BG Level Research Articles

900-P: HbA1c Is an Insufficient Glucose Control Assessment Tool in Type 1 and Type 2 Treated with Insulin

HbA1c is currently used for assessment of glucose control in type 1 and type 2 diabetes patients treated with different therapeutic regiments. Different conditions besides glucose concentration affect its level and, in many cases, HbA1c is insufficient to present glucose control. In our study we compare representativeness of usually used control assessment tools such HbA1c and multiple daily blood glucose measurements with results derived from CGM record. We studied a group of 106 patients (60 men, 46 women; mean age 58.23±10.81 years), 21 patients with type 1 diabetes (on intensified regimen) and 85 patients with type 2 diabetes (33 - on oral medications, 31 - on pre-mixed insulin, 21 - on intensified insulin regimen). Patients were observed for three-month period - they performed eight-point BG measurements at least three time weekly, HbA1c was measured at the end of this period and continuous glucose monitoring with iProTM was performed for seven days. In oral medication treated group a high positive correlation was found between HbA1c (7.13±0.85%) and average blood glucose level during period of CGM (7.15±1.80mmol/l) (p<0.01) with correlation coefficient were (r1=0.742) (p<0.05). In pre-mixed insulin treated group and type 2 with intensified regimen lower positive correlation was found (7.64±1.40% and 7.69±1.23%, respectively 7.64±1.48mmol/l and 7.60±1.30mmol/l), with r2=0.642 (p<0.01) and r3=0.570 (p<0.05). No correlation was found in type 1 diabetes group (r4=0.083). No correlations were found between HbA1c and number of excursions in other groups. Same trend of correlations was found comparing HbA1c and mean BG level in eight-point profile. We conclude that HbA1c is appropriate assessment tool only in oral treated type 2 diabetes patients. In type 1 and insulin treated type 2 patients HbA1c gives relative information about overall control with no precise presenting of glucose fluctuations and out-of-range values of BG. Disclosure T. Totomirova: None. M. Arnaudova: None. I. Daskalova: None.

Increased diet viscosity by oat β-glucans decreases the passage rate of liquids in the stomach and affects digesta physicochemical properties in growing pigs

Rheological properties of digesta play a role in digesta passage kinetics through the gastrointestinal tract, in turn affecting nutrient absorption kinetics. Therefore, we studied the effects of diet viscosity on digesta passage and physicochemical properties in pigs. Twenty male growing pigs (35 kg body weight at the start) were assigned to one of five diets with increasing dietary concentrations of β-glucans (BG; from 0 % to 10 %), in exchange for maize starch. After a 17-day adaptation period, pigs were euthanised and the mean retention time (MRT) of digesta solids (TiO2) and liquids (Cr-EDTA) in the stomach, and proximal and distal half of the small intestine was quantified. In the stomach, the MRT of liquids, but not of solids, increased when dietary BG level increased (6 min per % dietary BG, P = 0.008 and R2 = 0.35). Concomitantly, stomach DM content (5 g/kg per % dietary BG, P < 0.001 and R2 = 0.53) and apparent digesta viscosity (56 Pa × s at 1/s shear rate per % dietary BG, P = 0.003 and R2 = 0.41) decreased. In the proximal half of the small intestine, no effects of dietary BG level were observed. In the distal half of the small intestine, water-binding capacity (WBC) of digesta increased (0.11 g/g digesta DM per % dietary BG, P = 0.028 and R2 = 0.24) and starch digestibility decreased (0.3% per % dietary BG, P = 0.034 and R2 = 0.23) when dietary BG level increased. In the colon, apparent digesta viscosity at 45/s shear rate increased (0.1 Pa × s per % dietary BG, P = 0.03 and R2 = 0.24) in the proximal half of the colon, and digesta WBC increased (0.06 g/g digesta DM per % dietary BG, P = 0.024 and R2 = 0.26) in the distal half of the colon when dietary BG level increased. To conclude, increasing dietary BG level caused the MRT of liquids, but not that of solids, to increase in the stomach, resulting in reduced separation of the solid and liquid digesta fractions. This caused dilution of the stomach content and reduction in digesta viscosity when dietary BG levels increased. Effects of dietary BG level on physicochemical properties in the proximal small intestine were absent and may have been due to a low DM content. The WBC of digesta in the distal small intestine and colon increased when dietary BG level increased, as did apparent digesta viscosity in the proximal colon. This likely reflects the concentration of BG in digesta when moving through the gastrointestinal tract.

