte size justifies the decrease of SAT without a reduction in adipocyte number because of necrosis or apoptosis. Thus, immune cells and any other toxic damaging fat cells were not involved in the generation of LA. We speculate that adipocytes chronically exposed to high local insulin concentrations could become severely insulin resistant, dramatically increasing lipolysis and giving rise to "slimmed cells." Clinical LA regression could be explained by the active recruitment of preadipocytes, even if they were unable to differentiate and regenerate adipose tissue unless the insulin injection was removed.
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Affiliation(s)
- G Milan
- Department of Medical and Surgical Sciences, University of Padua, Via Ospedale, 105, 35128 Padua, Italy.
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Holstein A, Stege H, Kovacs P. Lipoatrophy associated with the use of insulin analogues: a new case associated with the use of insulin glargine and review of the literature. Expert Opin Drug Saf 2009; 9:225-31. [DOI: 10.1517/14740330903496402] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Andreas Holstein
- Lippe-Detmold Clinic, 1st Department of Medicine, Röntgenstr. 18, Detmold, D-32756, Germany ;
| | - Helger Stege
- Lippe-Detmold Clinic, Department of Dermatology, Röntgenstr. 18, Detmold, D-32756, Germany
| | - Peter Kovacs
- University of Leipzig, Interdisciplinary Centre for Clinical Research, Inselstraße 22, Leipzig, 04103, Germany
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Verschaeve L, Maes A. Support for the hypothesis that electro-stimulation is responsible for Lipoatrophia semicircularis. Med Hypotheses 2009; 73:802-6. [DOI: 10.1016/j.mehy.2009.01.058] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2008] [Revised: 11/27/2008] [Accepted: 01/12/2009] [Indexed: 11/16/2022]
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Maes A, Curvers B, Verschaeve L. Lipoatrophia semicircularis: An Electromagnetic Hypothesis. Electromagn Biol Med 2009. [DOI: 10.1081/jbc-120024627] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Del Olmo MI, Campos V, Abellán P, Merino-Torres JF, Piñón F. A case of lipoatrophy with insulin detemir. Diabetes Res Clin Pract 2008; 80:e20-1. [PMID: 18281121 DOI: 10.1016/j.diabres.2007.12.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2007] [Accepted: 12/29/2007] [Indexed: 11/19/2022]
Abstract
Lipoatrophy is a rare cutaneous side-effect that can develop at the site of insulin injection. Since the introduction of human recombinant insulin the number of cases has decreased although cases have been reported in association with the use of rapid acting insulin analogues and continuous subcutaneous insulin infusion (CSII), recently one case has been reported with the use of insulin glargine. Insulin-induced lipoatrophy is a subcutaneous fat atrophy at the sites of injection which is relevant not only because of the cosmetic problem, but also because of the variability of absorption it causes in the site of injection. This report describes a patient with a type 1 diabetes mellitus who develops a lipoatrophy induced by insulin detemir. To our understanding this is one of the first reported cases of lipoatrophy induced by insulin detemir.
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Affiliation(s)
- María I Del Olmo
- Endocrinology and Nutrition Department, University Hospital La Fe, Valencia, Spain
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Abstract
We describe the development of severe lipoatrophy in a patient treated with biphasic aspart. This complication of insulin therapy was common in the past with the use of animal insulins and became less common with the increasing purification of these and the introduction of recombinant human insulin. This patient developed severe lipoatrophy with the use of a premixed insulin containing the analogue insulin aspart. Lipoatrophy although rare can still occur even with the use of technologically advanced insulin preparations.
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Affiliation(s)
- S F Hussein
- Stafford District Hospital--Diabetes and Endocrine, Stafford, Staffordshire, UK.
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Abstract
INTRODUCTION Diphtheria Pertussis Tetanus (DPT) vaccine is universally used in infants and children. It is generally safe and well tolerated. Local reactions such as erythema, induration, palpable nodules, and injection site abscess are well known. Injection site lipoatrophy has not been reported earlier. PATIENTS AND METHODS Retrospective review of all cases presenting with lipoatrophy developing at injection site following DPT administration between 2000-2005 in 3 hospitals in New Delhi, India was performed. In each case, the patients were extensively evaluated for other possible causes of lipoatrophy. RESULTS 8 infants (2 boys & 6 girls), age range 4-12 months, had presented with injection site lipoatrophy following DPT vaccination. The duration between the last injection and lipoatrophy ranged from 4 to 8 weeks. All had been administered the vaccine in the buttock instead of the thigh, as generally recommended in infants. Majority (6/8) developed lipoatrophy after the second dose. No systemic causes were found. CONCLUSION DPT vaccine may, in rare instances, lead to injection site lipoatrophy. Inadvertent administration into the subcutaneous fat of the buttock may have been causative. Other possible mechanisms are discussed. Paramedics and general practitioners need to be educated to administer intramuscular vaccines in the thigh in infants and young children.
