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BackgroundRandomized controlled trials have demonstrated the benefits of sodium–glucose cotransporter 2 inhibitors (SGLT2is) in people with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD). However, real-world data on CKD progression and the development of end-stage kidney disease (ESKD) remains scarce. Our aim was to study renal outcomes of people with diabetic kidney disease (DKD) using SGLT2is in a highly prevalent DKD population.MethodsBetween 2016 and 2019 we recruited T2DM patients in the renal and diabetic clinics in a regional hospital in Singapore. Patients prescribed SGLT2is were compared with those on standard anti-diabetic and renoprotective treatment. The outcome measures were CKD progression [a ≥25% decrease from baseline and worsening of estimated glomerular filtration rate (eGFR) categories according to the Kidney Disease: Improving Global Outcomes guidelines] and ESKD (eGFR ResultsWe analysed a total of 4446 subjects; 1598 were on SGLT2is. There was a significant reduction in CKD progression {hazard ratio [HR] 0.60 [95% confidence interval (CI) 0.49–0.74]} with SGLT2is. The HR for eGFR ≥45 mL/min/1.73 m2 and 15–44 mL/min/1.73 m2 was 0.60 (95% CI 0.47–0.76) and 0.43 (95% CI 0.23–0.66), respectively. There was also a reduction in risk for developing ESKD for the entire cohort [HR 0.33 (95% CI 0.17–0.65)] and eGFR 15–44 mL/min/1.73 m2 [HR 0.24 (95% CI 0.09–0.66)]. Compared with canagliflozin and dapagliflozin, empagliflozin showed a sustained risk reduction of renal outcomes across CKD stages 1–4.ConclusionsThis real-world study demonstrates the benefits of SGLT2is on CKD progression and ESKD. The effect is more pronounced in moderate to advanced CKD patients.

A user-calibrated real-time continuous glucose monitoring (rt-CGM) system is compared to a factory-calibrated flash glucose monitoring (FGM) system and assessed in terms of accuracy and acceptability in patients with type 1 diabetes (T1D).Ten participants with T1D were enroled from a specialist diabetes centre in Singapore and provided with the Guardian Connect with Enlite Sensor (Medtronic, Northridge, CA, USA) and first-generation Freestyle Libre System (Abbott Diabetes Care, Witney, UK), worn simultaneously. Participants had to check capillary blood glucose four times per day. At the end of week 1 and week 2, participants returned for data download and were given a user evaluation survey.Accuracy evaluation between Guardian Connect and Freestyle Libre includes the overall mean absolute relative difference value (9.7 ± 11.0% vs. 17.5 ± 10.9%), Clarke Error Grid zones A + B (98.6% vs. 98.1%), sensitivity (78.9% vs. 63.4%), and specificity (93.4% vs. 81.0%). Notably, time below range (3.9 mmol/L) was 10.5% for FGM versus 2% for rt-CGM. From the evaluation survey, 90% of participants perceived rt-CGM to be accurate versus 40% for FGM, although the majority found both devices to be easy to use, educational, and useful in improving glycaemic control. However, due to the cost of sensors, only 30% were keen to use either device for continuous monitoring.Although rt-CGM was superior to FGM in terms of accuracy, the value of glucose trends in both devices is still useful in diabetes self-management. Patients and clinicians may consider either technology depending on their requirements.

Diabetes is prevalent, and it imposes a substantial public health burden globally and in the Asia-Pacific (APAC) region. The cornerstone for optimizing diabetes management and treatment outcomes is glucose monitoring, the techniques of which have evolved from self-monitoring of blood glucose (SMBG) to glycated hemoglobin (HbA1c), and to continuous glucose monitoring (CGM). Contextual differences with Western populations and limited regionally generated clinical evidence warrant regional standards of diabetes care, including glucose monitoring in APAC. Hence, the APAC Diabetes Care Advisory Board convened to gather insights into clinician-reported CGM utilization for optimized glucose monitoring and diabetes management in the region. We discuss the findings from a pre-meeting survey and an expert panel meeting regarding glucose monitoring patterns and influencing factors, patient profiles for CGM initiation and continuation, CGM benefits, and CGM optimization challenges and potential solutions in APAC. While CGM is becoming the new standard of care and a useful adjunct to HbA1c and SMBG globally, glucose monitoring type, timing, and frequency should be individualized according to local and patient-specific contexts. The results of this APAC survey guide methods for the formulation of future APAC-specific consensus guidelines for the application of CGM in people living with diabetes.