THE EFFECT OF MELATONIN ON THE ENERGY METABOLISM IN HEART OF DIABETIC RATS

The aim of this study was to determine the effect of melatonin on activity of pyruvate kinase (PK) and lactate dehydrogenase (LDH) in the heart tissue and on the activity of succinate dehydrogenase (SDG) and H+-ATPase in mitochondria of cardiomyocytes of rats with dexamethasone diabetes. Methods. The research was performed in compliance with the Rules of the work with test animals (1977) and the European Convention on the Protection of Vertebrate Animals used in experiments and other scientific purposes (18 March 1986). The experiments were carried out on 36 sexually mature male albino rats with the body mass 0.18 – 0.20 kg. The animals were divided into 3 groups:1) control group; 2) group with diabetes mellitus DM (BG level ≥ 8.0 mmol/l); 3) diabetic animals which were injected with melatonin. Melatonin (“Sigma”, USA) was injected intraperitoneally in a dose of 10 mg/kg of body weight daily over 13 days. Dexamethasone diabetes was evoked by daily subcutaneous administration of dexamethasone (solution for injection 4 mg / ml, KRKA, Slovenia) at a dose of 0.125 mg / kg body weight for 13 days (O.V. Stefanov, 2001). The mathematical model of the insulin-glucose correlation by the Homeostasis Model Assessment (HOMA) was used to evaluate the insulin resistance in the animals (D.R.Matthews et al., 1985). The blood was taken from the tail vein to evaluate the BG level using “OneTouchUltra” (“LifeScan”, USA). The rats were sacrificed on the 14th day of the experiments in accordance with the ethical treatment of animals. 5% homogenate was prepared from cold-isolated rat hearts on chilled 50 mM Tris-HCl buffer (pH = 7.4) with sucrose. Mitochondria were isolated by differential centrifugation. Enzyme activities in the mitochondrial fraction was determined by: succinate dehydrogenase (SDG) according to the method of Eshchenko N.D. et al. (1992), H + -ATP-ase - for Gabibiv M.M. (1986). Serum insulin content was determined using an automatic immunochemiluminescent analyzer (Snibe Co., Ltd, PRC) using a Maglumi test kit. The insulin resistance index (HOMA-IR) was calculated by the formula: HOMA-IR = (glucose (mmol / l) • insulin (mcU / ml)) / 22.5. To determine the enzymes activities by standart methods, heart muscle tissue was quickly removed, rinsed in saline, blotted, weighed and homogenized. Then the homogenate (5% in ice-cold 0.25 mM tris-HCl-buffer) was ultracentrifugated (10 min at 1500r/min) and the supernatant was used for measurements. Statistical analysis was performed using Statistica 10 (StatSoft Inc). Prior to analysis, Shapiro-Wilk test was used to assess the normality of the group data. According to the criterion, the samples distributions differed from normal distribution. Given these, use of the Mann-Whitney test was considered sufficient for valid conclusions to be made. Differences were considered to be statistically significant when P ≤ 0.05. Results. In the blood of all diabetic rats on the 14th day the glucose content exceeded 8.9 mmol / l, and the HOMA-IR index increased 7 times. According to results, we have obtained the activity of PK in the heart tissue of diabetic animals was 55% less than in control group. It can be explained by low uptake of glucose from the blood by heart muscle tissue in conditions of insulin resistance. Reduced glucose uptake by peripheral tissues, in turn, leads to a reduced rate of glucose metabolism. That means now substrate for next catabolic changes in glycolysis. The activity of LDH increases by 32% in the heart muscles of diabetic rats compared with the control values. We have found out that the activity of PK and LDH has become normalized by the introducing of melatonin in dose of 10 mg/kg of body weight. In the mitochondria of the animals with dexamethasone diabetes, the activity of SDG and H+ -ATPase is significantly lower than that in intact animals by 45 and 32%, respectively. Probably, melatonin enhances the uptake of glucose by heart muscles. The blood glucose content of diabetic rats, which were administered is not significantly different from that of the intact animals, and the HOMA-IR was 6.3 times lower than that of diabetic rats. The activity of SDG and H+-ATPase in the mitochondria of rats receiving both melatonin and dexamethasone does not differ from that of intact rats. Conclusion. A 14-day introduction of melatonin leads to a marked improvement of the state of carbohydrate metabolism as well as the energy metabolism in heart tissue that is accompanied by the normalization of the indices studied.

