High Variability Group Research Articles

Glycemic control, HbA1c variability, and major cardiovascular adverse outcomes in type 2 diabetes patients with elevated cardiovascular risk: insights from the ACCORD study

BackgroundAlthough recent guidelines advocate for HbA1c target individualization, a comprehensive criterion for patient categorization remains absent. This study aimed to categorize HbA1c variability levels and explore the relationship between glycemic control, cardiovascular outcomes, and mortality across different degrees of variability.MethodsAction to Control Cardiovascular Risk in Diabetes study data were used. HbA1c variability was measured using the HbA1c variability score (HVS) and standard deviation (SD). K-means and K-medians clustering were used to combine the HVS and SD.ResultsK-means clustering was the most stable algorithm with the lowest clustering similarities. In the low variability group, intensive glucose-lowering treatment significantly reduced the risk of adverse cardiovascular outcomes (HR: 0·78 [95% CI: 0·63, 0·97]) without increasing mortality risk (HR: 1·07 [0.81, 1·42]); the risk of adverse cardiovascular events (HR: 1·33 [1·14, 1·56]) and all-cause mortality (HR: 1·23 [1·01,1·51]) increased with increasing mean HbA1c. In the high variability group, treatment increased the risk of cardiovascular events (HR: 2.00 [1·54, 2·60]) and mortality (HR: 2·20 [1·66, 2·92]); a higher mean HbA1c (7·86%, [7·66%, 8·06%]) had the lowest mortality risk, when the mean HbA1c was < 7·86%, a higher mean HbA1c was associated with a lower mortality risk (HR: 0·63 [0·42, 0·95]). In the medium variability group, a mean HbA1c around 7·5% was associated with the lowest risk.ConclusionsHbA1c variability can guide glycemic control targets for patients with type 2 diabetes. For patients with low variability, the lower the HbA1c, the lower the risk. For those with medium variability, controlling HbA1c at 7·5% provides the maximum benefit. For patients with high variability, a mean HbA1c of around 7·8% presents the lowest risk of all-cause mortality, a lower HbA1c did not provide cardiovascular benefits but instead increased the mortality risk. Further studies, especially those with patients that reflect the general population with type 2 diabetes undergoing the latest therapeutic approaches, are essential to validate the conclusions of this study.

Multidimensional variability in ecological assessments predicts two clusters of suicidal patients

The variability of suicidal thoughts and other clinical factors during follow-up has emerged as a promising phenotype to identify vulnerable patients through Ecological Momentary Assessment (EMA). In this study, we aimed to (1) identify clusters of clinical variability, and (2) examine the features associated with high variability. We studied a set of 275 adult patients treated for a suicidal crisis in the outpatient and emergency psychiatric departments of five clinical centers across Spain and France. Data included a total of 48,489 answers to 32 EMA questions, as well as baseline and follow-up validated data from clinical assessments. A Gaussian Mixture Model (GMM) was used to cluster the patients according to EMA variability during follow-up along six clinical domains. We then used a random forest algorithm to identify the clinical features that can be used to predict the level of variability. The GMM confirmed that suicidal patients are best clustered in two groups with EMA data: low- and high-variability. The high-variability group showed more instability in all dimensions, particularly in social withdrawal, sleep measures, wish to live, and social support. Both clusters were separated by ten clinical features (AUC = 0.74), including depressive symptoms, cognitive instability, the intensity and frequency of passive suicidal ideation, and the occurrence of clinical events, such as suicide attempts or emergency visits during follow-up. Initiatives to follow up suicidal patients with ecological measures should take into account the existence of a high variability cluster, which could be identified before the follow-up begins.