AIMS This real-world observational clinical programme evaluated short and medium-term effects of intermittent flash glucose monitoring on HbA1c, glycaemic variability and lifestyle behavioural changes. METHODS Two first-generation Libre flash glucose monitoring sensors were provided 3-4 months apart with a food, activity diary, user evaluation survey and treatment modification after each sensor wear. T-tests were used to compare glucose variables within each sensor (week 1 vs. week 2) and between sensors (1st sensor vs. 2nd sensor). EasyGV software was used to calculate glycaemic variability. RESULTS From 42 type 1 diabetes and 120 type 2 diabetes participants, there was no statistically significant change in mean HbA1c for participants with type 1 diabetes at 3-4 months after the 1st sensor but there was a statistically significant HbA1c reduction for participants with type 2 diabetes [-4 mmol/mol (-0.4%), p = 0.008], despite no statistically significant differences in carbohydrate intake, exercise frequency and duration. Greater reduction was seen in those with baseline HbA1c> 86 mmol/mol (10%) in both type 1 [-12 mmol/mol (-1.1%), p = 0.009] and type 2 diabetes [-11 mmol/mol (-1.0%), p = 0.001). Both type 1 and type 2 diabetes showed improvements in Glucose Management Indicator and percentage time-above-range when comparing week 1 versus week 2 of the same sensor. Higher scan frequency resulted in improved glycaemic parameters and certain measures of glycaemic variability. The majority of participants (85%) agreed that flash glucose monitoring is a useful device but only 60% were keen to use it for daily monitoring. CONCLUSION Constant feedback from flash glucose monitoring improves glycaemic parameters within the first week of wear. Intermittent use 3-4 months apart resulted in greater improvements for those with higher baseline HbA1c.

To evaluate the effects of Roux-en-Y gastric bypass (RYGB) versus best medical treatment in Asians with type 2 diabetes mellitus (T2DM) and class I obesity.In this 5-year single-centre, open-label randomized controlled trial, participants were randomized to RYGB or medical treatment including newer classes of diabetes medications (ClinicalTrials.gov:NCT02041234). The primary endpoint was diabetes remission defined as HbA1c ≤ 6% (≤42 mmol/mol) and discontinuation of glucose-lowering medication at 12 months post-intervention and beyond. Glycaemia and weight changes were assessed. Continuous glucose monitoring was performed.Of 28 subjects randomized, 26 were analyzed in the final cohort (14 medical, 12 RYGB; age:44 ± 10 years, 34.6% males, BMI:29.4 ± 1.6 kg/mOver 5 years, RYGB outperforms best medical treatment in glycemia and weight improvements for Asians with T2DM and class I obesity.

Background The impact of lockdown measures can be widespread, affecting both clinical and psychosocial aspects of health. This study aims to assess changes in health services access, self‐care, behavioural, and psychological impact of COVID‐19 and partial lockdown amongst diabetes patients in Singapore. Methods We conducted a cross‐sectional online survey amongst people with diabetes with the Diabetes Health Profile‐18 (DHP‐18). Hierarchical regression analyses were performed for each DHP‐18 subscale (Psychological Distress, Disinhibited Eating and Barriers to Activity) as dependent variables in separate models. Results Among 301 respondents, 45.2% were women, 67.1% of Chinese ethnicity, 24.2% were aged 40 to 49 years, 68.4% have Type 2 diabetes and 42.2% on oral medications alone. During the pandemic and the lockdown, nearly all respondents were able to receive care safely from the clinics they attend (94%) and obtain their medications and diabetes equipment and supplies (97%) when needed. Respondents reported less frequent engagement in physical activity (38%), checking of blood pressure (29%) and blood glucose (22%). Previous diagnosis of mental health conditions (β = 9.33, P = .043), Type 1 diabetes (β = 12.92, P = .023), number of diabetes‐related comorbidities (β = 3.16, P = .007) and Indian ethnicity (β = 6.65, P = .034) were associated with higher psychological distress. Comorbidities were associated with higher disinhibited eating (β = 2.49, P = .014) while ability to reach their doctor despite not going to the clinic is negatively associated with psychological distress (β = −9.50 P = .002) and barriers to activity (β = −7.53, P = .007). Conclusion Health services access were minimally affected, but COVID‐19 and lockdown had mixed impacts on self‐care and management behaviours. Greater clinical care and attention should be provided to people with diabetes with multiple comorbidities and previous mental health disorders during the pandemic and lockdown.