라인댄스와 스트레칭 복합운동이 노인들의 대사증후군, 혈류동태 및 폐기능에 미치는 영향

Purpose: This study investigates the effects of the combined exercise with line dance and stretching on the indicators of metabolic syndrome, hemodynamics and pulmonary function in the elderly.BR Methods: The combined exercise was applied to 31 elderly subjects (male, n=15; female, n=16) with an average age of about 75 years. The combined exercise was consisted of line dance and static stretching. It was applied to subjects twice a week for 60 minutes per session for 5months (20 weeks). In the study, we analyzed the changes of metabolic syndrome index (blood pressure, BP; blood glucose, BG; waist circumstance, WC; triglyceride, TG; high density lipoprotein cholesterol, HDL-C), hemodynamics indicators (pulse wave korotkoff sound systolic time, TP-KS; pressure rate product, PRP ;total peripheral resistance, TPR), and pulmonary function index (forced vital capacity, FVC) before and after combined exercise. BR Results: The combined exercise significantly lowered the DBP levels in both genders and the BG level in elderly women, but it significantly elevated the TG level in elderly women. The combined exercise did not significantly change the blood flow dynamic indexes in both genders. The combined exercise significantly elevated the level of FVC in elderly women.BR Conclusion : The combined exercise, consisting of line dance and static stretching, partially improves the indicators of metabolic syndrome and pulmonary function in the elderly, but there are some gender differences. After applying combined exercise to the elderly, the index of the metabolic syndrome, hemodynamics and lung function tends to be better than maintenance levels. However, the combined exercise significantly elevates the TG level in elderly women. Therefore, further studies are needed to determine the adequacy of TG as a risk factor for vascular disease.

Common inpatient hypoglycemia phenotypes identified from an automated electronic health record-based prediction model.

Common inpatient hypoglycemia risk factor patterns (phenotypes) from an electronic health record (EHR)-based prediction model and preventive strategies were identified. Patients admitted to 2 large academic medical centers who were in the top fifth percentile of a previously developed hypoglycemia risk score and developed hypoglycemia (blood glucose [BG] of <50mg/dL) were included in the study. Frequencies of all combinations of ≥4 risk factors contributing to the risk score among these patients were determined to identify common risk patterns. Clinical pharmacists developed clinical vignettes for each common pattern and formulated medication therapy management recommendations for hypoglycemia prevention. A total of 401 admissions with a hypoglycemic event were identified among 1,875 admissions whose hypoglycemic risk was in the top fifth percentile among all admissions that received antihyperglycemic drugs and evaluated. Five distinct phenotypes emerged: (1) frail patients with history of hypoglycemia receiving insulin on hospital day 1, (2) a rapid downward trend in BG values in patients receiving an insulin infusion or with a history of hypoglycemia, (3) administration of insulin in the presence of an active nothing by mouth order in frail patients, (4) repeated low BG level in frail patients, and (5) inadequate night-time BG monitoring for patients on long-acting insulin. The 5 themes jointly described 53.0% of high-risk patients who experienced hypoglycemia. Five distinct phenotypes that are prevalent in patients at greatest risk for inpatient hypoglycemia were identified.

Attitude towards Choice Based Credit System of Graduate Level Students in Higher Education: A Study on government Degree College for women Anantnag Kashmir

“Choice Based Credit System (CBCS) is a programme in which the students have a choice to choose from the prescribed courses, which are referred as core, elective or minor or soft skill courses and they can learn at their own pace and the entire assessment is graded-based on a credit system.” CBCS the academic reform necessarily includes changes in admission procedures in various courses, modification in assessment and examination methods, switch over from annual to semester system, acceptance of grade and credit system, CBCS, teachers’ assessment, and other related reforms. In Govt. Degree College for Women Anantnag Kashmir the CBCS has been started in its BG level courses across the discipline since (2015). As this is the reformed structure of education system, so still this system has not been materialized in full form. The students as well as the teachers community has different perception and attitude regarding this new form of curriculum as well as examination system. The present study is an attempt to know the level of attitude of BG level Arts and Science students towards CBCS.

Antidiabetic Effect of Rosella-Stevia Tea on Prediabetic Women in Yogyakarta, Indonesia

ABSTRACTBackground: Rosella tea (Hibiscuss sabdariffa. Linn) with stevia sweetener (Stevia rebaudiana Bertoni) is a combined herbal drink that is expected to have antidiabetic effect by lowering glucose levels in people with diabetes and prediabetes. This research investigates the effect of rosella-stevia tea to decrease fasting blood glucose (FBG) and 2 hours postprandial blood glucose (2-hour postprandial BG) level in prediabetic women.Method: This is quasi-experimental research with control and treatment (rosella-stevia tea) group. Each group consists of 12 prediabetic women aged 30–60 years. Rosella-stevia tea (5 g rosella powder, 125 mg stevia sweetener) was administered to the treatment group twice a day for 14 days.Result: Rosella-stevia tea consumption affects blood glucose levels. Rosella-stevia tea consumption significantly lowered the FBG level (from 111.25 ± 7.20 mg/dL to 88.58 ± 13.19 mg/dL; p < 0.01) but not the 2-hour postprandial BG level (from 123.25 ± 37.61 mg/dL to 106.92 ± 18.82 mg/dL). There are no significant differences in the control group (FBG level from 106.00 ± 5.27 mg/dL to 102.08 ± 8.36, and 2-hour postprandial BG level from 119.83 ± 16.43 mg/dL to 128.00 ± 23.54 mg/dL).Conclusion: Rosella-stevia tea consumption can lower the FBG level but not the 2-hour postprandial BG level in prediabetic women.