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Affiliation(s)
- Kabir Sardana
- Department of Dermatology, Maulana Azad Medical College and Chacha Nehru Bal Chikitsalaya, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India.
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Shimizu I, Furuya K, Osawa H, Fujii Y, Makino H. A case of insulin-induced localized lobular panniculitis with evidence for the phagocytosis of insulin by histiocytes. Endocr J 2007; 54:477-80. [PMID: 17457015 DOI: 10.1507/endocrj.k06-173] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Insulin-induced localized lipoatrophy is a well-known localized side effect. Although an immune process has been suggested as its etiology, no definitive evidence has been reported to show that insulin is involved. Here, we report the first evidence for the phagocytosis of insulin by histiocytes as a very early stage of lipoatrophy, which was reproducible in two different lobular panniculitis tissues from a 71 year-old male patient. He had taken a subcutaneous insulin injection in his arms because of a sight disturbance. Since these subcutaneous tumors were likely due to inflammation by insulin, a biopsy sample was taken from the subcutaneous tumor of his right arm with his consent. The primary antibodies for insulin (1 : 200) and CD68 (1 : 50) were obtained from DAKO (guinea pig anti-insulin and mouse anti-human CD68). HE staining revealed the infiltration of mononuclear cells and histiocytes into the subcutaneous fat tissue, and some parts of this tissue had fibrosis with rich collagen fibers. These findings are consistent with a lobular panniculitis. Some histiocytes contained intracellular substances with a positive immunoreactivity to insulin. This activity was reduced when the anti-insulin antibody was preincubated with an excess amount of insulin antigen. The same substances were also positive to CD68. Thus, the phagocytosis of insulin by histiocytes appears to occur in this region. Therefore, the activation of subcutaneous macrophages by the complex of insulin and insulin antibodies may account for the initial autoimmune process.
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Affiliation(s)
- Ikki Shimizu
- Department of Diabetes & Endocrinology, Ehime Prefectural Central Hospital, Matsuyama, Japan
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Radermecker RP, Piérard GE, Scheen AJ. Lipodystrophy reactions to insulin: effects of continuous insulin infusion and new insulin analogs. Am J Clin Dermatol 2007; 8:21-8. [PMID: 17298103 DOI: 10.2165/00128071-200708010-00003] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Management of diabetes mellitus can be responsible for cutaneous adverse events. For example, lipoatrophy or lipohypertrophy can develop at the site of insulin injections. Lipohypertrophy remains a frequent complication of insulin therapy irrespective of the insulin source and mode of administration. Lipoatrophy at insulin injection sites is considered to be an immune complex-mediated inflammatory lesion; however, it has become a rare event since the advent of human insulin. Nowadays, continuous subcutaneous insulin infusion (CSII) using a portable pump and/or injections of insulin analogs with an altered amino acid sequence compared with native insulin may cause lipodystrophy in diabetic patients. Some case reports describe the recovery of lipoatrophy following the use of CSII and/or short-acting insulin analogs. Conversely, exceptional cases of lipoatrophy have occurred in patients receiving lispro insulin analog via CSII. Lipodystrophy reactions remain a potential problem when managing diabetic patients with new insulin therapy technologies.
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Affiliation(s)
- Régis P Radermecker
- Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, University Hospital Sart Tilman, University of Liège, Liège, Belgium.
