Known Diagnosis Of Diabetes Research Articles

8772 Impact of Stress Hyperglycemia on Individuals Hospitalized for COVID-19 with and without Diabetes

Abstract Disclosure: E. Burguera-Couce: None. V.O. Cheng: None. J.G. Monteiro: None. G. Gopalakrishnan: None. Background: Stress hyperglycemia (SH), the physiologic increase in blood glucose during severe illness, has been linked with poor outcomes in certain disease states1. Hyperglycemia in the setting of diabetes (DM) has been well established as a predictor of poor outcomes in Coronavirus disease 2019 (COVID-19) infection2-4. The impact of SH on health outcomes for individuals without DM (NoDM) hospitalized with COVID-19 infection is less clear with studies reporting variable outcomes in this population4-6. Objective: To evaluate the impact of SH on health outcomes among hospitalized individuals with COVID-19Methods: Data from 1001 individuals with SH (defined as ≥ 2 instances of BG above 180 mg/dL) admitted in Rhode Island with COVID-19 infection during the first-wave (March 1-June 30, 2020) and second-wave (July 1, 2020-February 28, 2021) was analyzed. Multivariate logistic regression was conducted to compare DM status for length of stay (LOS), ICU admission, mechanical ventilation (MV) and in-hospital mortality, and was adjusted for age, race/ethnicity, gender, insurance, and wave. Model investigating risk factors associated with poor outcomes (ICU admission, MV or in-hospital mortality) in hospitalized individuals with SH was additionally adjusted to include BMI, Chronic kidney disease (CKD), hypertension (HTN), pulmonary disease, and cardiovascular diseases. Results: 17.0% (170) of the cohort had NoDM. Average age (67.6±13.9), gender (57.1% male) and race/ethnicity (Caucasian/White 48.9%, Hispanic 28.0%, Black 13.2% and Other 10.0%) noted in the overall cohort. Individuals with NoDM were more likely to be Caucasian/White (57.7 vs 47.1%, p-value=0.0122), and more likely to require LOS ≥1-week (OR 2.32[1.57-3.44]), ICU admission (2.26[1.60-3.20]) and MV (3.39[2.35-4.89]). NoDM was also associated with higher in-hospital mortality (3.44[2.39-4.96]). The risk of poor outcomes was significantly higher in NoDM compared to DM (ICU admission 47.7 vs 28.6%, MV 45.3 vs 20.1%, Mortality 41.8 vs. 18.2%). In multivariate analysis, Caucasians/Whites (0.50[0.29-0.87]) were less likely to have poor outcomes than the other races. NoDM (3.55[2.40-5.25]), male gender (1.57[1.16-2.13]), CKD stage 5 (1.94[1.40-2.68]), and admission during the first-wave (2.64[1.89-3.70]) were identified as independent risk factors for poor outcomes in SH associated with COVID-19. Conclusion: Our study showed that individuals without a known diagnosis of diabetes hospitalized with COVID-19 who experienced SH during their hospital course had worse outcomes when compared to individuals with diabetes and hyperglycemia. NoDM, male gender, nonwhite race/ethnicity, CKD stage 5 and admission during the first wave were identified as independent risk factors for poor outcomes in COVID-19 hospitalizations with hyperglycemia. Presentation: 6/1/2024

Proactive review for people with diabetes in hospital: a cluster randomised feasibility trial with process evaluation, protocol V3.1