Diabetes Alert Dogs (DADs): An assessment of accuracy and implications.

To test the accuracy of Diabetes Alert Dogs (DADs) by comparing recorded alerts to continuous glucose monitoring (CGM) device readings during waking and sleeping hours. 14 individuals (7 adults with type 1 diabetes and 7 youth with type 1 diabetes/parents) who owned DADs for ≥6 mos wore masked CGM devices over a several-week period while recording DAD alerts electronically and in paper diaries. During waking hours, sensitivity scores across participants were 35.9% for low BG events and 26.2% for high BG events. DAD accuracy was highly variable with 3/14 individual dogs performing statistically higher than chance. Sensitivity scores were lower during sleep hours of the person with diabetes (22.2% for low BG events and 8.4% for high BG events). DAD accuracy during sleeping hours was also highly variable, with 1/11 individual dogs performing statistically better than chance. Rate of change analyses indicated that DADs were responding to absolute BG level, rather than rapid shifts in glucose levels. In this study the majority of DADs did not demonstrate accurate detection of low and high BG events. However, performance varied greatly across DADs and additional studies are needed to examine factors contributing to this variability. Additionally, more research is needed to investigate the significant gap between the positive experiences and clinical outcomes reported by DAD owners and the mixed research findings on DAD accuracy.

Glycemic Outcomes 3 Years After Implementation of a Peri-Operative Glycemic Control Algorithm in an Academic Institution

While hyperglycemia in the postoperative setting has been linked to an increase in surgical complications, limited data are available to inform the management of patients with diabetes in the operating room and the immediate peri-operative period. We describe the results of a peri-operative glycemic control program that standardized intravenous insulin with a target glucose (BG) range of 120 to 180 mg/dL for patients with diabetes presenting with a BG level >180 mg/dL and included transition to subcutaneous insulin. Patients with known diabetes and a BG >180 mg/dL who underwent surgery were included. The control group included 260 patients from March 2, 2008 through December 31, 2008. The intervention group included 588 patients following protocol implementation from April 1, 2009 through December 31, 2012. Data included demographic information, hospital BG values, length of stay (LOS), mortality, and wound infections. The intervention group had significantly lower BG on arrival in the postoperative care unit (182.2 vs 194.9 mg/dL, P = .012). Mean BG during the first 24 hours after surgery was lower in the intervention group (182.1 vs. 190.5 mg/dL), and there were fewer BG values >200 mg/dL in the intervention group (P = .005). The percentage of BG values <70 mg/dL during the hospital stay was lower in the intervention group (1.94 vs. 2.43%, P<.01). There was no significant difference in mortality, LOS, or wound infections. Following implementation of a hospital-wide peri-operative glycemic control algorithm, we found a reduction in peri-operative BG levels and hypoglycemia rates. Ongoing research is needed to assess the impact on clinical outcomes. BG = blood glucose CCI = Charlson comorbidity index EHR = electronic health record ICD-9 = International Classification of Disease-9 IV = intravenous LOS = length of stay OR = operating room PACU = postoperative care unit POC = point-of-care.

Abstract TP317: Hyperglycemia Strongly Predicts Large Ischemic Infarct Growth Despite Full Endovascular Reperfusion