Factors Associated With Residual Apnea-Hypopnea Index Variability During CPAP Treatment

CPAP is the first-line therapy for OSA. A high or variable residual apnea-hypopnea index (rAHI) reflects treatment failure and potentially is triggered by exacerbation of cardiovascular comorbidities. Previous studies showed that high rAHI and large rAHI variability are associated with underlying comorbidities, OSA characteristics at diagnosis, and CPAP equipment, including mask type and settings. What factors are associated with predefined groups with low to high rAHI variability? This registry-based study included patients with a diagnosis of OSA who were receiving CPAP treatment with at least 90days of CPAP remote monitoring. We applied the hidden Markov model to analyze the day-to-day trajectories of rAHI variability using telemonitoring data. An ordinal logistic regression analysis identified factors associated with a risk of having a higher and more variable rAHI with CPAP treatment. The 1,126 included patients were middle-aged (median age, 66 years; interquartile range [IQR], 57-73 years), predominantly male (n= 791 [70.3%]), and obese (median BMI, 30.6kg/m2 (IQR, 26.8-35.2kg/m2). Three distinct groups of rAHI trajectories were identified using hidden Markov modeling: low rAHI variability (n= 393 [35%]), moderate rAHI variability group (n= 420 [37%]), and high rAHI variability group (n= 313 [28%]). In multivariate analysis, factors associated with high rAHI variability were age, OSA severity at diagnosis, heart failure, opioids and alcohol consumption, mental and behavioral disorders, transient ischemic attack and stroke, an oronasal mask, and level of leaks when using CPAP. Identifying phenotypic traits and factors associated with high rAHI variability will allow early intervention and the development of personalized follow-up pathways for CPAP treatment.

Impact of Tacrolimus Trough Variability on Acute Rejection Following Lung Transplantation

Acute rejection is a risk factor for the development of chronic lung allograft dysfunction, the leading cause of morbidity and mortality in lung transplant recipients. Calcineurin inhibitors are the cornerstone of immunosuppression regimens after lung transplantation. We retrospectively evaluated the association of tacrolimus level variability with total acute rejection score at 12 months post-transplant. Secondary outcomes included the development of chronic lung allograft dysfunction and antibody-mediated rejection at 24months post-transplant. There were 229 lung transplant recipients included. The mean (standard deviation) total rejection score of the cohort was 1.6 (1.7). Patients with high tacrolimus variability at 0 to 3, 3 to 6, and 6 to 12 months on average scored 0.18 (mean 1.6 vs 1.5; 95% CI): -0.3 to 0.66, P=.46), 0.14 (mean 1.7 vs 1.5; 95% CI: -0.32 to 0.6, P=.55), and 0.12 (mean 1.6 vs 1.5; 95% CI: -0.34 to 0.58, P=.62) point higher in 12-month total acute rejection scores, respectively; however, these differences were not statistically significant. The incidences of chronic lung allograft dysfunction and antibody-mediated rejection were numerically greater in the high variability group throughout certain periods; however, this was not consistent throughout all study timeframes and statistical significance was not evaluated. High tacrolimus variability was not associated with increased 12-month total acute rejection score. Further studies are needed to assess long-term outcomes with tacrolimus level variability.

The Effects of Training Variability and Pitch Aptitude on the Overnight Consolidation of Lexical Tones.

Although variability of training materials has the potential to benefit the learning of lexical tones, the benefit is contingent on an individual's pitch aptitude. Previous studies did not segregate immediate learning and consolidation after an overnight interval, and little is known about how pitch aptitude differences affect consolidation. This study examined whether pitch aptitude predicts overnight consolidation of Cantonese level tones through high-variability (HV) and low-variability (LV) training. Two groups of Mandarin-speaking participants were first assessed in terms of pitch threshold and tone discrimination, which tapped into different aspects of pitch aptitude. They then received Cantonese level tone identification training in either an HV or an LV condition. The participants were trained in the evening, were tested after training, and returned after 24 hr for overnight consolidation assessment. The results indicate that pitch aptitude, measured through pitch threshold, may have predicted overnight consolidation and training progress of the HV group but not those of the LV group. In the HV group, compared with high-aptitude learners, low-aptitude learners benefited temporarily from training variability but did not consolidate the tonal knowledge as much as their high-aptitude counterparts did after 24 hr. The findings suggest that individual learners had difficulty learning nonnative tones by virtue of memory consolidation. Higher pitch aptitude ability (pitch threshold) may provide protection against the decay of learned tones and facilitate tone consolidation. The findings imply that the early emergence of tonal representation is a dynamic process among individuals of nonnative speakers who are exposed to training variability. https://doi.org/10.23641/asha.20539998.

