Alternative site testing of blood glucose in children and adolescents with type I Diabetes

Nekoliko studija koje su uključivale odrasle osobe sa šećernom bolešću tipa 1 (T1ŠB) ukazalo je na to da rezultati mjerenja glukoze u krvi (GUK) na alternativnim mjestima (AM) i iz jagodice prsta nisu istovjetni. Različitosti su uočene u mjerenjima nakon obroka, nakon davanja inzulina, tijekom i nakon tjelesne aktivnosti. Naše ispitivanje je provedeno radi uvida da li sličnosti razine GUK s AM uočene u odraslih nalazimo u djece i adolescenata. Mjerenje GUK je obavljeno iz kapilarne krvi jagodica prsta i podlaktica, prije doručka i prije večere, ali najmanje dva sata nakon davanja inzulina i dva sata nakon obroka, i to OneTouch*Ultra samomjeračem (LifeScan). Studiji su pristupila 24 ispitanika s T1ŠB, sudionika ljetnog kampa u Dalmaciji. Nakon završetka kampa ispitanici su intervjuirani o iskustvima s AM. Ukupno je obavljeno 217 mjerenja iz AM i jagodice prsta. Linearna regresija pokazala je da izmjerene razine GUK iz AM koreliraju s razinama iz jagodice prsta (p<0,001, R=0,96). Analizom pomoću tzv. Clarkove mrežne analize greške, gdje je referentna vrijednost GUK iz jagodice prsta, 89,9% razine GUK iz AM bilo je u zoni A, 8,3% u zoni B, 2% u zoni D. Tzv. Parkesova analiza mrežne greške pokazala je 90,3% rezultata iz AM u zoni A, 10% u zoni B te niti jedan u zonama C i D. U 37% ispitanika postoji manji subjektivni osjećaj boli, a 46% njih ne osjeća bol pri korištenju AM. Njih 25% ističe jednostavnost mjerenja pri korištenju AM, a samo 29% će češće koristiti AM u kućnim uvjetima s obzirom na mjerenja u kampu. Povremeno ili rijetko će koristiti AM 71% ispitanika (42% zbog duljeg mjerenja, a 58% zbog težeg dobivanja krvi za mjerenje, odnosno zbog vidljivih tragova uboda). Tijekom trajanja kampa razine GUK korištenjem AM dobro koreliraju s razinama GUK iz jagodice prsta. Izneseno pokazuje da uz dobro usvajanje uputa, uporaba AM donosi objektivne i sigurne rezultate GUK.Several previous studies in adults with type 1 diabetes have documented that glucose levels obtained at alternative sites and at fingertip are not the same, a difference was noticed after a meal, after insulin application or during and after exercise. This study was done specifically to look at alternative site testing (AST) to determine if the site differences previously observed in adults are also found in children and adolescents. Glucose measurements were made using OneTouch Ultra System at fingertip and forearm sites, before breakfast and dinner, but at least two hours after insulin application and two hours after a meal. Twenty-four diabetics attending a summer camp in Dalmatia participated in the testing. At the completion of the camp, the children were questioned about their experience with AST. A total of 217 forearm measurements were made. Linear regression analysis showed that forearm glucose values were highly correlated with fingertip values (p<0.001, R=0.96). Using Clarke Error Grid analysis with fingertip readings as the reference values, 89.9% of values fell in zone A, 8.3% in zone B, 2% fell in zone D. Parkes Error Grid analysis showed 90.3% of values in zone A, 10% in zone B and none in zone C and D. Although 37% of the diabetics examined had a slight subjective feeling of pain, 46% did not feel pain using AST, 25% emphasized the simplicity of measuring blood glucose using AST and only 29% will use AST more frequently at home in regards to using it at the summer camp. 71% will periodically or rarely use AST (41% because it requires more time and 58% because it was harder to obtain blood for measurement or visible stab wounds were present). Glucose values obtained from forearm sites in children and adolescents studied in real life at the diabetic camp correlated closely with fingertip values. This suggests that when children follow the current guidlines for AST largely developed in adults, the results are reliable and can safely be utilized

The role of preoperative lymphoscintigraphy in surgery planning for sentinel lymph node biopsy in malignant melanoma

AIM: To evaluate four years of preoperative lymphoscintigraphy experience and the accuracy of sentinel lymph node biopsy in our institution in melanoma patients with various tumor thicknesses. An additional aim was to evaluate the recurrence rate related to pathohistological findings. - - - - - METHODS AND PATIENTS: During the period from February 2002 to November 2005, 201 patients underwent sentinel node biopsy. Lymphoscintigraphy for identification of sentinel nodes was performed four to six hours prior to operation of the patient. Sentinel lymph node biopsy using an intraoperative hand-held gamma probe was performed in all patients, together with wide local excision of biopsy wound or primary lesion (N=56). Immediate complete basin dissection was performed in patients with sentinel node metastases. In four patients delayed complete lymph node dissection was performed after definitive histopathologic examination of sentinel nodes. The accuracy of sentinel node biopsy was determined by comparing the intraoperative rates of sentinel node identification and the subsequent development of nodal metastases in regional nodal basins in patients with tumor-negative sentinel nodes and in those with tumorpositive sentinel nodes. - - - - - RESULTS: Using preoperative lymphoscintigraphy, we identified sentinel nodes in all but one of the 201 patients (99.0%), and in 248 nodal basins (1.2/patient) we observed 372 sentinel nodes (1.52 sentinels/basin; 1.8 sentinels/patient). The highest number of sentinel nodes was noticed in the groin of patients with melanoma on the lower extremities (1.5/patient), followed by the axilla (1.3/patient). Anomalous lymphatic drainage patterns were observed in 15.0% of all patients. The identification rate of sentinel nodes was 99.0% overall: 100% for the groin basins, and 98.0% for the axilla and head and neck basin. Forty-two patients (20.8%) had tumor-positive sentinel nodes. Ten patients (5.0%) had local or distant recurrences during a median follow-up of 23.1 months (range 2-46). The rate of false-negative lymphatic mapping and sentinel node biopsy as measured by nodal recurrence in patients with tumor-negative sentinel nodes was 1.3%. During the follow-up period, three of 201 patients died from other diseases and three patients died as the result of melanoma metastases, with a median follow-up of 13.5 months (range 12-22). - - - - - CONCLUSION: Preoperative lymphoscintigraphy is a sensitive, inexpensive and essential method for the identification of drainage basins, determination of the number and position of sentinel nodes and their location outside the usual nodal basins. Scintigraphic findings may lead to changes in surgical management due to the unpredictability of lymphatic drainage. The low incidence of regional disease recurrence in patients with tumor-negative sentinel nodes supports the use of preoperative lymphoscintigraphy and sentinel node biopsy as a safe and accurate procedure for staging the regional nodal basin in patients with malignant melanoma