Background and Aims / Part 1

The care of patients who undergo bariatric surgery is complex. These patients are not only severely obese, they are also burdened by the other expressions of the metabolic syndrome including type 2 diabetes, polycystic ovary syndrome, NASH, hypertension among other associated diseases. They pose challenges in selection, in assessment, in preparation for surgery, in post-operative care and, especially, in the management of late complications, including neuropathies due to malnutrition, episodic hypoglycemic attacks, internal hernias and mental health challenges

Methods / Part 2

Review of current approach to bariatric surgery. Comparison with other multidisciplinary centers such as pediatric hospitals, cancer centers, heart institutes

Results / Part 3

Surgeons do not have the resources, the time nor the training to address these issues alone. Interdisciplinary care is required at every stage of the progression before, during and after bariatric surgery.

Conclusions

Accordingly, it is time to follow the successful examples in the care of cancer and heart disease with the establishment of metabolic centers staffed by the various disciplines involved in the care of these complex and challenging patients. This presentation will review the early and long term outcomes of bariatric surgery, the shared pathology of the various expressions of the metabolic syndrome, the organizational structure of the proposed centers and approaches to certification for quality control.

Background and Aims

To investigate whether the Lower limb vascular intervention or Autologous platelet-rich gel (APR) treatment would benefit patients with diabetic lower extremity arterial disease (LEAD) with foot ulcer.

Methods

A total 82 diabetic LEAD with foot ulcer patients were recruited and divided into 3 groups: group A (30 patients received basal treatment), group B (21 patients received basal and autologous platelet-rich gel treatment), group C (31 patients received basal and Lower limb vascular intervention treatment), all patients had a routine follow-up visit for 6 months. The baseline characters and parameters were detected. After treatment, changes from baseline of all parameters were recorded. The differences among each groups and the relationship among each parameters were conducted.

Results

There were no difference in ABI and major amputation between group A and B (P>0.05), compared with group A and B, the ABI and major amputation rate of the C group were improved (P<0.05); There were no significant difference in Tcpo2, heal rate and minor amputation between A and C group (P>0.05), and compared with group A and C, the Tcpo2, heal rate and minor amputation of B group were improved (P<0.05). The logistic regression analysis indicated that the major amputation was mainly associated with ABI, and the minor amputation was mainly associated with Tcpo2. The lower limb vascular intervention can improve the ABI and reduce the major amputation, and the APR improves the Tcpo2 and reduces the minor amputation.

Conclusions

In diabetic LEAD with foot ulcer, major amputation was mainly associated with ABI, while minor amputation was mainly associated with Tcpo2. Interventional surgery mainly improves the ABI and reduces the incidence of major amputation with the improvement of macro-vascular, and the APR mainly improves the local Tcpo2, and reduces the incidence of minor amputations with the improvement of microcirculation.

Background and Aims

To evaluate intercourse of microcirculatory bed, EF parameters changes with nerves electrical activity metrics and compare them among patients with different HbA1C.

Methods

Patients (N=161) were divided into 3 groups: G1 -HbA1C<7% (N=46, men 54%, age 53.15±8.71), G2 -7≤HbA1C<9% (N=64.55% male, age 53.6±9.3), G3 -HbA1C>9%, N=51.51% males, age 53.53±8.54).

Digital capillaroscopy included capillary coiling (CC), polymorphism, network density, perivascular zone, arterial/ apex/ venous segments diameters estimation. Pulse wave velocity (PWV), endothelial function (EF) were measured by plethysmography. N.suralis, n.peroneus M-response amplitude (Mr-A), excitation propagation velocity (EPV), M-response triggering threshold (Mr-TT), residual latency were evaluated with stimulation electromyography.

Results

G2 in comparison to G1 revealed: decreased n.suralis Mr-A (p=0.04), reduced EPV (p=0.03), higher Mr-TT detection rate (p<0.01); decreased n.peroneus Mr-A (p=0.03); reduced EPV (p=0.02); increased capillary polymorphism (p=0.02), CC (p=0.06), venous/arterial segment ratio (p=0.04), increased PWV (p=0.02). Comparison between G3 and G2 also revealed statistical significance.

Microcirculatory disorders are minimally associated with diabetic polyneuropathy: direct correlation of capillary density with n.suralis EPV (p<0.05), and inverse correlation with increased n.peroneus Mr-TT (p<0.05).