Greater individual variability in functional brain activity during working memory performance in Schizophrenia Spectrum Disorders (SSD)

Heterogeneity has been a persistent challenge in understanding Schizophrenia Spectrum Disorders (SSD). Traditional case-control comparisons often show variable results, and may not map well onto individuals. To better understand heterogeneity and group differences in SSD compared to typically developing controls (TDC), we examined variability in functional brain activity during a working memory (WM) task with known deficits in SSD. Neuroimaging and behavioural data were extracted from two datasets collectively providing 34 TDC and 56 individuals with SSD (n = 90). Functional activity in response to an N-Back WM task (3-Back vs 1-Back) was examined between and within groups. Individual variability was calculated via the correlational distance of fMRI activity maps between participants; mean correlational distance from one participant to all others was defined as a ‘variability score’. Greater individual variability in functional activity was found in SSD compared to TDC (p = 0.00090). At the group level, a case-control comparison suggested SSD had reduced activity in task positive and task negative networks. However, when SSD were divided into high and low variability subgroups, the low variability groups showed no differences relative to TDC while the high variability group showed little activity at the group level. Our results imply prior case-control differences may be driven by a subgroup of SSD who do not show specific impairments but instead show more ‘idiosyncratic’ activity patterns. In SSD but not TDC, variability was also related to cognitive performance and age. This novel approach focusing on individual variability has important implications for understanding the neurobiology of SSD.

High intrapatient variability of tacrolimus exposure associated with poorer outcomes in liver transplantation.

Tacrolimus (TAC) is a dose‐dependent immunosuppressor with considerable intrapatient variability (IPV) in its pharmacokinetics. The aim of this work is to ascertain the association between TAC IPV at 6 months after liver transplantation (LT) and patient outcome. This single‐center cohort study retrospectively analyzed adult patients who underwent transplantation from 2015 to 2019 who survived the first 6 months with a functioning graft. The primary end point was the patient’s probability of death and the secondary outcome was the loss of renal function between month 6 and the last follow‐up. TAC IPV was estimated by calculating the coefficient of variation (CV) of the dose‐corrected concentration (C0/D) between the third and sixth months post‐LT. Of the 140 patients who underwent LT included in the study, the low‐variability group (C0/D CV < 27%) comprised 105 patients and the high‐variability group (C0/D CV ≥ 27%) 35 patients. One‐, 3‐, and 5‐year patient survival rates were 100%, 82%, and 72% in the high‐variability group versus 100%, 97%, and 93% in the low‐variability group, respectively (p = 0.005). Moreover, significant impaired renal function was observed in the high‐variability group at 1 year (69 ± 16 ml/min/1.73 m2 vs. 78 ± 16 ml/min/1.73 m2, p = 0.004) and at 2 years post‐LT (69 ± 17 ml/min/1.73 m2 vs. 77 ± 15 ml/min/1.73 m2, p = 0.03). High C0/D CV 3–6 months remained independently associated with worse survival (hazard ratio = 3.57, 95% CI = 1.32–9.67, p = 0.012) and loss of renal function (odds ratio = 3.47, 95% CI = 1.30–9.20, p = 0.01). Therefore, high IPV between the third and sixth months appears to be an early and independent predictor of patients with poorer liver transplant outcomes.