BackgroundDiabetes inpatient specialist services vary across the country, with limited evidence to guide service delivery. Currently, referrals to diabetes inpatient specialists are usually ‘reactive’ after diabetes-related events have taken place, which are associated with an increased risk of morbidity/mortality and increased length of hospital stay. We propose that a proactive diabetes review model of care, delivered by diabetes inpatient specialist nurses, may contribute to the prevention of such diabetes-related events and result in a reduction in the risk of harm.MethodWe will conduct a cluster randomised feasibility study with process evaluation. The proactive diabetes review model (PDRM) is a complex intervention that focuses on the prevention of potentially modifiable diabetes-related harms. All eligible patients will receive a comprehensive, structured diabetes review that aims to identify and prevent potentially modifiable diabetes-related harms through utilising a standardised review structure. Reviews are undertaken by a diabetes inpatient specialist nurse within one working day of admission. This differs from usual care where patients are often only seen after diabetes-related harms have taken place. The trial duration will be approximately 32 weeks, with intervention delivery throughout. There will be an initial 8-week run-in phase, followed by a 24-week data collection phase. Eight wards will be equally randomised to either PDRM or usual care. Adult patients with a known diagnosis of diabetes admitted to an included ward will be eligible. Data collection will be limited to that typically collected as part of usual care. Data collected will include descriptive data at both the ward and patient level and glucose measures, such as frequency and results of capillary glucose testing, ketonaemia and hypoglycaemic events. The analysis aims to determine the fidelity and acceptability of the intervention and the feasibility of a future definitive trial. Whilst this study is primarily about trial feasibility, the findings of the process evaluation may lead to changes to both trial processes and modifications to the intervention. A qualitative process evaluation will be conducted in parallel to the trial. A minimum of 22 patients, nurses, doctors, and managers will be recruited with methods including direct non-participant observation and semi-structured interviews. The feasibility of a future definitive trial will be assessed by evaluating recruitment and randomisation processes, staffing resources and quality of available data.DiscussionThe aim of this cluster randomised feasibility trial with a process evaluation is to explore the feasibility of a definitive trial and identify appropriate outcome measures. If a trial is feasible and the effectiveness of PDRM can be evaluated, this could inform the future development of inpatient diabetes services nationally.Trial registrationUK Clinical Research Network, 51,167. ISRCTN, ISRCTN70402110. Registered on 21 February 2022.

Hyperglycemia and insulin infusion in pancreatoduodenectomy: a prospective cohort study on feasibility and impact on complications.

Hyperglycemia is a risk factor for postoperative complications but its impact on outcome after pancreatoduodenectomy (PD) is scarcely studied. This prospective cohort study aimed to assess the effect of continuous insulin infusion on postoperative complications and blood glucose, as well as to evaluate the impact of hyperglycemia on complications, after PD. One hundred patients planned for PD at Skåne University Hospital, Sweden were prospectively included for perioperative continuous insulin infusion and a historic cohort of 100 patients was included retrospectively. Median blood glucose levels were calculated and data on complications were analyzed and compared between the historic cohort and the intervention group as well as between normo- and hyperglycemic patients. Median glucose levels were significantly lower in the intervention group compared to the historic cohort up to 30 days postoperatively (median glucose 8.5mmol/l (interquartile range 6.4-11) vs. 9.1mmol/l (interquartile range 6.8-17) ( P =0.007)). No significant differences in complication rates were recorded between these two groups. The incidence of complications classified as Clavien ≥3 was higher in hyperglycemic patients (100 vs. 27%, P =0.024). Among hyperglycemic patients the prevalence of preoperative diabetes was higher compared to normoglycemic patients (52 vs.12%, P <0.001). In patients with a known diagnosis of diabetes, a trend, although not statistically significant, towards a lower incidence of postoperative pancreatic fistula grade B and C, as well as postpancreatectomy hemorrhage grade B and C, was seen compared to those without preoperative diabetes (6.8 vs. 14%, P =0.231 and 2.3 vs. 7.0%, P =0.238, respectively). Insulin infusion in the early postoperative phase after PD is feasible in a non-ICU setting and significantly decreased blood glucose levels. The influence on complications was limited. Preoperative diabetes was a significant predictor of postoperative hyperglycemia and was associated with a lower incidence of clinically significant postoperative pancreatic fistula.

Prevalence of increased risk of type 2 diabetes in general practice: a cross-sectional study in Norway