Ramadan fasting, a month-long annual practice for Muslims, can be challenging for those who have diabetes mellitus with or without associated complications or pre-existing comorbidities, as well as healthcare providers involved in their care. Inadequate preparation for this fasting period can result in increased complications. We reviewed the current practice of Muslims with diabetes mellitus in Singapore who intend to fast during Ramadan, with particular attention on locally available evidence. Adequate preparation for Ramadan fasting, including pre-Ramadan assessment, optimisation of glycaemic control, structured Ramadan-focused diabetes education, medication adjustment, glucose monitoring and test fasting, can lead to benefits in terms of improvements in metabolic control and reduced risk of fasting-related complications in people with diabetes mellitus. While there are ongoing efforts to reduce risk during this period, larger-scale national programmes are needed to avert complications and assess the long-term effects of Ramadan fasting in the local population.

Diabetes is a risk factor for developing severe COVID‐19, but the pathogenesis remains unclear. We investigated if the association of diabetes and COVID‐19 severity may be mediated by inflammation. We also hypothesized that this increased risk may extend to prediabetes. Hospitalized patients in Singapore with COVID‐19 were subdivided into three groups in a retrospective cohort: normoglycemia (HbA1c: ≤5.6%), prediabetes (HbA1c: 5.7%–6.4%) and diabetes (HbA1c: ≥6.5%). The primary outcome of severe COVID‐19 was defined by respiratory rate ≥30, SpO2 ≤93% or intensive care unit admission. The association between clinical factors on severe COVID‐19 outcome was analyzed by cox regression. Adjusted mediation analysis of C‐reactive protein (CRP) on the relationship between diabetes and severe COVID‐19 was performed. Of 1042 hospitalized patients, mean age 39 ± 11 years, 13% had diabetes, 9% prediabetes and 78% normoglycemia. Severe COVID‐19 occurred in 4.9% of subjects. Compared to normoglycemia, diabetes was significantly associated with severe COVID‐19 on both univariate (hazard ratio [HR]: 9.94; 95% confidence interval [CI]: 5.54–17.84; p, Research Highlights Inflammation, as measured by the biomarker C‐reactive protein, partially mediates the association between diabetes and adverse COVID‐19 outcomes, including the risk of developing severe COVID‐19, dyspnea, need for intensive care unit and length of stay.Level of glycaemia in patients with diabetes does not correlate with severe COVID‐19.Prediabetes is not an adverse prognostic marker in COVID‐19.

Background The impact of lockdown measures can be widespread, affecting both clinical and psychosocial aspects of health. This study aims to assess changes in health services access, diabetes self-care, behavioral and psychological impact of COVID-19 and partial lockdown in Singapore. Methods We conducted a cross-sectional online survey amongst people with diabetes with the Diabetes Health Profile-18 (DHP-18). Hierarchical regression analyses were performed for each DHP-18 subscale (Psychological Distress, Disinhibited Eating and Barriers to Activity) as dependent variables in separate models. Results Among 301 respondents, 45.2% were women, majority were ethnic Chinese (67.1%), aged 40 to 49 years (24.2%), have Type 2 diabetes (68.4%) and on oral medications (42.2%). During the lockdown, nearly all respondents were able to obtain their medications, supplies (94%) and contact their doctors (97%) when needed. Respondents reported less physical activity (38%), checking of blood pressure (29%) and blood glucose (22%). Previous diagnosis of mental health conditions (β=11.44, p= 0.017), diabetes-related comorbidities (β= 3.98, p= 0.001) and Indian ethnicity (β= 7.73, p= 0.018) were significantly associated with higher psychological distress. Comorbidities were associated with higher disinhibited eating (β= 2.71, p= 0.007) while mental health condition was associated with greater barriers to activities (β= 9.63, p= 0.033). Conclusion Health services access were minimally affected but COVID-19 and lockdown had mixed impact on self-care and management behaviors. Greater clinical care and attention should be provided to people with diabetes with greater number of comorbidities and previous mental health disorders during the pandemic and lockdown.

