The 57th Annual American Diabetes Association Meeting & Scientific Sessions was held from June 21 to 24, 1997 in Boston, Massachusettes. Here is a brief summary of interesting news and scientific reports from the meeting. Additional information about products and research will be published in the coming weeks.
Classification GuidelinesAfter two years of work, the ADA announced new classification and diagnosis guidelines for diabetes. The goals for the new guidelines were:
- Focus on the cause of diabetes rather than the treatment regimen
- Develop a standard that can be used worldwide
- Eliminate the confusion surrounding the use of insulin
Under the new guidelines, Type 1 diabetes is now referred to as immune mediated diabetes mellitus to highlight its autoimmune etiology (cause). The type is indicated by an Arabic number one ("1"), not a Roman numeral one ("I"). Type 1 diabetes was formerly called insulin-dependent diabetes or juvenile diabetes. Type 1 diabetes is positively diagnosed by the presence of specific immunological indicators, such as islet cell antibodies, insulin antibodies, or GAD antibodies.
For a more complete review of the guidelines, with information important for Type 2 diabetes, see Classification and Diagnosis of Diabetes.
ResearchThe research information presented at the conference included work that is in various states of completion. Many discussions after presentations demonstrated lack of consensus on the meaning of test results or epidemiologic data. The information presented here is exciting, but should not be interpreted to mean anything other than what is presented. In particular, the work on islet transplants, both allogenic and xenogenic, is not ready for clinical application -- yet.
- The Introduction to Transplantation Tolerance Symposium included four excellent discussions about the underlying autoimmunity of both transplant graft rejection (allogenic and xenogenic) and islet cell destruction found in IDDM. Both of these must be eliminated for islet cell transplants to work. Highlights from the symposium:
- Researchers have developed techniques that prevent xenogenic (cross species) graft rejection in animals, successfully eliminating the need for immunosuppressant drugs. In short, cells from a pig can be implanted into a human without the commonly used -- and very toxic -- immunosuppressant drugs. Scientists mask certain antigens on the porcine cells that trigger the immune response. This prevents graft rejection but does not interfere with other immune system function. This technique has been used successfully in a small number of human patients with Parkinson's Disease in which fetal porcine neurons were implanted into the patients' brains.
- Scientists have identified the two different autoimmune responses to allogenic (same species) transplants in the NOD mouse (an animal model for human IDDM). At the molecular level, the two responses (CD8 for graft rejection and CD4 for IDDM) are very different. Introducing anti-CD8 antibodies prevents graft rejection but doesn't prevent recurrence of the underlying CD4-mediated IDDM. Introducing anti-CD4 antibodies extends the life of transplanted islets by preventing the autoimmune response that causes IDDM.
- There is evidence that the destruction of transplanted islet cells is caused by free radicals and that this destruction can be reduced or prevented by the introduction of agents that stop free radicals at the time of transplant.
- In the NOD mouse, which spontaneously develops IDDM, treatment early in life with an agent called CTLA4Ig, which blocks one of the essential communication pathways between T cells and Beta cells, completely prevents development of IDDM. Further, treatment with CTLA4Ig was shown to modify the animal's immune system. NOD mice that received an allogenic transplant of islet cells in conjunction with CTLA4Ig, had the graft removed, and later had another graft implanted from the same source as the original graft, were able to remain insulin-free, proving that CTLA4Ig changed the underlying immune system of the mouse so that it did not present the autoimmunity that causes IDDM after transplant.
- Transplantation summary: Scientists know how to prevent rejection of certain transplants from same and different species donors without the use of immunosuppressant drugs. Scientists believe they understand how the second immune response -- that which causes IDDM -- works and how it can be masked to prevent the recurrence of IDDM after transplant. Both must be perfected before islet cell transplantation can be considered for children with diabetes. The underlying science and technology is very complex. Much work needs to be done as this technique moves from the NOD mouse to humans. -- JH.
- There were many interesting poster presentations. A post presentation is just that -- enlarged, poster-sized pages that are posted on a bulletin board for people to read. The authors are available at scheduled times to discuss the topic of the paper. The following poster presentations are a few that might be of interest to children with diabetes and their families:
- Correlation of Number of Outpatient Diabetes Visits to a Comprehensive Pediatric Diabetes Center and Other Measures with HbA1c by Francine Kaufman, Sue Carpenter and Mary Halvorson of Los Angeles, California, concludes that children who live in an urban setting and who visit a pediatric diabetes clinic three to four times a year achieve lower HbA1c values (< 8.0, assay reference 3-6%) than children who visit less often.