Inter-Trial Variability of Context Influences the Binding Structure in a Stimulus-Response Episode

There is strong evidence that stimuli and responses are bound together in a direct (binary) fashion into an episodic representation called stimulus-response episode (or event file). However, in an auditory negative priming study in which participants were required to respond to the target stimulus and to ignore the distractor stimulus, context information (i.e., a completely task-irrelevant stimulus) was found to rather modulate the binding between the distractor stimulus and the response, instead of entering into a binary binding with the response itself (Mayr et al., 2018). The current study demonstrates that simply increasing the variability of the context across trials leads to a binary binding between the context and the response. The same auditory negative priming task was implemented, and participants were either assigned to the high-variability group (8 different context sounds) or the low-variability group (2 different context sounds). For the low-variability group, results replicated previous findings of contextual modulation of the binding between the distractor stimulus and the response. For the high-variability group, however, repetition of the context per se retrieved the prime response, indicating a binary binding between the context and the response. Together, the current findings provide evidence that the inter-trial variability of context information is a determinant of how context is bound in a stimulus-response episode. Possible underlying mechanisms are discussed.

Neural responses in novice learners’ perceptual learning and generalization of lexical tones: The effect of training variability

The acoustics of lexical tones are highly variable across talkers, and require second-language (L2) learners’ flexibility in accommodating talker-specific tonal variations for successful learning. This study investigated how tone training with high vs. low talker-variability modulated novice learners’ neural responses to non-native tones. A passive oddball paradigm tested Mandarin-speaking participants’ neural responses to Cantonese low–high and low-mid tonal contrasts in the pretest and posttest. Participants were trained using a tone identification task with feedback, either with high or low talker-variability. The results of mismatch negativity (MMN) showed no group difference in the pretest whereas the high-variability group demonstrated greater neural sensitivity to the low–high tonal contrast produced by a novel talker and a trained talker in the posttest. The finding provides (tentative) novel evidence that training variability may benefit perceptual learning of the relatively easy tone pair and facilitate the formation of talker-independent representations of non-native tones by novice learners.

Right Hemisphere Lateralization of Character Transposition Processing: Evidence From Early N1 Response

The acoustics of lexical tones are highly variable across talkers, and require second-language (L2) learners’ flexibility in accommodating talker-specific tonal variations for successful learning. This study investigated how tone training with high vs. low talker-variability modulated novice learners’ neural responses to non-native tones. A passive oddball paradigm tested Mandarin-speaking participants’ neural responses to Cantonese low–high and low-mid tonal contrasts in the pretest and posttest. Participants were trained using a tone identification task with feedback, either with high or low talker-variability. The results of mismatch negativity (MMN) showed no group difference in the pretest whereas the high-variability group demonstrated greater neural sensitivity to the low–high tonal contrast produced by a novel talker and a trained talker in the posttest. The finding provides (tentative) novel evidence that training variability may benefit perceptual learning of the relatively easy tone pair and facilitate the formation of talker-independent representations of non-native tones by novice learners.

A novel classification of glucose profile in pregnancy based on continuous glucose monitoring data.

To investigate the glucose profile of women with and without gestational diabetes mellitus (GDM) by simultaneously analyzing several factors of continuous glucose monitoring (CGM) data. CGM was conducted for 2 weeks in the second trimester of pregnant women whose random blood glucose level was ≥100 mg/dl. A 75-g oral glucose tolerance test was performed around day 7, and the index of hyperglycemia, relative hypoglycemia, and indices of glucose variability were extracted from CGM data. Unsupervised hierarchical clustering was performed to categorize glucose profiles of the participants. CGM data were obtained from 29 women. Glucose profiles were categorized into three clusters: low glucose levels with less glucose variability group (L group, n = 7); moderate glucose levels with moderate-to-high glucose variability group (M group, n = 18); and high glucose levels with high glucose variability group (H group, n = 4). The waveforms of the glucose profiles were very different among the three groups. Women with GDM tended to be more frequent in the H group than in the M and L groups (75.0%, 16.7%, and 14.3%, respectively; p = 0.053). Maternal age was significantly higher and the proportion of multiparous women was significantly larger in the H group compared to L group (p = 0.002 and 0.015, respectively). A comprehensive analysis of CGM data could help us extract a subgroup of women with characteristics of GDM.