This study explores the association between perioperative hypoglycaemia and surgical outcomes in subjects with diabetes, undergoing colorectal surgery. A retrospective review of 149 subjects with Type 2 Diabetes Mellitus (DM) who underwent colorectal surgery between 2010 and 2015 was performed. Perioperative glucose levels, glycated haemoglobin (HbA1c) measurements within 3 months of surgery and surgical complications based on Clavien-Dindo classification were analysed. The mean age was 67 years (67 ± 11.2). Perioperative hypoglycaemia was found in 7.4% of subjects. The mean HbA1c of subjects with Clavien 2 and above surgical complications were higher than patients with Clavien 1 or no complications, Hba1c 7.6% (7.6 ± 2.5%) and 7.0% (7.0 ± 1.1%, p = 0.008), respectively. Similar findings in subjects with Clavien 3 and above complications, HbA1c of 8.2% (8.2 ± 3.9%) as compared to those with Clavien 2 and below complications, 7.2% (7.2 ± 1.5%, p = 0.001). Adjusted multivariate analysis showed that hypoglycaemia was significantly associated with Clavien 2 and above surgical complications, OR of 19.0 (CI 2.23–162, p = 0.007). Preoperative hypoglycaemia was associated with Clavien 2 and above surgical complications, OR 10.7 (CI 1.22–94.1, p = 0.032). Suboptimal glycaemic control (Hba1c >8.0%) was significantly associated with Clavien 2 and above complications, OR 2.48 (CI 1.04–5.91, p = 0.04), but not with Clavien 3 and above complications, OR 1.50 (CI 0.450–4.98, p = 0.511). Perioperative hypoglycaemia is associated with adverse surgical outcomes in diabetic patients undergoing colorectal surgery. Prevention of hypoglycaemia may improve surgical outcomes. HbA1c is an independent predictor for adverse surgical outcomes.

Methods: This is a single-centre, prospective observational controlled cohort study. Muslim patients aged 18 to 75 years with type 2 diabetes and estimated glomerular rate (eGFR) ≥ 45 ml/min/1.73 m2 were eligible if they had no contraindication to observe Ramadan fasting. Patients in study group received stable dose of SGLT2 Inhibitor for ≥ 3 months prior to enrolment and during study period, while patients in control group were not on SGLT2 inhibitor before and during study period. All participants were to attend baseline visit within 2 months before Ramadan and follow-up visit during Ramadan. Results: A total of 68 patients of similar baseline characteristics were included in the study: 35 in study group and 33 in control group. During Ramadan fasting, patients from study and control group had similar change in weight (LS mean change of -1.8 vs. -1.1kg, p=0.205), eGFR (LS mean change of -6.0 vs. -4.2ml/min/1.73m2; p= 0.399), sitting systolic BP (LS mean change of - 8.0 vs. -10.4mmHg, p=0.569), sitting diastolic BP (LS mean change of -3.7 vs. - 3.5mmHg, p=0.934) and plasma β-hydroxybutyrate level (LS mean change of -0.01 vs. -0.02mmol/L, p=0.649). Conclusions: Continued use of SGLT2 Inhibitors during Ramadan in the study had no increased risk in eGFR deterioration, ketonemia, hypoglycaemia and postural hypotension. Disclosure Y. Shao Yanli: None. G.J. Lim: None. C. Chua: None. Y. Wong: None. E. Yeoh: None. K. Low: None. C. Sum: None.