Introduction: Ischemic infarct core grows at variable rates despite early reperfusion. The purpose of this study was to determine the predictors of infarct growth despite full recanalization of a large vessel occlusion in acute ischemic stroke. Method: Patients with acute ischemic stroke due to ICA or MCA occlusion who received endovascular therapy with Thrombolysis in Cerebral Infarction scale (TICI) scores of 2b or greater were subsequently selected between July 2012 and May 2016. The Alberta Stroke Program Early CT Score (ASPECT) was measured on the initial CT or MRI upon arrival and subsequently on the 24-hour scan. The infarct growth (delta d) was measured as initial ASPECT minus 24-hour ASPECT. Large and small infarct growth was defined as delta d of &gt;= to3 and &lt; 3 respectively. The relationship between the infarct growth and baseline variables of blood glucose level(BG), time of symptoms onset to recanalization time and baseline ASPECT score were assessed using statistical analysis. Results: Total of 76 patients were included. 32% had large infarct growth (25/76). The initial ASPECT score was not significantly different between the the 2 subgroups of large and small delta d (7.5 vs 6, P= 0.97). Baseline BG level was significantly higher in the group with larger infarct growth (160 vs 128, P=0.006). The baseline BG level of more than 150 was found as the threshold between the 2 subgroups (P=0.0003). No association was found between the infarct growth and history of diabetes (P= 0.7). Conclusion: Our data suggests that infarct growth occurs in relatively high percentage of ischemic stroke patients despite early full reperfusion of the large vessel occlusion. We showed that baseline blood glucose level particularly levels of higher than 150 is significantly associated with larger infarct growth. Therefore, it can be used as a strong predictive value in early recognition of this patient population.

Co-Administration of Cabergoline and Gliclazide Improve Glycemic Parameters and Lipid Profile in T2DM

Type 2 diabetes mellitus (DM) is a progressive metabolic disorder that is associated with basal hyperinsulinemia, insulin resistance and impaired insulin release. Glycemic control is a fundamental part of the management of type 2 DM and difficult to achieve. Different antidiabetic agents can handle diabetic metabolic abnormalities. The development of antidiabetic agents with novel mechanisms of action is highly desirable. Cabergoline, D2 agonist, is expected to play a role in the glycemic control. Objective: Evaluation of the glycemic efficacy of cabergoline on diabetic patients. Design: Fifty type 2 diabetic patients participated in the study for four months; 25 patients receive gliclazide (60-120 mg) once daily and 25 patients receive cabergoline 0.5 mg twice weekly within 2 hrs of wakening plus gliclazide. 10 healthy people with matched age participated as a control group. Fasting and post prandial BG level were measuredmonthly. HbA1c, fasting insulin, HOMA IR and lipid profile were measured at baseline and after four months. Results: Treatment of the patients with cabergoline and gliclazide resulted in greater significant (p<0.05) decrease in FBG, PPBG, HbA1c compared treatment with gliclazide only. Insulin levels were reduced and insulin sensitivity was enhanced with improvement in lipid profile. Conclusion: Cabergoline is well-tolerated new antidiabetic line acting with a unique insulin sensitizing actions.

Effects of Packed Red Cell Transfusion on Blood Glucose Concentrations in Beta Thalassemia Major (BTM) Ashort Presentations of Personal Experience

The most accurate method with which to evaluate altered glucose metabolism in patients with TM is still controversial. Even if the annual oral glucose tolerance test (OGTT) by the age of 10 years is the recommended method, a diagnosis of ’normal’ glucose tolerance during OGTT does not exclude abnormal postprandial glucose levels at home . There is now evidence that the OGTT method, evaluating fasting and 2-h post load glucose, may miss episodes of hyperglycaemia . Furthermore, the credibility of Hb A1c has been questioned because the hemoglobin composition of patients’ erythrocytes are considerably modified, due to regular and frequent transfusions. The results may be falsely increased or decreased depending on the proximity to transfusion, shortened erythrocyte lifespan and the assay used . It has been demonstrated recently that the continuous glucose monitoring system (CGMS) is a useful and valid tool in defining glucose metabolism in children and adults affected by TM with early glucose derangements . Indeed, the CGMS allows monitoring of glycaemic profiles throughout a period of 72 h for a total of 288 glycaemic registrations per day. It identifies glycaemic excursions and constitutes a valid device to understand the 24-h glycaemic trend and profiles. Rimondiet al. investigated the value of using CGMS in six TM patients with abnormal glucose homeostasis after an oral glucose tolerance test (OGTT) . Two-hour OGTT glucose values and CGMS fluctuations were classified as normal if < 7.8 mmol/l, impaired if 7.8 to 11.1 mmol/l, diabetic if > 11.1 mmol/l. The TM patients spent from 1 to 23% of the time with a blood glucose level from 7.8 to 11.1 mmol/l. we evaluate three patients with Beta Thalassemai major using CGMSPatient 1 A 15 year old male with TM presented with nocturia. His FBG was 5.6 mmol/L and OGTT showed a BG level at 2hrs of 8.5 mmol/l. His CGMS showed a diabetic range of BG after dinner and overnight. Based on this tracing, a basal insulin (Glargine) was prescribed at night. A satisfactory response was recorded by CGMS .Patient 2 A 14 year old girl with TM with no symptoms related to glycemic abnormalities. Her FBG was 4.9 mmol/L and an OGTT showed a BG level at 2 hrs of 6.9 mmol/L (IGT). CGMS tracing showed prolonged persistent hyperglycemia after lunch suggesting a need for prandial insulin to cover her carbohydrate load. Insulin aspart before lunch properly controlled her glycemia . Patient 3 A 13 year old boy with TM had a normal FBG (4.5 mmol/L) and OGTT (2h BG =7.6 mmo/l). Applying CGMS monitoring showed IGT state. Furthermore, the effect of packed red cell transfusion showed marked reduction of his BG before meals and overnight. This is the first case to document the rapid beneficial effect of blood transfusion on glycemia in patiens with Beta thalssemia Major Advances in TM care have led to improved survival and quality of life in patients with TM; however, many chronic endocrine diseases have emerged as a result of potential endocrine complications by routine screening and a high index of suspicion is imperative for patients with TM to receive timely treatment.Our results demonstrate that the CGMS is a useful method to detect the variability of glucose fluctuations and offers the opportunity for better assessment of glucose homeostasis in TM patients. Proper and early iron chelation or the use of intensive iron chelation in those with high iron load the new oral chelators have been shown to decrease or reversethese glycemic abnormalities.In addition, optimization of insulin therapy with the help of CGMS appears to be clinically useful and costeffective approach. DisclosuresNo relevant conflicts of interest to declare.

