The American Diabetes Association 2006 Scientific Sessions were held in Washington, D.C. from June 9-13, 2006 and offered an opportunity to learn about the latest in diabetes research, meet with researchers and clinicians, and meet with industry representatives. Children with Diabetes had a small booth and several volunteers to help show our web site and share information about our conferences to the 12,000+ attendees.
Research, Abstracts and Poster Presentations
- In Performance of the FreeStyle NavigatorTM Continuous Glucose Monitoring System during Home Use, a team of seven, led by Bruce Bode, M.D., reported on a multi-center clinical trial of the Navigator under home use conditions. Results were presented in a poster and as part of a standing-room-only symposium on the product held on Friday evening. Key data from this study include:
- 86% of hypoglycemic alarms (70 mg/dl) were verified by a fingerstick blood glucose check
- 99% of hyperglycemic alarms (240 mg/dl) were verified
- Participants with type 1 diabetes had a 42% reduction in the time spent hypoglycemic (< 70 mg/dl)
- Sensor life of five days was demonstrated
- Patients showed an improvement in glycemic control after a short time of use
- Automated Feedback-Controlled Insulin Delivery in Children with Type 1 Diabetes: A Preliminary Report by Stuart Weinzimer, Garry Steil, Natalie Kurtz, Karena Swam, and William Tamborlane presented the first data on the use of a closed loop glucose sensor and insulin pump system in children. 14 kids, ages 13-18, spent 36 hours in the Yale clinical research center. Seven kids has a completely closed loop system and seven added a "priming bolus" 5-15 minutes before meals, all using the Medtronic MiniMed Paradigm insulin pump and Medtronic MiniMed CGMS sensor. This brief study showed that this type of system can work in kids, that the priming bolus reduce post-prandial excursions, and that overnight control using the sensor could reduce the risk of nighttime hypoglycemia.
- In Missed Meal Boluses - Their Impact and Prevention, Dr. Peter Chase of the Barbara Davis Center for Childhood Diabetes reported that missed meal boluses are the number one cause for poor control and elevated HgA1c levels for subjects on CSII therapy. While pump therapy is a huge advance in diabetes management, only careful use of this tool and attention to aspects of human behavior -- i.e., memory -- garner good control. His study showed that initiation of pump therapy in children and adolescents resulted in 50% of the subjects with 0.5% to 1.5% lower HgA1c, 30% who stayed the same and 20% who actually increased their HgA1c by at least 0.5%. Most of this increase was the result of missed meal boluses. Two missed boluses per week increased HgA1c by 0.5% and 4 missed boluses by 1.0%. With review of therapy at office visits patients recalled missing about 1 bolus per week, but downloaded information from the pump showed that 2 boluses were missed. Also, about 50% of the patients bolused after eating, 25% during the meal and 25% after the meal. Meal time alarm bolus reminders improved HgA1c across the board. The take home message was that you can improve your diabetes control with an insulin pump but you must remember to bolus for all meals and snacks consumed. Also of interest, 10% of teenage girls missed meal boluses for the purpose of weight loss.
- In the meeting of the Council on Diabetes in Youth, the presentations and discussions centered around the ADA's guidelines for HbA1c levels in children, which vary by age and include both upper and lower bounds. While the guidelines recommend a higher HbA1c target for young kids to reduce the risk of severe hypoglycemia, the general consensus was that lower HbA1c levels are easier to achieve in younger patients and much harder to achieve in teens. Dr. William Tamborlane of Yale also argued that setting lower limits for the youngest age group was not in the best interest of the patient, since you would never intentionally worsen care if your HbA1c were below the lower limit (7.5%) and you had no problems with hypoglycemia. The ADA consensus guidelines for HbA1c in children are:
- 7.5% to 8.5% in children under age 6
- < 8% for children 6-12 (no lower limit)
- < 7.5% for children 13-19 (no lower limit)
- Persistent Differences in Glycaemic Control Across 21 International Centres: Hvidoere Study Group Centre Differences Study 2005 noted that HbA1c results varied considerably and consistently over time among a group of centers studied in 1998 and again in 2005. Only two centers improved over seven years (0.5 and 0.7% in HbA1c). Clearly, the choice of a diabetes care center can have a profound affect on one's outcome as measured by HbA1c.
- Achieving Pediatric ADA HbA1c Goals: Insulin Pump Therapy vs Injection Therapy, a team from the Barbara Davis Center found a that kids ages 6-12 had a significantly lower HbA1c when they used an insulin pump than when they used multiple injection therapy (7.64 +/- 0.87% vs. 8.20 +/- 0.93%, p=0.0021). In kids ages 13-19, the difference was much smaller (8.43 +/- 1.18% vs. 8.75 +/- 1.40%, p=0.0978). The team concluded that diabetes care providers should consider starting pump therapy at younger ages.