Does high-variation training facilitate transfer of training in paediatric transthoracic echocardiography?

Factors that facilitate transfer of training in paediatric echocardiography remain poorly understood. This study assessed whether high-variation training facilitated successful transfer in paediatric echocardiography. A mixed-methods study of transfer of technical and interpretive skill application amongst postgraduate trainees. Trainees were randomised to a low or high-variation training group. After a period of 8 weeks intensive echocardiography training, we video-recorded how trainees completed an echocardiogram in a complex cardiac lesion not previously encountered. Blinded quantitative analysis and scoring of trainee performance (echocardiogram performance, report, and technical proficiency) were performed using a validated assessment tool by a blinded cardiologist and senior cardiac physiologist. Qualitative interviews of the trainees were recorded to ascertain trainee experiences during the training and transfer process. Sixteen trainees were enrolled in the study. For the cumulative score for all three components tested (echocardiogram performance, report, and technical proficiency), χ2 = 8.223, p = .016, which showed the high-variation group outperformed the low-variation group. Two common themes which assisted in the transfer emerged from interviews are as follows: (1) use of strategies described in variation theory to describe abnormal hearts, (2) the use of formative live feedback from trainers during hands-on training. Training strategies exposing trainees to high-variation training may aid transfer of paediatric echocardiography skills.

Postoperative Glycemic Variability and Adverse Outcomes After Posterior Cervical Fusion.

Posterior cervical decompression and fusion (PCDF) is a procedure commonly performed to help alleviate symptoms and improve quality of life in patients experiencing cervical spondylotic myelopathy, multilevel stenosis, and cervical deformity. Although various risk factors have been linked to adverse outcomes in patients after PCDF, this is the first study that specifically explores postoperative glycemic variability and its association with adverse outcomes. A retrospective cohort study was conducted with a total of 264 patients after PCDF procedures that had available postoperative blood glucose measurements. Patients were divided into tertiles based on their coefficient of variation as an indicator of glycemic variability. Outcomes measured included inpatient complications, length of stay (LOS), 90-day readmission, revision, and surgical site infection rates. Results showed a significant difference in glycemic variability among tertiles with respect to LOS (P = 0.01). The average LOS for the first, second, and third tertiles was 3.90 (3.20, 4.59), 5.73 (4.45, 7.00), and 6.06 (4.89, 7.22), respectively. Logistic regression analysis showed significantly higher odds of readmission (odds ratio: 4.77; P = 0.03) and surgical site infections (odds ratio: 4.35; P = 0.04) in the high glycemic variability group compared with the low glycemic variability group within 90 days of surgery. No significant difference was noted among tertiles with respect to inpatient complications. This study establishes a relationship between postoperative glycemic variability and LOS, as well as 90-day readmission and surgical site infection rates after PCDF. Our results suggest that limiting fluctuations in blood glucose levels may curtail inpatient healthcare costs related to in-hospital stay. Although immediate postoperative glycemic variability is ultimately acceptable, before discharge, proper glucose management plans should be in place to help prevent adverse patient outcomes.

Seasonal variations in exposure to methylmercury and its dietary sources among pregnant Inuit women in Nunavik, Canada