- The Action Profile of Lispro is not Blunted by Mixing in the Syringe with NPH Insulin by Stonny Joseph, Anna Burakowska, James Woodworth, Mark Evans, David Hopkins, and Benito Cerimele concludes that mixing lispro insulin with NPH immediately before injection did not retard lispro's rapid absorption. This is good news for those who are moving to lispro from regular and who use NPH as a basal insulin.
- IDDM Risk Associated with Various HLA-DRB103, DQB10201/DRB104, DQB10302 Genotypes: Implications for General Population Screening by Marian Rewers, Teodorica Bugawan, Marie Allen, Brenda Beaty, Sunanda Babu, Michelle Hoffman and Rebecca Garcia of Denver, Colorado, reports that the HLA-DRB1*03/0401(0402), DQB1*0302 genotypes are present in only 0.73% of the U.S. population and increase risk for IDDM by a factor of 40. 9% of children with this genotype develop IDDM by the age of 20, and they account for 25% of all IDDM patients. (Siblings of children with diabetes can be screened for this genotype by participating in the DAISY study.)
- Lispro Insulin is Suitable for External but not for Internal Implantable Pumps by S. Demirdjian, S. Savin, P. Zirinis, C. Bardin, F. Chast, G. Slama and J.L. Selam of Paris, France report that lispro insulin is more stable than the insulins commonly used in external insulin pumps, but not at temperatures that would be experienced in an implantable pump (38° C).
- Hepatitis B Immunisation and Incidence of IDDM in Children and Adolsecents in Canterbury by Jinny Willis, Russell Scott, Brian Darlow, Helen Lunt and Peter Moore of Christchurch, New Zealand, reports that the increase in the incidence of IDDM reported in Canterbury, New Zealand since 1970 was not caused by the introduction of Hepatitis B vaccinations, and that immunization at birth does not reduce the risk of developing IDDM, countering claims made by J.B. Classen in Diabetologia [30:500-502, 1996] and the New Zealand Medical Journal [24 May 1996].
- Educational video game for juvenile diabetes; results of a controlled trial by S.J. Brown, D.A. Lieberman and B.A. Gemeny of Raya Systems Inc.; Y.C. Fan and D.M. Wilson of Stanford University Medical Center; and D.J. Pasta of DMA Corporation; reports that "well-designed, educational video games can be effective interventions" after the study demonstrated that kids who played the Packy & Marlon® Super Nintendo® game has better communication with their parents about their diabetes and had a decrease in unscheduled urgent doctor visits. Kids now have one more reason why they should be allowed to play video games! [Med.Inform. (1997), Vol. 22, No. 1, 77-89]
- Amylin Pharmaceuticals presented information published in several medical journals demonstrating that injections of an analogue of amylin (the second hormone secreted by the beta cells and only discovered in 1987) reduce post-meal blood sugar levels in adults with Type 1 diabetes by delaying gastric empyting. At present, it is unclear whether an amylin analogue, injected with insulin, will improve glycemic control in children with diabetes. Beta-cell Dysfunction in Diabetes: The Roles of Amylin and Insulin, a paper written by the company, describes the role of amylin.
- Bayer Diagnostics unveiled the Glucometer DEX, a new blood glucose meter that uses technology similar to the Glucometer Elite but with the test strips enclosed in a sealed disk. The Glucometer DEX eliminates the major complain that people have about the Glucometer Elite -- the difficulty in handling its test strips.
- Cell Robotics, Inc., showed the Lasette, a laser finger perforator that is designed to replace traditional steel lancets. Product literature says that the laser dramatically reduces the pain associated with blood testing. The Lasette uses rechargeable batteries and has an expected life of several years. Pricing is expected to be within the reach of home users. This device is undergoing clinical testing at this time and is not available for sale by Cell Robotics, Inc.
- MiniMed demonstrated their new Sof-serter automatic soft-set inserter. Serving much same function for the soft-set that the Inject-Ease does for syringes, the Sof-serter makes inserting a soft-set pump infusion set simple. Highly recommended for users of MiniMed insulin pumps. (I tested it and can report that it was painless.)
- Palco Labs showed a new, improved lancing device called the auto-Lancet that combines the ease of use of the Soft Touch with an adjustable depth head similar to that found on the Softclix. This new lancing device will be sold by Palco, B-D and Boehringer-Mannheim.
For Additional Information
- Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus, published in the July 1997 issue of Diabetes Care, details the new classification and diagnostic guidelines of the American Diabetes Association.
- You can search the abstracts of material presented at the 57th Annual American Diabetes Association Meeting at the 57th Scientific Sessions Abstract Search page.
Last Updated: Thursday August 26, 2004 10:56:10
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