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Beltrand J, Guilmin-Crepon S, Castanet M, Peuchmaur M, Czernichow P, Levy-Marchal C. Insulin Allergy and Extensive Lipoatrophy in Child with Type 1 Diabetes. Horm Res Paediatr 2006; 65:253-60. [PMID: 16582568 DOI: 10.1159/000092515] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2005] [Accepted: 01/14/2006] [Indexed: 01/02/2023] Open
Abstract
Insulin allergy and lipoatrophy in type 1 diabetic patients have been previously reported but the mechanisms are not well documented. Here, we report a case emphasizing the role of abnormal local immune reaction associated with cytokine hyper production. The patient is a 7-year-old boy with a familial history of common variable immunodeficiency. Eight months after the diagnosis of type 1 diabetes, he developed signs of insulin allergy expressed as continuously extensive and profound lipoatrophy contrasting with a well-preserved metabolic control. Specific insulin allergy was confirmed by skin prick tests that showed lymphoid activated cells in the subcutaneous tissue at the site of insulin injection. All therapies reported in the literature (antihistaminic, local steroid, change to lispro insulin, immunosuppressive treatment, subcutaneous insulin pump, peritoneal insulin infusion) were not efficient. It is suggested that familial disorders of immune cell functions with abnormal and excessive cytokine production might explain these adverse effects triggered by insulin with severe allergic reactions and lipoatrophy.
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Affiliation(s)
- Jacques Beltrand
- Inserm U 690 'Diabète de l'enfant et développement', Robert Debré Hospital, Paris, France.
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Affiliation(s)
- Alberto J S Ramos
- Endocrinology and Diabetes Unit, Department of Preventive Social and Internal Medicine, Alcides Carneiro University Hospital, Campina Grande, Paraiba, Brazil.
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Abstract
The analogue insulins were developed to more clearly mimic the basal and prandial components of insulin secretion for subjects with diabetes mellitus. Analogues are now widely used and have largely taken over from the conventional human recombinant insulins. It is important that these insulins are not only as effective as their predecessors, but are also safe and well-tolerated. In this manuscript, the authors review the adverse effects reported with analogue insulins and make a comparison with standard insulin treatments.
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Affiliation(s)
- Ali D Kamal
- University of Birmingham, Undergraduate Centre, Birmingham Heartlands & Solihull NHS Trust, Birmingham & Division of Medical Sciences, UK
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Bauerschmitz J, Bork K. Multifocal disseminated lipoatrophy secondary to intravenous corticosteroid administration in a patient with adrenal insufficiency. J Am Acad Dermatol 2002; 46:S130-2. [PMID: 12004291 DOI: 10.1067/mjd.2002.107490] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Multifocal disseminated lesions of circumscribed lipoatrophy have not been described as an adverse reaction of intravenously applied drugs. A unique patient with adrenal insufficiency is reported who received corticosteroids intravenously and then had multiple lesions develop that were similar to focal lipoatrophy as known to occur secondary to faulty intradermal injections of corticosteroids.
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Abstract
The lipodystrophies are rare disorders characterized by selective but variable loss of adipose tissue. Metabolic complications, such as insulin resistance, diabetes mellitus, hypertriglyceridemia, and fatty liver, increase in severity with the extent of fat loss. The lipodystrophies can be classified into two major types: familial and acquired. The main subtypes of familial lipodystrophies are congenital generalized lipodystrophy, an autosomal recessive disorder characterized by near complete lack of metabolically active adipose tissue from birth, and familial partial lipodystrophy, Dunnigan type, an autosomal dominant disorder characterized by loss of subcutaneous fat from the extremities at puberty and excess fat accumulation in the face and neck. Recently, a gene for congenital generalized lipodystrophy was localized to chromosome 9q34, and a gene for familial partial lipodystrophy, Dunnigan type, to chromosome 1q21-22; the genes, however, remain to be identified. Patients with acquired generalized lipodystrophy have generalized loss of subcutaneous fat, but those with acquired partial lipodystrophy have fat loss limited to the face, trunk, and upper extremities. Both varieties occur approximately three times more often in women, begin during childhood, and have underlying autoimmunity. Patients infected with the human immunodeficiency virus (HIV) who are receiving therapy that includes HIV-1 protease inhibitors have been reported to develop a lipodystrophy characterized by loss of subcutaneous fat from the extremities and face but excess fat deposition in the neck and trunk. Localized lipodystrophies can be caused by drugs, pressure, panniculitis, or unknown mechanisms. Current management of patients includes cosmetic surgery, diet, and drug therapy for control of diabetes and dyslipidemia.
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Affiliation(s)
- A Garg
- Department of Internal Medicine and the Center for Human Nutrition, University of Texas Southwestern Medical Center, Dallas 75235-9052, USA
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