Among populations living in close connection with the sea, rivers and lakes for subsistence, diet varies according to local monthly wildlife species availability and food preferences. This may lead to variations in methylmercury (MeHg) exposure over a year, although no biomonitoring studies have documented this issue in Circumpolar populations, the most exposed to international Hg emissions. Our aim was to characterize seasonal variations in MeHg exposure among pregnant Inuit women from Nunavik and to identify country foods responsible for these variations.Between October 2016 and March 2017, 97 participants were recruited. Blood mercury (Hg) was tested and hair Hg was measured by centimeter as a surrogate for monthly MeHg exposure over the past year. Latent class growth analysis was conducted to identify groups of pregnant women with similar hair Hg monthly trajectories. Country foods consumption was documented by season. Seasonal daily intakes of MeHg were estimated based on concentrations in country foods.Retrospective monthly hair Hg analyses revealed that MeHg exposure was lowest in winter, and highest in summer and early fall months. Three latent classes (groups) of pregnant women with similar trajectories of monthly hair Hg variations were identified: high (n = 20, 21%), moderate (n = 38, 41%) and low variation (n = 35, 38%). Beluga meat was the country food contributing to most of daily MeHg intake, primarily during summer and fall, and was the only one associated with the odds of being classified into moderate and high variation groups (OR 95% CI: 1.19 [1.01–1.39] and 1.25 [1.04–1.50]).These findings underscore the importance of monthly variations in exposure to MeHg due to the seasonality of local foods consumed and responsible for elevated MeHg exposure. Further studies critically need to understand local diet fluctuations over a year to adequately assess MeHg exposure, adopt timely preventive interventions and evaluate the effectiveness of the Minamata Convention.

Blood Pressure Variability and Atrial Fibrillation in Patients with Acute ST Segment Elevation Myocardial Infarction: The Relation with Left Atrial Electromechanical Delay – A 1-Year Follow-Up Study

Purpose: To investigate the association between 24-h blood pressure variability (BPV) and atrial electromechanical delay (EMD) in patients with ST segment elevation myocardial infarction (STEMI) who developed new-onset atrial fibrillation (NOAF). Materials and Methods: A total of 175 STEMI patients (age 56.6 ± 10.5 years) who underwent primary percutaneous coronary intervention were subjected to in-hospital 24-h ambulatory BP monitoring, comprehensive echocardiography, and assessment of atrial EMD. The parameters of BPV analyzed were: (a) 24-h standard deviation (SD), (b) the coefficient of variation, and (c) the average of the daytime and nighttime SDs weighted for the duration of the daytime and nighttime interval (SD_dn). Results: Based on the median of BPV index (SD_dn) = 9.5 mm Hg of all participants, patients were stratified into low and high variability groups (SD_dn: 7.1 ± 1.5 vs.13.5 ± 2.9; p < 0.001). Of the 175 patients with STEMI, 29 (16.7%) patients developed NOAF; 26 (28.9%) were in the high variability group and 3.5% were in the low variability group (p < 0.001). Echocardiographic data showed that the left atrial volume index (p < 0.01) and E/e′ ratio (p < 0.001) were significantly higher in patients with high BPV. Inter and intra-atrial EMD were significantly increased in the high variability group compared to the low variability group (p < 0.001). With multiple linear analysis, there was significant correlation between SD_dn and intra-left atrial and inter-atrial EMD (p < 0.001 and <0.01, respectively). Cox regression analysis revealed that SD_dn and intra-atrial EMD were independent predictors for NOAF in patients with STEMI (OR = 3.75 and 02.72, respectively; p < 0.001). ROC analysis revealed that SD_dn ≥12.8 was the optimal cut-off value for predicting NOAF during follow-up. Conclusions: Short-term BPV was associated with NOAF during the 1-year follow-up in patients with STEMI. In addition, BPV was correlated significantly with atrial EMD. Herein, BPV was predicted to be an early predictor of NOAF in patients with STEMI.

Execution redundancy: the effect of varying technique for a similar outcome on player’s groundstroke performance

Execution redundancy, defined as varying technique for a similar outcome, is a newer defined type of variability which opens new avenues of thinking about tennis training. 19 club-level tennis players were put through different training interventions: low variability where players had to rally to hit a target and maintain technique; and, high variability where players did the same but varied technique slightly. The high variability group improved after a retention period of 1 week in a test of accuracy (measuring average distance of 4 balls hit to a target) and success (measuring number of balls over the net and within a target radius of 500cm). The results suggest that that varying technique for a similar outcome improves performance more than low variability, possibly due mechanisms surrounding increased exploration creating better adapted motor patterns. The results show positive support for variability of this kind of training, but care needs to be taken to ensure that sound biomechanical and technical principles are observed.