Tight glycemic control in type 1 diabetes (T1D) is limited by hypoglycemia, while glycemic variability (GV) confers independent risk for the development of diabetes-related complications. We aimed to establish the values for indices of hypoglycemia and GV in T1D Singaporean subjects. One-hundred and thirty one subjects (73% Chinese, 11% Malay, 12% Indian; 48% male) were recruited from a single center. Eighty subjects submitted glucose records performed over 4 weeks. Ryan lability index and HYPO score were calculated in subjects with at least 3 glucose readings/day. Key characteristics, indices of hypoglycemia and GV are summarized in the table. Hypo score and LBGI were significantly correlated (r=0.63). ADRR and mLI correlated with each other (r=0.79), and with LI (ADRR r=0.72, mLI r=0.93), S.D.(r=0.78 and 0.79), %CV (r=0.45 and 0.56) and HbA1c (r=0.53 and 0.44). LI correlated with S.D. (r=0.58) but not %CV or HbA1c Our results indicate differences compared to other populations. There were fewer subjects with hypoglycemia than Edmonton (85%), or Korean T1D subjects (71%), with much lower Hypo scores in our cohort (90th percentile of 76 vs. 1047 in Edmonton and 377 in Korean subjects). Ryan LI was comparable to the Edmonton cohort, but ADRR, LI and mLI were lower than Korean T1D subjects. Population-specific values should be established, to determine appropriate cut-offs for access to treatments such as islet transplantation. Clinical characteristics and glycemic indicesCharacteristicResultsGlycemic parametersResultsHypoglycemia awareness ScoresResultsGlycemic variability IndicesResultsAge of diagnosis, years19 (12 – 27)Average HbA1c (%)8.2 (7.3 – 9.2)Clarke score ≥424.6%Average daily risk range (ADRR) (n=53)Median (Interquartile range), 90th percentile25.0 (17.7 – 37.0), 40.6Duration of diabetes, years14 (8 – 19)Average Glucose (mmol/L)9.2 (8.0 – 11.2)Gold score ≥428.3%Ryan lability index (n843)Median (Interquartile range), 90th percentile168.5 (93.3 – 333.6), 432.8Insulin use (units/kg/day)0.77 (0.61 – 0.91)S.D. (mmol/L)4.4 (3.5 – 5.2)Hypoglycemia IndicesRyan lability index/no. of BG readings/day (modified Li, mLI)Median (Interquartile range), 90th percentile44.6 (27.0 – 63.1), 83.7Type of insulin regimen (twice daily, 3 times/day, 4 or more/day, insulin pump) (%)6.5/17.7/59.7/16.1%CV37.9 (9.9 – 44.5)Ryan Hypo score (n=43)Median (Interquartile range), 90th percentile 13 (0 – 25), 76Low blood glucose index (LBGI) (n=80)Median (Interquartile range), 90th percentile1.1 (0.5 - 2.1), 3.5% patients with at least 1 episode of hypoglycemia < 3 mmol/L38.8 Disclosure A. Koh: None. S.N. Fun: None. E. Yeoh: None.

Aim To evaluate the sustainability of the benefits of continuous subcutaneous insulin infusion therapy in routine practice in a cohort of adults with diabetes. Methods The clinical records of all adults starting continuous subcutaneous insulin infusion over 12 years at our centre were included in this study. Baseline and mean annual HbA1c levels were recorded. The frequency of mild-to-moderate and severe hypoglycaemia and hypoglycaemia awareness were analysed in a subgroup. Results Adequate data were available from 327 patients, of whom 71% were female. The patients' mean ± sd age was 41 ± 14 years, the mean ± sd (range) follow-up for continuous subcutaneous insulin infusion was 4.3 ± 2.7 (1–12) years. The mean ± sd HbA1c concentration fell by 8 ± 5 mmol/mol (0.7 ± 0.5%) at year 1 [to 63 ± 12 mmol/mol from 70 ± 18 mmol/mol (7.9 ± 1.1% from 8.6 ± 1.6%); P

OBJECTIVE Impaired awareness of hypoglycemia (IAH) increases the risk of severe hypoglycemia (SH) sixfold and affects 30% of adults with type 1 diabetes (T1D). This systematic review and meta-analysis looks at the educational, technological, and pharmacological interventions aimed at restoring hypoglycemia awareness (HA) in adults with T1D. RESEARCH DESIGN AND METHODS We searched The Cochrane Library, MEDLINE, Embase, Science Citation Index Expanded, Social Sciences Citation Index, PsycINFO, and CINAHL from inception until 1 October 2014. Included studies described HA status at baseline. Outcome measures were SH rates, change in HA, counterregulatory hormone responses, and glycemic control. RESULTS Forty-three studies (18 randomized controlled trials, 25 before-and-after studies) met the inclusion criteria, comprising 27 educational, 11 technological, and 5 pharmacological interventions. Educational interventions included structured diabetes education on flexible insulin therapy, including psychotherapeutic and behavioral techniques. These were able to reduce SH and improve glycemic control, with greater benefit from the latter two techniques in improving IAH. Technological interventions (insulin pump therapy, continuous glucose monitoring, and sensor-augmented pump) reduced SH, improved glycemic control, and restored awareness when used in combination with structured education and frequent contact. Pharmacological studies included four insulin studies and one noninsulin study, but with low background SH prevalence rates. CONCLUSIONS This review provides evidence for the effectiveness of a stepped-care approach in the management of patients with IAH, initially with structured diabetes education in flexible insulin therapy, which may incorporate psychotherapeutic and behavioral therapies, progressing to diabetes technology, incorporating sensors and insulin pumps, in those with persisting need.