- In Insulin Aspart Continuous Subcutaneous Infusion in Preschool Children: Superior Caregiver Satisfaction Version Multi-Injection Therapy, a team from Poland followed 61 preschool children using multiple injections or pumps. While the study found no difference in A1c between the groups, the caregivers of the kids using pumps expressed a significantly higher level of satisfaction with both quality of life and low frequency of hypoglycemia.
- In Use of the CozMonitor® Blood Glucose Module in Youth with Type 1 Diabetes, a team from the Barbara Davis Center in Denver followed 34 youth ages 9 to 21 years for six months to determine if the CozMonitor® -- essentially a FreeStyle meter that is attached directly to the Cozmo insulin pump -- would make a difference in glycemic control. While those participants who used the CozMonitor® found it convenient, there was no change in control between the experimental group and the control group.
- In Diabetes and the Transition to College, a team from Carnegie Mellon University and the University of Pittsburgh followed 16 adolescents who received care at Children's Hospital of Pittsburgh from the summer before college through their second semester of college. Overall, metabolic control deteriorated over the transition to college (mean A1c increased from 7.77 to 8.23). For parents of college students with diabetes, this likely does not come as a surprise. The study shows the importance of continued support for teenagers as they move off to college.
- As could be expected, Positive Interactions in the Family: Link with Glycemic Control, from a team including Lori Laffel, Tim Wysocki, and Barbara Anderson, reported that higher levels of positive caregiver behaviors were associated with a lower HbA1c level in children with type 1 diabetes. Positive caregiver behaviors included praising, complimenting, making suggestions, good-natured joking, and stating the other's opinion. Negative caregiver behaviors included interrupting, negative judgements, making demands, sarcasm, criticism, and personal attacks. This study showed the importance of the family in caring for a child with type 1 diabetes. Several other posters also showed the importance of positive family contributions to the level of glycemic control in kids with type 1 diabetes.
- In Very Low Dose Glucagon Averts Insulin Induced Hypoglycemia in Patients with Type 1 Diabetes Mellitus, led by William Isley and Steven Edelman, looked at using an insulin pump to infuse very low doses of glucagon for nine hours to determine if the infusion would reduce the risk of hypoglycemia. As might be expected, it did. The team is now looking at overnight infusions of very low dose glucagon to reduce the incidence of nighttime hypoglycemia.
- In Regional Brain Activation During Hypoglycemia in Type 1 Diabetes: A fMRI Study, a team from multiple hospitals and centers in Boston (including Joslin and Harvard Medical School) looked at fMRI scans of brains in adults with type 1 diabetes and control subjects during periods of euglycemia and periods of hypoglycemia. During the "Working Memory Task," which relies on parts of the brain that are impacted by diabetes, people with type 1 diabetes used less of their brain than control subjects. This may indicate that their brains have adapted to previous hypoglycemia and perform more efficiently, requiring fewer areas of the brain to perform the task. It's not clear how this finding relates to the Joslin study Nationwide Long-term Study Shows Brain Function Not Impaired By Tight Diabetes Control and Severe Hypoglycemia, also released at the 2006 ADA conference.
Products and Product News
There was surprisingly little new in the way of diabetes products shown at the 2006 Scientific Sessions. Among the few newsworthy items were:
- Abbott Diabetes Care showed a new version of their FreeStyle meter, called the FreeStyle Freedom, which looks like a slightly enlarged FreeStyle Flash, but without the port light. The Freedom was also shown at the 2005 ADA meeting. More importantly, Abbott also showed a new ketone test strip for their Precision Xtra, which requires only 1.5 microliters of blood (a 70% reduction) and yields results in 10 seconds (three times faster). This new ketone strip is end fill or top fill and comes with a "SmartChip Technology" calibration chip that will allow any Precision Xtra meter to take advantage of the new ketone strip. Boxes of the new ketone strips are white with a purple strip and should be available in local stores shortly. ADC also have a very busy section of their booth for a discussion of Navigator.
- LifeScan showed their new OneTouch Ultra2 meter, which allows for easy recording of pre and post meal blood glucose levels.
- The Exubera inhaler was shown and could be handled. Many people who had a chance to hold it and learn more about it commented that the inhaler was larger than they imagined and that the cleaning process was more involved than they had expected.
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