HDL-Cholesterol, Its Variability, and the Risk of Diabetes: A Nationwide Population-Based Study.

The bidirectional relationship between low high-density lipoprotein cholesterol (HDL-C) and glucose intolerance is well established. Recent studies suggested an association of lipid variability with various health outcomes. To investigate the combined effect of HDL-C levels and their variability on the risk of diabetes. A population-based cohort study. In all, 5,114,735 adults without known diabetes in the Korean National Health Insurance System cohort who underwent three or more health examinations from 2009 to 2013 were included. Visit-to-visit HDL-C variability was calculated using variability independent of the mean (VIM) and the coefficient of variation (CV). Low mean and high variability groups were defined as the lowest and highest quartiles of HDL-C mean and variability, respectively. Newly developed diabetes. There were 122,192 cases (2.4%) of incident diabetes during the median follow-up of 5.1 years. Lower mean or higher variability of HDL-C was associated with higher risk of diabetes in a stepwise manner, and an additive effect of the two measures was noted. In the multivariable-adjusted model, the hazard ratios and 95% CIs for incident diabetes were 1.20 (1.18 to 1.22) in the high mean/high VIM group, 1.35 (1.33 to 1.37) in the low mean/low VIM group, and 1.40 (1.38 to 1.42) in the low mean/high VIM group compared with the high mean/low VIM group. Similar results were observed when modeling the variability using CV and in various subgroup analyses. Low mean and high variability in HDL-C were independent predictors of diabetes with an additive effect. Both elevating and stabilizing HDL-C may be important goals for reducing diabetes risk.

OR14-3 The Association of Glycemic Control and Glycemic Variability with Treatment Patterns and Diabetes-Related Events in the Adult Patients (Pts) with Type 1 Diabetes (T1D): Results from the T1D Exchange Clinic Registry

This cross-sectional analysis evaluated the association of A1C control/variability with treatment patterns and outcomes in adult pts with T1D.The association of A1C control (categorized into <7.0%; 7.0-8.0%; 8.0-9.0%; and ≥9.0%) and variability (defined as intrapersonal mean [M] and adjusted standard deviation [SD] of A1C values, categorized into low M/low SD = low; low M/high SD = medium; high M/low SD = high; and high M/high SD = very high) with pt characteristics, treatment patterns, and diabetes-related events (e.g. diabetic ketoacidosis [DKA], hypoglycemia, and comorbidities) were evaluated using T1D Exchange Clinic Registry data (05-01-2016 to 07-31-2017). Pts were required to have A1C values and key outcomes at exam, and ≥4 A1C values measured within 1 year from exam date for A1C variability analysis. Pts with a history of pancreas or islet cell transplant or currently pregnant were excluded. The association between A1C control/variability and diabetes-related outcomes were evaluated using multiple logistic regression adjusting for covariates.8331 and 2466 pts were included for A1C control and A1C variability analysis, respectively. The majority of the adult T1D pts did not achieve A1C<7.0% (78% pts had A1C≥7.0%) and had increased A1C variability (65% pts in medium to very high groups).Compared with the A1C<7.0% group, pts in the A1C≥9.0% group were significantly younger (29 vs 43 years) and with significantly shorter T1D duration (16 vs 25 years); both p<0.001. Ethnic minorities, lower socioeconomic status, being single, and smoking were also associated with poor A1C control; all p<0.001. Pts on pump or other adjunctive treatment (non-insulin injection, statin use, continuous glucose monitoring [CGM] use) were more likely to have better A1C control (all p<0.001). Poor A1C control (≥9.0%) was significantly associated with greater risk for DKA (adjusted odds ratio [aOR] of 5.7 for the A1C≥9.0% group vs <7.0%), retinopathy (aOR 2.5), neuropathy (aOR 1.8), micro nephropathy (aOR 1.9), and renal disease (aOR 1.9); all p<0.01.Similar associations were observed between A1C variability and pt demographics and disease duration. Pts on pump, statin use, or CGM use were more likely to have low A1C variability; all p<0.001. The very high A1C variability group (high M/high SD) was significantly associated with greater risk for DKA (aOR of 13.5 vs the low A1C variability group), severe hypoglycemia (aOR 4.8), neuropathy (aOR 2.2), micro nephropathy (aOR 2.3), and renal disease (aOR 2.8); all p<0.05.Lack of glycemic control and stability are associated with younger age, shorter disease duration, ethnic minorities, and low socioeconomic status. This study confirms the previously established association between glycemic control and diabetes-related complications and highlights the association of glycemic variability across both acute and long-term diabetes-related complications.

