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Objectives Hybrid closed loop systems (HCL) improve the management of type 1 diabetes (T1DM). T1DM adolescent patients represent a risk category also if they are in an automated insulin infusion delivery therapy. Case presentation We describe a series of four cases in which adolescent patients have adopted incorrect behaviours in the managing of HCL systems, challenging the algorithm skills. Two patients performed fabricated sensor calibrations. The other two did not perform pre-prandial insulin boluses correctly. Despite these behaviours, the algorithm corrected the glucose values in three out of four patients. Only in one case, where fabricated calibrations were too frequent, the automatic system failed to restore the glycemic balance. Conclusions Fabricated calibrations seem to be more important than uncorrected insulin boluses to challenge the HCL systems.

Background: When very low doses of insulin are used insulin dilution, a procedure prone to errors, is recommended.Case presentation: We managed a neonate with pancreas agenesis with insulin pump therapy from the first days of life to 16 months of age without insulin dilution. Predictive low glucose suspend mode first and then closed loop control were used. No episodes of severe hypoglycemia were observed. Conclusions: Though limited to a single patient with pancreas agenesis we believe that the use of pump should be warranted in patients with permanent neonatal diabetes mellitus and intestinal malabsorp-tion, even with undiluted insulin.(c) 2022 Diabetes India. Published by Elsevier Ltd. All rights reserved.

Background: Glycemia following pizza consumption is typically managed with a dual-wave insulin bolus. This study evaluated the effect of a simple bolus on glycemia following consumption of traditionally prepared pizzas with long (24 h) or short (8 h) dough fermentation periods. Research Design and Methods: On two separate evenings, children with type 1 diabetes (n = 38) receiving sensor-integrated pump therapy consumed traditionally prepared pizza with either short (pizza A) or long (pizza B) dough fermentation, and blood glucose was monitored over 11 h. A simple insulin bolus was administered 15 min preprandially. The carbohydrate and amino acid contents of the two types of pizza were analyzed by liquid chromatography and high-resolution mass spectrometry (LC-HRMS). Results: The mean (±standard deviation) time in range 3.9-10.0 mmol/L was 73.2% ± 23.2%, and 50.8% ± 26.7% of glucose measurements were within the range 3.9-7.8 mmol/L. However, during the 2 h after bolus administration, the mean time in range 3.9-7.8 mmol/L was significantly greater with pizza B than with pizza A (73.3% ± 31.5% vs. 51.8% ± 37.4%, respectively, P = 0.009), and the time in hyperglycemia (>10 mmol/L) was significantly shorter (mean percentage 6.1% ± 19.0% vs. 17.7% ± 29.8%, respectively, P = 0.019). LC-HRMS analysis showed that long fermentation was associated with a lower carbohydrate content in the pizza, and a higher amino acid content. Conclusions: Glycemia following consumption of traditionally prepared pizza can be managed using a simple bolus 15 min before eating. Glycemic control can be further improved by increasing the dough fermentation time. Study registration: NCT03748251, Clinicaltrials.gov.

Background and Aims Pizza is considered a "junk food", because of high content of fat and carbohydrates. The glycaemic response to pizza could change according to the fermentation of the dough. Dual-wave bolus is usually used to manage pizza meal. Aim of our study was to evaluate glycemic response in a pediatric population with T1DM, after consumption of pizzas made with two different kinds of fermentation but the same Italian recipe,with a simple wave bolus. Method We enrolled 18 patients with T1DM on CSSI to evaluate their glycaemic response to the short and the long fermented pizza (less than 8 hours or more than 24 hours). Results We observed that glucose values were between 70 and 180 mg/dl for a good percentage of time in both types of pizza during all the periods of observation. For male patients the mean percentage of time between 70-180 mg/dl, for 2 hours after bolus, was 71% for the first pizza and 95% for the second (p=0·044). Considering the same time window, there was a significant difference as far as percentage of time is concerned for patients with metabolic compensation ”not in target” with SG

Choosing the right infusion set site can be an important factor in obtaining good glycemic control, especially in very young children. In an attempt to identify the best infusion site, we performed a crossover study in six preschool children with type 1 diabetes using insulin pump therapy.We enrolled six patients 5.2±0.7 years old (range, 4-6 years), with type 1 diabetes for more than 1.5 years, using insulin pump therapy for at least 6 months. For each patient, body mass index, glycated hemoglobin, and all data downloaded from the system were evaluated on two occasions: the first with the infusion set placed on the buttock and the second on the abdomen, each for 3 days. The order of infusion set placement was randomized. Mean capillary blood glucose, mean continuous glycemia, mean area under the curve (AUC) using the trapezoidal rule for both140 mg/dL and70 mg/dL, insulin daily dose, carbohydrate/insulin ratio, total basal insulin, total bolus insulin, and mean amplitude of glucose excursions (MAGE) were evaluated.Mean glycemic values, mean AUC140 mg/dL, and MAGE were significantly lower when the infusion set was placed on the buttock versus the abdomen (144.6±31.9 mg/dL vs. 166.0±34.8 mg/dL [P=0.000], 28.4±18.3% vs. 48.8±28.2% [P=0.000], and 32±10 vs. 60±15 mg/dL [P0.001], respectively), whereas mean AUC70 mg/dL was higher (1.47±2.77% vs. 0.87±1.03% [P0.001]).The present findings suggest that preschool children with type 1 diabetes using insulin pump therapy could benefit from inserting the infusion set in the buttock instead of the abdomen.