Ghislaine Houde

Dietitian-coached management in combination with annual endocrinologist follow up improves global metabolic and cardiovascular health in diabetic participants after 24 months.

This 24 month study evaluated the effect of dietitian coaching combined with minimal endocrinologist follow up on the glycemic control and cardiovascular risks of diabetic participants, compared with conventional endocrinologist follow up. Participants with type 1 or type 2 diabetes were assigned to either the control group with conventional endocrinologist follow up (C; n = 50) or the dietitian-coached group (DC; n = 51) with on-site diabetes self-management education every 3 months combined with annual endocrinologist followup. Over the 24 month intervention, weight (-0.7 vs. +2.1 kg; p = 0.04), BMI (+0.3 vs. +0.7 kg/m(2); p = 0.009), and waist circumference (-1.3 vs. +2.4 cm; p = 0.01) significantly differed between the DC and control groups. HbA(1C) dropped significantly in participants of the DC versus the control group (-0.6% vs.-0.3%; p = 0.04). This was accompanied by improved overall energy intake (-548 vs. -74 kcal/day; p = 0.04). However, no link associated glycemic control to nutrient intake or intensiveness of pharmacotherapy. Coaching by a dietitian improves glycemic control and reduces certain cardiovascular risk factors in diabetic subjects, demonstrating that a joint dietitian-endocrinologist model of care provides a convenient strategy for cardiovascular risk management in the diabetic population.

Gestational Diabetes Mellitus Identification Based on Self-Monitoring of Blood Glucose

In Sherbrooke, the gestational diabetes mellitus (GDM) Regional Committee proposed GDM screening during the first trimester for all pregnant women based on a 50 g glucose challenge test (50 g GCT) followed directly by capillary self-monitoring blood glucose (SMBG) at home. We evaluated implementation of committees recommendations on the clinical trajectory of women receiving prenatal care at our institution. We analyzed data collected systematically by the Blood Sampling in Pregnancy clinic from 2008 to 2011. We evaluated the clinical trajectory of 7710 pregnant women to assess GDM screening/diagnoses and referral rates to the diabetes care centre (DCC) for education and treatment during both the first and second trimesters. The Canadian Diabetes Association glycemic treatment targets in women with GDM were used as diagnosis thresholds and DCC referral decisions: Fasting glucose of 5.3 mmol/L and postprandial 2 h glucose of 6.7 mmol/L. We found that pregnant women were 28.0±4.8 years old, and their body mass indexes were 24.5±5.5 kg/m(2). During the first trimester, 47% of women were screened for GDM, mostly (84%) using the 50 g GCT. Following SMBG, 5.7% were referred to the DCC. Only 32% of women with early GDM had >1 GDM risk factor. Thereafter, 67% of normoglycemic women screened during the first trimester were screened again during the second trimester. Among women screened during the second trimester, most screening was done using 50 g GCT, and 8.8% were referred to the DCC following SMBG. Implementation of 50 g GCT testing followed by direct home SMBG was well implemented in our area. The importance of early GDM screening and rescreening during the second trimester still needs to be emphasized.

CSII: Longer Catheter Usage Time, a Reasonable Goal.