Objective The effect of Ramadan fasting and continuing sodium-glucose co-transporter-2 (SGLT2) inhibitor use on ketonemia, blood pressure and renal function in Muslim patients with type 2 diabetes. Methods This is a single-centre prospective observational controlled cohort study. Muslim patients aged 21–75 years with type 2 diabetes and estimated glomerular filtration rate (eGFR) ≥ 45 ml/min/1.73 m2 were eligible if they had no contraindication to observe Ramadan fasting. Patients in study group were on stable dose of SGLT2 inhibitor for at least 3 months before enrolment and continued during study period, while patients in control group were not on SGLT2 inhibitor before and during study period. All participants attended baseline visit before Ramadan and follow-up visit during Ramadan. Results A total of 68 patients of similar baseline characteristics were included in the study: 35 in study group and 33 in control group. During Ramadan fasting, patients from study and control group had similar change in weight (LS mean change of −1.8 versus −1.1 kg, p = 0.205), eGFR (LS mean change of −6.0 versus −4.2 ml/min/1.73 m2, p = 0.399), sitting systolic BP (LS mean change of −8.1 versus −10.4 mmHg, p = 0.569), sitting diastolic BP (LS mean change of −3.7 versus −3.5 mmHg, p = 0.934) and plasma β-hydroxybutyrate level (LS mean change of −0.01 versus −0.02 mmol/L, p = 0.649). Conclusions Ramadan fasting was associated with significant changes in weight, BP and eGFR regardless whether patients were on SGLT2 inhibitor treatment. Continued use of SGLT2 Inhibitors during Ramadan did not increase ketonemia, nor increase risk of eGFR deterioration and hypoglycaemia.

Patients with diabetic kidney disease (DKD) on anti-diabetic agents, are at greater risk of glycemic variations, both hypoglycemia and hyperglycemia. We aimed to compare glycemic control (using HbA1c) and hypoglycemia incidence in patients with Stage 3 DKD (eGFR 30-60 mL/min per 1.73 mThirty patients with HbA1c 8% were randomized to 6-day retrospective CGM or SMBG. In the CGM group, CGM was worn at the beginning and 6 weeks. HbA1c, assessment of hypoglycaemia events (self-reported and BG 4 mmol/L from CGM/SMBG data) and medication adjustment were performed at baseline and 3 months. All patients received education on hypoglycaemia avoidance.Fourteen patients were allocated to CGM and 16 to SMBG. Mean (±SD) eGFR was 42.9 ± 10.3 mL/min. Majority (86.7%) of patients had diabetes duration10 years and on insulin therapy (90%). HbA1c improved significantly from baseline 9.9 ± 1.2 to 9.0 ± 1.5% (P 0.001) at 3 months, with no difference between CGM (9.8 ± 1.2 to 8.8 ± 1.8%, P = 0.009) or SMBG (9.9 ± 1.3 to 9.1 ± 1.1%, P = 0.007) groups (P = 0.869 between groups). In the CGM group, percentage duration in hyperglycaemia (BG 10 mmol/L) reduced from baseline 65.4 ± 22.4% to 54.6 ± 23.6% (P = 0.033) at 6 weeks, with a non-significant rise in percentage duration in hypoglycaemia from 1.2 ± 2.2% to 4.0 ± 7.0% (P = 0.176). There was no difference in self-reported and documented hypoglycaemia events.In a pilot study of DKD patients, short-term episodic use of CGM reduced time spent in hyperglycaemia range without significantly increasing time-exposure to hypoglycaemia. However, both CGM and SMBG were equally effective in improving glycaemic control.

Hypoglycemia is a major barrier toward achieving glycemic targets and is associated with significant morbidity (both psychological and physical) and mortality. This article reviews technological strategies, from simple to more advanced technologies, which may help prevent or mitigate exposure to hypoglycemia. More efficient insulin delivery systems, bolus advisor calculators, data downloads providing information on glucose trends, continuous glucose monitoring with alarms warning of hypoglycemia, predictive algorithms, and finally closed loop insulin delivery systems are reviewed. The building blocks to correct use and interpretation of this range of available technology require patient education and appropriate patient selection.

The cribriform morular variant of papillary thyroid carcinoma (CMV-PTC) is a rare morphologic entity that is associated with familial adenomatous polyposis (FAP). We report a case of a young lady with an incidentally discovered right-sided neck nodule on ultrasonography with a diagnosis of CMV-PTC confirmed on thyroidectomy and review the literature associated with the clinical presentation, imaging characteristics, pathological findings and the association with FAP.