New digital tool to facilitate subcutaneous insulin therapy orders: an inpatient insulin dose calculator.

BackgroundInpatient hyperglycemia is associated with adverse outcomes in hospitalized patients, with or without known diabetes. The adherence to American College of Endocrinology and American Diabetes Association guidelines recommendations for inpatient glycemic control is still poor, probably because of their complexity and fear of hypoglycemia.ObjectiveTo create software system that can assist health care providers and hospitalists to manage the insulin therapy orders and turn them into a less complicated issue.MethodsA software system was idealized and developed, according to recommendations of major consensus and medical literature.ResultsHTML software was developed to be readily accessed from a workstation, tablet or smartphone. Standard initial daily total dose of insulin was 0.4 units/kg and could be modified by distinct factors, such as chronological age, renal and liver function, and high dose corticosteroids use. Insulin therapy consisted of basal, prandial and correction insulin according to nutritional support, glycemic control and outpatient treatment for diabetes. Human insulin or insulin analogues could be options for insulin therapy. Sensitivity factor was based on 1800 Rule for rapid-acting insulin and the 1500 Rule for short-acting insulin. Insulin-naïve patients with initial BG level less than 250 mg/dL were considered to have an initial step-wise approach with prandial and correction insulin. The calculator system has allowed insulin dose readjustments periodically, according to daily average blood glucose measurements.ConclusionWe developed software that can be a useful tool for all public hospitals, where generally human insulin is the only available.

A pilot study of continuous glucose monitoring in critically ill patients: Do they perform well enough for use in glycaemic control?

Glycaemic control (GC) in the intensive care unit (ICU) has proven difficult and contentious. Continuous glucose monitors (CGM) have been mooted as a solution to provide better control with less clinical effort. The aim of this study was to assess the reliability of CGM devices in critically ill patients, as well as the impact of device type (inter-device) and sensor location (inter-site) on performance. Ten patients were enrolled in this pilot trial and each patient was monitored using 3 concurrent CGM devices: a Medtronic Guardian real-time on their abdomen and Medtronic iPro2 recorders on their abdomen and thigh. The Guardian real-time had an overall MARD of 24%, compared to ~12% for the iPro2 devices. Bland Altman plots showed Guardian SG errors were associated with BG level, but iPro2 SG errors were not associated with BG level. Inter-device SG discrepancies were larger than inter-site discrepancies, when comparing concurrent data and CGM device type, or calibration method, tends to have a larger impact on SG accuracy than sensor location. Three case studies showed several interesting findings regarding CGM behaviour in critically ill patients. CGM devices are capable of performing very well in critically ill patients, but certain illnesses/conditions, as well as drugs/therapies may impact SG data. These factors require further investigation before CGMs can be implemented as standard clinical practice and/or for GC.