The interrelation between EF and n.suralis Mr-A was determined. The correlation of PWV was revealed with: n.suralis Mr-TT and n.peroneus increase, n.peroneus low-amplitude F-waves with fallout and EPV.

Conclusions

Motor neuropathy was found more distinct than sensorial in 7≤HbA1C<9% group.

Interrelation between microvascular and neurological disorders identified minimally. Only capillary density correlated with EPV n.suralis, n.peroneus Mr-TT. Macrovascular violations (PWV increase, EF decrease) more than microvascular were associated with nerves electrical activity impairment. Interrelations between microcirculation, stimulation electromyography parameters and glucose+HbA1C were found.

Background and Aims

Aims: to assess the effects of associated autoimmune diseases on glycemic control, growth, metabolic parameters in children with type 1 diabetes (T1D) and to select the most predictive genetic, immune and metabolic risk factors of polyglandular autoimmunity in children with T1D.

Methods

72 children with combined autoimmune pathology (main group, age 11.98±3.79 years) and 75 patients with isolated T1D (control group, age 11.09±3.31 years) were recruited. Groups were comparable in age (p=0.17) and T1D duration (p=0.26). Anthropometric parameters, insulin doses, biochemical blood parameters, glycosylated hemoglobin (HbA1c), thyroid hormones and thyroid peroxidase antibodies (anti-TPO) levels were assessed.

Results

In the main group 49 children had combinations of T1D with autoimmune thyroiditis (AIT), 17 − celiac disease, 2 – Graves' disease, 4 – AIT and celiac disease. Body mass index and height z-scores in both groups corresponded to the mean age values and didn’t differ significantly (p=0.82 and 0.71 respectively). HbA1c level in children with combined autoimmune pathology was higher than in the control group (8.23±1.91% vs 7.47±1.22%, p=0.006). There was no difference in insulin requirement (p=0.93).

Both groups demonstrated similar values of biochemical blood parameters: lipidogram, serum iron, and ferritin (p>0.05). Higher anti-TPO antibodies were revealed in the main group (327.41±469.91 IU/ml) compared to the control group (40.42±26.33 IU/ml, p=0.0001).

Conclusions

At the present stage of the study we hasn’t found any difference in anthropometric and biochemical parameters in children with coexisting disorders compared with patients with isolated T1D. Children with polyglandular autoimmune pathology showed more poor glycemic control indicators.

Background and Aims

Lipohypertrophy (LH) is a chronic complication of diabetes mellitus that caused by subcutaneous injections of insulin. Nowadays, on the basis of results of ultrasonography of subcutaneous fat prevalence of LH in diabetic patients is still high. The aim has been to develop prevention of insulin induced LH in diabetic patients.

Methods

This study was done on 140 diabetic patients on insulin therapy a mean 8 years. On first stage patients were divided into two groups. First–117 patients with LH, second–23 diabetics without LH. All known LH risk factors were statistically processed using Spearman rank correlation coefficients. Results were statistically significant when p<0,05. On second stage 65 patients from first group were divided into two subgroups. First–50 patients with LH and corrected risk factors, second (control)–15 diabetics with LH and uncorrected risk factors. Ultrasonography were used in assessing new LH in these subgroups after 3 and 6 month.

Results

10 factors were remained after statistic analysis on first stage (p>0,05). Further, in first subgroup only 2 patients (4%) had new LH, while in second–9 diabetics (60%) had new pathologic areas of subcutaneous fat after 3 month. And in first subgroup only 6 patients (12%) had new pathologic areas of subcutaneous fat, while in second–12 diabetics (80%) had new LH after 6 month.

Conclusions

There were stated that only 10 risk factors strongly influence on LH progress. Correction of these risk factors doesn`t lead to development of new subcutaneous fat pathological changes and could be used to prevent LH in diabetic patients in clinical daily practice.

Background and Aims

With the support of the University of Virginia, the ARG controller without pre-meal boluses was successfully tested on the DiAs platform in the first clinical trials in Latin America. To further develop the ARG algorithm, the design of an own platform was carried out in view of future trials.

Methods

The GluControl platform (Figure) is based on the Android APS (AAPS), which is in turn designed from the Open APS. Initially, the connection with the same commercial devices as those used in the clinical trials were considered: Roche Accu-Chek Spirit Combo insulin pump and DexCom G4 Platinum CGM. Thereafter, GluControl was also tested using Freestyle Libre and the MiaoMiao Bluetooth adapter. To run the system, Motorola Moto G5 and One cell-phones were used, in which the ARG controller and a user interface were developed. Multiple-patient remote monitoring and online registry of the main system variables were also implemented.