Continuous subcutaneous insulin infusions systems (CSII) are commonly used by patients with type 1 diabetes (T1D). A catheter (KT) allows transfer of insulin from the reservoir to the subcutaneous tissue. In clinical practice, KT are replaced every 2 or 3 days. This avoids skin irritation and other adverse events (AEs), including increases in mean blood glucose levels with longer usage. Historically, this commonly held assumption has been that the trade-off is worth it. Pfützner et al recently reported a study on 22 adult T1D patients, all chronic users of CSII. The 6-month randomized crossover (2 x 3-month) study was conducted prospectively, in a real-world setting. Investigators assessed tolerability of 2-day and 4-day use. The number of KT-related AEs, treatmentrelated AEs, and other various AEs were significantly higher with 4-day use. With 2-day use, HbA1c improved (7.4 ± 1.2 vs 7.6 ± 1.2%, P < .05) and patient treatment satisfaction was higher. According to the authors, these data support the 2to 3-day replacement recommendation; authors also expressed doubts on the economic benefits of longer KT wear. It seems to us that the Pfützner study data can be interpreted differently. In this type of study, AE frequency is the main issue. However, AE categories were poorly defined, and questionnaires used to record AEs were not validated. The alarming total number of AEs (n = 2664) in addition to hyperglycemia (n = 615) and hypoglycemia (n = 888) implies that CSII is an uneasy method, complicated on average by 1 AE daily. This unexpected deduction contradicts the overall treatment satisfaction reported by participants but is in line with a recent report pointing that AEs related to CSII and especially to KT usage are inappropriately assessed. Clarity of such studies would be increased if key numbers such as number of participants reporting AEs, KT used, KT changes, frequency of glycemia testing, real failure rate, and so on were reported in standardized fashion. Satisfaction scores (2.1 ± 0.6 vs 2.3 ± 0.6, P < .05) were lower with 4-day use. However, it is doubtful that this statistical difference translates into clinically measurable outcome. This is particularly so because scores were ranked on the positive side of the spectrum, that is, from 1 (very satisfied) to 6 (not at all satisfied). Finally, the cost-benefit of changing KT every 2 to 3 days or less frequently was not assessed and would require longer and larger trials. Pfützner et al emphasize 2-day use. An important drawback of frequent KT replacement is the expense incurred by patients and health care systems. The 2 to 3-day replacement regimen however is not an evidence-based practice, with most reports in the scientific literature, including the Pfützner study, emanating from manufacturers themselves. Continuous glucose monitoring systems (CGMs) are transitioning from 7-day to 14-day wear. In our opinion, research should attempt to reduce the number of KT-related issues and extend the life of infusion sets in order to match CGMs life. Combining CGMs, algorithm, and insulin delivery system would reduce the number of required sites and be extremely convenient for awaited automated closed-loop insulin delivery.

Establishment of reference intervals for the salivary cortisol circadian cycle, by electrochemiluminescence (ECLIA), in healthy adults

OBJECTIVES To determine salivary cortisol reference intervals in a healthy adult population, at 6 different time points during a 24-hour (h) period. METHODS In a prospective study, salivary cortisol concentrations were measured upon waking, one-hour post-waking and at specific times of the day: at 12 h00, 16 h00, 20 h00 and midnight. Samples were analyzed by the first and second-generation electrochemiluminescence assays (ECLIA) from Roche Cobas Cortisol®. RESULTS Salivary cortisol values were obtained from 134 healthy volunteers. Reference intervals for the first-generation assay were 6.14-33.19 nmol/L (95% prediction interval) at waking, 5.42-28.06 nmol/L one-hour post-waking, 3.62-16.23 nmol/L at 12 h00, 2.78-15.27 nmol/L at 16 h00, 2.08-14.90 nmol/L at 20 h00 and 2.09-16.92 nmol/L at midnight. Mean salivary cortisol values were 14.63 nmol/L at waking and 6.44 nmol/L at midnight. Reference intervals for the second-generation assay were 1.50-22.02 nmol/L (2.5th to 97.5th percentiles) at waking, 1.50-20.87 nmol/L one-hour post-waking, 1.50-12.51 nmol/L at 12 h00, 1.50-13.03 nmol/L at 16 h00, 1.50-9.52 nmol/L at 20 h00 and 1.50-6.28 nmol/L at midnight. Values for the second-generation assay at all 6 different time points were almost half of the first-generation assay. The second-generation assay showed a better correlation with LC-MS/MS (r = 0,97). CONCLUSION Our study confirms that reference intervals for salivary cortisol are not comparable across first and second-generation Roche Cobas Cortisol® assays. Furthermore, the second-generation assay has a better correlation with LC-MS/MS and a better analytical performance (accuracy and precision).