Neurological outcome and time to target temperature during therapeutic hypothermia in post-cardiac arrest patients

Method: We conducted a database study at Cochin hospital in Paris, France. Between December 2006 and January 2010, we included 381 patients who were all resuscitated from an OHCA (excepted those with a primary neurological cause or moribunds). A moderate glycemic control was applied in all patients (aiming to maintain glycemia between 5.1 and 7.7mmol/l). BG was measured every 3h during the first 48h. The median glycemia and the largest delta were assessed. Amultivariate analysis was performed to determine parameters that independently influenced the main outcome (CPC level at ICU discharge). Results: 136/381 patients (36%) had a favorable outcome (CPC 1–2). Median BG level was 7.6mmol/l [6.3–9.8] in patients with a favorable outcome compared to 9.0mmol/l (IQR: 7.1–10.6) for patientswithanunfavorableneurologic outcome (p 8.4mmol/l) was found to be an independent predictor of poor neurological issue (OR=0.43; 95% CI [0.24–0.78], p=0.006). Other predictive factors of poor outcome were an unshockable rhythm, cardiac arrest location, a no flow >4min and a low flow >15min. Finally an increase in median BG was associated with an increase in the proportion of patients with a poor neurological outcome (Fig. 1). Conclusion: Even after adjustment with usual prognostic factors, an increase in glycemia during the first 48h is associated with an unfavorable neurological outcome.

Comparison on Efficacy and Safety of Three Inpatient Insulin Regimens for Management of Non-Critical Patients with Type 2 Diabetes

Background: Hyperglycemia in hospitalized patients is associated with poor clinical outcomes. Scheduled Subcutaneous Insulin therapy has been recommended for better glycemic control. Aims: To compare efficacy and safety of traditional sliding scale insulin (SSI) versus modified 70/30 insulin versus basal plus supplemental scale (SS) insulin regimens for glycemic control of inpatients with diabetes. Methods: In a prospective trial, 62 patients with diabetes were randomized to receive either hospital SSI (N = 22), or twice daily 70/30 insulin plus supplemental lunchtime insulin for BG ≥ 150 mg/dL (N = 21) or once every night glargine plus prandial glulisine for BG ≥ 150 mg/dL (N = 19). 70/30 insulin and glargine were started respectively at 0.4 and 0.2 U/kg/day for BG ≤ 200 mg/dL or 0.5 and 0.3 U/kg/day for BG above 200 mg/dL. Results: Starting at BG level of 204 ± 68, 200 ± 50 and 241 ± 94 mg/dL in SSI, 70/30 insulin and glargine/glulisine groups respectively, (F(2,35.47) = 1.467, p = 0.244, Welch test), mean daily BG after first day of hospitalization was statistically significant (F(2,35.58) = 7.043, p = 0.003, Welch test) lower in 70/30 insulin group (171 ± 38 mg/dL) compared to (218 ± 71 mg/dL) in SSI group (p = 0.026) and (225 ± 65 mg/dL) in glargine/glulisine group (p = 0.01). Conclusions: With poorly educated nursing staff, basal plus SS insulin failed to provide adequate glycemic control. However, tailored 70/30 insulin regimen resulted in statistically significant glycemic control compared to traditional SSI.

(1,3)- -D-Glucan as a Prognostic Marker of Treatment Response in Invasive Candidiasis

(1,3)-β-D-glucan (BG) is a biomarker for invasive candidiasis (IC). The usefulness of BG level as a prognostic marker of treatment outcome is not well characterized. Two hundred fifty-seven patients with proven IC were enrolled in an anidulafungin study. Clinical and microbiological responses at the end of therapy were evaluated. Serial serum BG was measured. Correlation of initial and final BG levels with overall outcome was assessed in each patient. Two hundred three patients had at least 2 BG levels and outcomes assessed. The majority of IC was caused by non-Candida albicans (53%) and found in the blood (84%). Overall, treatment success was 85%. In successfully treated patients, the mean ± SD initial and final BG were 573 ± 681 pg/mL and 499 ± 635 pg/mL (P = .03), respectively; while in treatment-failure patients, the levels were 1224 ± 1585 pg/mL and 1293 ± 1283 pg/mL (P = .29), respectively. A negative slope in BG levels correlated with a successful treatment outcome with a positive predictive value (PPV) of 90%, and a positive slope in BG levels correlated with treatment failure with a negative predictive value (NPV) of 90%. The cutoff value for initial BG <416 pg/mL has potential to predict treatment success with a PPV of 89%. A decrease in BG levels during therapy is associated with treatment success. An initial BG of <416 pg/mL has potential to predict successful treatment outcomes. Baseline and consecutive serum BG measurements may be useful as prognostic markers of treatment outcome in patients with IC receiving primarily echinocandin therapy.