Results

The base system (GluControl, Dexcom G4 and Roche Spirit Combo) was tested during 240hs, showing adequate CL operation for 93% of total time. Regarding the algorithm, an ARG version with disconnection mitigation techniques was tested using the glucose measurements from the clinical trials. The average relative error in total delivered insulin with respect to Matlab controller implementation was 5,37%, while the difference compared to the clinical trials results with DiAs-based implementation was of 6,94%.

Conclusions

An open-source APS platform including a monitoring system for several patients was introduced. Results are comparable to those obtained by other well-known systems for clinical trials.

Background and Aims

Activation of the hexosamine pathway of glucose metabolism in hyperglycemia leads to the formation of glyoxal, methylglyoxal, and later malonic dialdehyde. These products have a negative effect on the blood vessels wall in patients with type 2 diabetes mellitus (T2DM). The aim of the study was to evaluate the effectiveness of the antioxidant drug N-acetylcysteine in patients with T2DM and lower extremities microangiopathy for correction of glyoxal, metiglyoxal and malonic dialdehyde levels.

Methods

20 men with T2DM and lower extremities microangiopathy with N-acetylcysteine treatment combined with recommended therapy ​​and 30 healthy men (control group) in the study were involved. N-acetylcysteine ​​administered in a daily dose of 600 mg intravenously for 7 days. Methods of high-performance liquid chromatography used.

Results

In patients with T2DM and lower extremities microangiopathy, the glyoxal level increased to the third day (by 56%) and decreased to the control values to the seventh day. The level of methylglyoxal did not change to the third day, but decreased by 5 times to the seventh day. The dynamics of the malonic dialdehyde level decreased on the third (by 15%) and seven (by 47%) days.

Conclusions

The use of N-acetylcysteine allows to decrease the amount of ketoaldehydes in the blood and, thereby, to reduce the manifestation of vascular complications.

Background and Aims

Chronic kidney disease (CKD) is considered as an important factor in the disruption of the synthesis and regulation of 25(OH) vitamin D. Also, in patients with CKD terminal stage the thyroid function decrease is considered as one of the risk factors of adverse outcomes. Comparative analysis of the vitamin 25(OH)D and thyroid hormones levels in patients with diabetes mellitus and CKD was this research aim

Methods

Patients with type 1 and type 2 diabetes mellitus (DM) (n = 14, average age 54.5 years) and comparison group without carbohydrate metabolism disorders (n = 17, average age 52 of the year) were examined. In both groups, patients had a terminal stage of CKD and received renal replacement (лучше substitution therapy) therapy. The thyroid-stimulating hormone, thyroxine levels and vitamin 25(OH)D in the blood were determined

Results

The incidence of severe deficiency of vitamin 25(OH)D in the group of patients with DM was higher (81.8%) compared with the group of patients without DM (45.5%) (p<0.05). Correlation analysis revealed the presence of a feedback relations between the content of vitamin 25(OH)D in the blood and the daily average glycaemia in patients with DM (r=-0.66, p<0.05). An analysis of the thyroid hormones profile revealed thyroid hypofunction - subclinical hypothyroidism in 28.5% of all examined patients. A comparative analysis of this parameters not detected statistically significant differences (p>0.05) between two groups.

Conclusions

High prevalence of vitamin 25(OH)D deficiency in patients with end-stage renal failure and DM were found. More than a quarter of patients receiving renal substitution therapy had subclinical hypothyroidism.

Background and Aims

Endogenous hyperinsulinism caused by an insulinoma is a rare condition, potentially causing severe hypoglycaemia. The definite therapy for insulinoma is a pancreas-sparing surgery. That is why accurate preoperative localization of the tumour is important. However, most insulinomas are solitary, benign and rather small in size, which often makes their localization difficult. In about 10% of insulinomas, conventional imaging (CT, EUS, MRI, somatostatin receptor scintigraphy) is negative. Glucagon-like peptide-1 receptors (GLP-1R) are expressed in high percentage and density in virtually all insulinomas. The aim of this study was to evaluate GLP-1R imaging with the use of [Lys⁴⁰(Ahx-HYNIC-^99mTc/EDDA)NH₂]-exendin-4 in localization of insulinoma, when conventional imaging was negative or inconclusive.