Relationship between serum phosphorus variation and prognosis in elderly patients with maintenance hemodialysis

Objective To investigate the relationship between serum phosphorus variability and prognosis in elderly patients with maintenance hemodialysis (MHD). Methods A total of 121 patients over 60 years treated with MHD from hemodialysis center of Jiangyin people’s hospital were enrolled from October 2010 to June 2016 in this study. According to their median of coefficient of variation (CV) of blood phosphorus, the patients were divided into high variation group (CV≥0.18 mmol/L) and low variation group (CV<0.18 mmol/L). The relationship of serum phosphorus CV with all-cause mortality and cardiovascular disease mortality was assessed respectively. Results Forty patients (33.1%) died for all cause and 17 patients (14.0%) died for cardiovascular disease. Compared with patients in low phosphorus variation group, patients had a higher all-cause in high phosphorus variation group (40.6% vs.20.6%, P=0.002), higher cardiovascular disease mortality was observed in high variation group as well (24.1% vs.4.8%, P=0.003). COX regression analysis showed that high CV of phosphorus (HR=2.442, 95%CI: 1.253-4.760, P=0.009) , low serum creatinine (HR=0.998, 95%CI: 0.996-1.000, P=0.017) and high C-reactive protein were independent risk factors for all-cause mortality. Moreover, high CV of phosphorus (HR=5.244, 95%CI: 1.486-8.507, P=0.010) and low albumin (HR=0.829, 95%CI: 0.711-0.967, P=0.017) were independent risk factors for cardiovascular disease mortality. Kaplan-Meier method showed that patients with high phosphorus variation had higher all-cause and cardiovascular disease mortality than patients with low phosphorus variation(P=0.001). Conclusions The high CV of phosphorus is independently correlated with all-cause and cardiovascular disease mortality in elderly patients with MHD. Key words: Renal Dialysis; Phosphorus; Aged; Prognosis

Verb Variability and Morphosyntactic Priming With Typically Developing 2- and 3-Year-Olds.

This study was specifically designed to examine how verb variability and verb overlap in a morphosyntactic priming task affect typically developing children's use and generalization of auxiliary IS. Forty typically developing 2- to 3-year-old native English-speaking children with inconsistent auxiliary IS production were primed with 24 present progressive auxiliary IS sentences. Half of the children heard auxiliary IS primes with 24 unique verbs (high variability). The other half heard auxiliary IS primes with only 6 verbs, repeated 4 times each (low variability). In addition, half of the children heard prime-target pairs with overlapping verbs (lexical boost), whereas the other half heard prime-target pairs with nonoverlapping verbs (no lexical boost). To assess use and generalization of the targeted structure to untrained verbs, all children described probe items at baseline and 5 min and 24 hr after the priming task. Children in the high variability group demonstrated strong priming effects during the task and increased auxiliary IS production compared with baseline performance 5 min and 24 hr after the priming task, suggesting learning and generalization of the primed structure. Children in the low variability group showed no significant increases in auxiliary IS production and fell significantly below the high variability group in the 24-hr posttest. Verb overlap did not boost priming effects during the priming task or in posttest probes. Typically developing children do indeed make use of lexical variability in their linguistic input to help them extract and generalize abstract grammatical rules. They can do this quite quickly, with relatively stable, robust learning occurring after a single optimally variable input session. With reduced variability, learning does not occur.