Assessment of the clinical outcome of a symptom-based outpatient hyperglycemia protocol

IntroductionAcute hyperglycemia (blood glucose [BG] ≥400 mg/dL) is common in primary care. An outpatient protocol was developed to streamline the treatment of acute hyperglycemia. The objective was to determine if an outpatient hyperglycemia protocol could achieve a BG level of <300 mg/dL within 4 hours.MethodsAdult diabetic patients with acute symptomatic hyperglycemia (>400 mg/dL) without acute illness were recruited. Enrolled patients were managed with a protocol that included administration of 0.15 units/kg rapid-acting insulin given subcutaneously, hydration, hourly fingerstick blood sugars (FSBS), laboratory assessment, tailored diabetes education, and follow-up within 72 hours. Independent variables for data analysis included age, baseline FSBS, sodium, potassium, chloride, blood urea nitrogen, serum creatinine, CO2, venous glucose, and etiology (medications, diet, personal stress).ResultsFor the 27 patients enrolled, the average initial FSBS level (n=23) was 484 mg/dL, the average final FSBS level (n=27) was 274 mg/dL, and average time to achieve BG levels of <300 mg/dL was 2.35 hours. The protocol was successful in 20 patients (74%). The causes for seven protocol failures were nonclinical in nature. The patients’ weight and total time to goal were significantly associated with odds of protocol success. Personal stress significantly correlated with protocol failure. The protocol success group had a higher sodium level than the failure group (P=0.01). Weight and baseline BG showed decreased odds of protocol success (P=0.05 and P=0.04, respectively).ConclusionsResults of this pilot study suggest acute hyperglycemia without other acute illness can be managed on an outpatient basis. Outpatient interventions to addres s acute hyperglycemia need further investigation. Managing acute hyperglycemia in the outpatient setting could potentially decrease hospital admissions for hyperglycemic hyperosmolar syndrome and mild diabetic ketoacidosis.Electronic Supplementary MaterialSupplementary material is available for this article at 10.1007/s13300-011-0001-4 and is accessible for authorized users.

The (1,3)β- d -Glucan Test as an Aid to Early Diagnosis of Invasive Fungal Infections following Lung Transplantation

The Fungitell assay for (1,3)β-D-glucan (BG) detection in serum has been evaluated in patients with invasive fungal infections (IFIs) and healthy controls and for the early diagnosis of IFI in cancer patients. We evaluated the BG assay for the detection of IFI in lung transplant recipients. Serial serum samples were prospectively collected from patients undergoing lung transplants at Duke Hospital. Fungal infections were classified according to revised European Organization for Research and Treatment of Cancer/Mycoses Study Group criteria. A receiver operator characteristic (ROC) curve was generated; possible causes for false-positive and false-negative tests were investigated by linear regression analysis. Seven hundred fifty-six serum specimens from 59 subjects without IFI and 41 specimens from 14 patients with proven or probable IFI were tested. The area under the ROC curve was 0.69. Based on a 60-pg/ml positive cutoff, per-patient sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 64%, 9%, 14%, and 50%, respectively; per-test estimates were 71%, 59%, 9%, and 97%, respectively. The majority (92%) of patients not diagnosed with an IFI had at least one BG level of ≥60 pg/ml, and 90% had at least one BG level of ≥80 pg/ml. Respiratory colonization with mold and hemodialysis significantly affected mean BG levels. In conclusion, the accuracy of the BG test is marginal and its utility as a tool for the early diagnosis of IFI is questionable in the lung transplant population. Although the NPV of the BG test is high, the low PPV limits its utility as a screening tool for early diagnosis of IFI.

Antifungal prophylaxis with micafungin in neutropenic patients with hematological malignancies

The aim of the study was to assess the antifungal prophylactic efficacy, safety, and tolerability of micafungin, 150 mg daily, and to evaluate the usefulness of monitoring 1,3-β-d-glucan (BG) in neutropenic patients undergoing chemotherapy for hematological malignancies. This investigation was a retrospective, non-randomized study. A group of patients who did not receive systemic antifungal prophylaxis was compared to another group of patients who received micafungin 150 mg daily. All patients admitted with hematological malignancy and undergoing chemotherapy or stem cell transplant were included. The plasma BG level was measured once weekly. The clinical endpoint was the diagnosis of invasive fungal infection (IFI). Antifungal prophylaxis led to a significant decrease in the occurrence of IFI (from 12.3% to 1.5%, p = 0.001). Few severe adverse effects clearly attributable to micafungin were seen. Sensitivity, specificity, positive predictive value, negative predictive value, and efficiency of BG values >8.9 pg/mL for diagnosis of IFI were 0.90, 0.99, 0.82, 0.99, and 0.99, respectively. Micafungin, 150 mg daily, is an effective and safe drug for antifungal prophylaxis, and monitoring of BG antigenemia is a useful tool for diagnosis of IFI in neutropenic patients with hematological malignancies.