Methods

Whole-body GLP-1R SPECT/CT was performed four hours after administration of [Lys⁴⁰(Ahx-HYNIC-^99mTc/EDDA)NH₂]-exendin-4 in patients with suspected insulinoma and negative or inconclusive conventional imaging (CT/EUS/MRI/SRS). The results of the GLP-1R scintigraphy were evaluated by an experienced nuclear medicine physician. Following surgical excision of the lesion, the diagnostic performance of the GLP-1R scintigraphy was analysed using histopathological evaluation and patient’s symptoms resolution as the gold standard.

Results

Seven female patients with biochemically confirmed endogenous hyperinsulinism during fasting test were enrolled in our study. In all patients, focal uptake of the radiopharmaceutical in the pancreas was found and surgery was performed. No metastases were found. In all cases, insulin-producing neuroendocrine tumors were confirmed by histopathological analysis and patient’s symptoms resolved after surgery. The sensitivity and specificity of GLP-1R scintigraphy were 100%.

Conclusions

GLP-1R imaging with the use of [Lys⁴⁰(Ahx-HYNIC-^99mTc/EDDA)NH₂]-exendin-4 is a highly efficient diagnostic modality for localization of insulinoma.

Background and Aims

Diabetic Retinopathy (DR) is a fast-progressing disease, often resulting in blindness, early diagnosis being crucial to prevent further damage. Eye Fundus Images (EFI) can be analyzed to detect lesions and the degree of DR. Automated detection of individual lesions helps visualizing the lesions, characterizing their location, size and severity, and also detecting the degree of DR [1]. Deep learning is state-of-the-art in segmentation procedures. Aim: Evaluate state-of-the-art, deep learning-based, segmentation of EFI.

Methods

IDRID Diabetic Retinopathy dataset with 55 train and 28 test Eye Fundus Images (EFI), together with corresponding groundtruth label masks; DeepLabV3 vs Fully Convolutional Network (FCN): segmentation using deep convolution neural networks (DCNN) trained to recognize the lesions; DCNN is used to recognize lesions in test dataset; Metrics: (A) = Global Accuracy and Iou; (B) Per-lesion accuracy (OD=Optic Disk, HA=Haemorrhages, HE=Hard Exudates, SE=Soft Exudates, MA=MicroAneurisms, BK=bkground);

Results

Training Runtime: DeepLabV3 19 minutes with 1 GPU; FCN 635 minutes with 1 GPU; Accuracy (A) DeepLabV3 (acc 82.2%, IoU 32%), FCN (88.5%, IoU 38%); (B) DeepLabV3 (OD 95.3%, SE 84.1%, HA 65.3%, HE 95.2%, MA 83.9%, BK 80%), FCN (OD 95.3%, SE 62.1%, HA 58.1%, HE 80.2%, MA 63%, BK 89%).

Conclusions

Results show that DCNN approaches achieve relatively high accuracy but low IoU, and DeepLabV3 achieves better accuracy over individual lesions. Future work: the approaches need further developments to improve IoU, our focus of future work on the subject.

Background and Aims

The purpose of this study is to compare the cross-section-area(CSA) of ​​the median nerve according to the severity of carpal tunnel syndrome(CTS) in patients electrophysiologically diagnosed as CTS alone and diabetic polyneuropathy(DPN) with CTS.

Methods

DPN is diagnosed according to the criteria set forth in The Diabetes Control and Complications Trial. CTS is characterized by the Steven’s criteria. The severity of CTS was determined using Steven's classification. The CSA of the median nerve is measured at the distal wrist crease and forearm 12cm proximal to the distal wrist crease using ultrasonography.

Results

The comparison of median nerve CSA and wrist-to-forearm ratio showed significant differences between normal and CTS group, and normal and DPN-CTS group, but there was no significant difference between CTS group and DPN-CTS group (Table1,2).

Median nerve CSA at the distal wrist crease and the wrist-to-forearm ratio of CTS group and DPN-CTS group were compared according to CTS severity. There was no significant difference between both groups of any severity (Table3,4).

Conclusions

The results of this study concluded that median nerve swelling at the wrist level in DPN CTS patients was thought to be due to compression effects on the wrist rather than the metabolic effect of diabetes.