BackgroundType 2 diabetes (T2D) is a global public health problem, but the onset can be delayed or prevented with adequate intervention in individuals with increased risk. Therefore, a major challenge in general practice is to identify individuals at risk of diabetes. However, limited knowledge is available about the prevalence of high diabetes risk individuals in a primary care population. In a cohort of consecutive patients in general practice we examined the prevalence of known diabetes and estimated risk of diabetes using The Finnish Diabetes Risk Score (FINDRISC) calculator, by sociodemographic and clinical characteristics.MethodsThis study was a cross-sectional study conducted in four general practices in Western and Eastern Norway. A total of 1682 individuals, 20–80 years of age, were assessed for eligibility from May to December 2019. We excluded patients who actively declined participation (n = 112), were lost because of various organization challenges (n = 103) and patients who did not fulfil the inclusions criteria (n = 63). Diabetes prevalence and prevalence of individuals at risk of T2D with 95% confidence intervals (CI) were estimated for the total sample, by age group and for men and women separately. We tested for differences between groups using t-test for continuous variables and chi-square test (Pearson Chi-Square) for categorical variables.ResultsOf 1404 individuals, 132 reported known diabetes, yielding a prevalence of 9.9% (95% CI 8.4–11.6). Among participants without a known diagnosis of diabetes, the following estimates of elevated risk assessment scores were found: FINDRISC score ≥ 11 32.8% (95% CI 30.3–35.4) and FINDRISC ≥ 15 10.0% (95% CI 8.6–11.9). Comparable results were found between the sexes.ConclusionsDetection of unknown diabetes and individuals with increased risk, is of high public health relevance for early implementation of preventive measures aimed to reduce the risk of diabetes and its complications through lifestyle modification. A simple, non-expensive questionnaire, such as FINDRISC, may be valuable as an initial screening method in general practice to identify those in need for preventive measures.

Hyperglycemia and Glycemic Variability in Hospitalized Patients and its Impacts on Morbidity and Mortality: An Integrative Literature Review

The constant change in plasma glucose is related to increased mortality, morbidity, length of stay and complications in patients in the hospital context. Dysglycemia increases the risk of infections, thrombosis and leads to slower wound healing. The main objective of this work was to carry out a literature review of the literature regarding the assessment and management of glycemic variability in hospitalized patients. An electronic search was performed for articles published in journals indexed through the PubMed database, using the following combination of descriptors verified in the MESH database: “Glycemic Control” OR “Blood Glucose” AND “Patient Readmission”, AND “Inpatients” OR “Hospitalization”. Studies published between January and September 2022 were admitted. People with diabetes mellitus (DM) are more likely to be hospitalized due to comorbidities and complications specific to their disease. Hyperglycemia in hospitalized patients, even in the absence of a known diagnosis of diabetes, is associated with higher mortality and longer mean length of stay.

Effects of glucocorticoids on interstitial glucose concentrations in individuals with hematologic cancer and without known diagnosis of diabetes: a pilot study.

ABSTRACTObjective To analyze interstitial glucose behavior during glucocorticoid use in non-diabetic patients receiving chemotherapy for hematologic malignancies.Methods Prospective pilot study carried out to assess interstitial glucose levels in 15 non-diabetic individuals with hematologic malignancies who received glucocorticoids in combination with chemotherapy. The FreeStyle Libre flash monitoring system (Abbott Diabetes Care) was used for up to 14 days to measure interstitial glucose.Results Median age and body mass index were 53 (42-61) years and 25 (23-28) kg/m2 respectively. Interstitial glucose levels >180mg/dL lasting at least one hour were detected in 60% of participants. Interstitial glucose profile parameters (median and peak interstitial glucose levels and percentage of time during which interstitial glucose levels were >180mg/dL) were significantly (p<0.01) higher during glucocorticoid use (115mg/dL, 218mg/dL and 10% respectively) than after glucocorticoid discontinuation (97mg/dL, 137mg/dL and 0% respectively). Mean interstitial glucose levels increased in the afternoon and at night during glucocorticoid use.Conclusion This pilot study was the first to evaluate interstitial glucose levels in non-diabetic individuals using glucocorticoids in treatment of hematologic cancer. Glucocorticoid use during chemotherapy significantly increases interstitial glucose levels in these patients.

Blood pressure lowering and risk of new-onset type 2 diabetes: an individual participant data meta-analysis

SummaryBackgroundBlood pressure lowering is an established strategy for preventing microvascular and macrovascular complications of diabetes, but its role in the prevention of diabetes itself is unclear. We aimed to examine this question using individual participant data from major randomised controlled trials.MethodsWe performed a one-stage individual participant data meta-analysis, in which data were pooled to investigate the effect of blood pressure lowering per se on the risk of new-onset type 2 diabetes. An individual participant data network meta-analysis was used to investigate the differential effects of five major classes of antihypertensive drugs on the risk of new-onset type 2 diabetes. Overall, data from 22 studies conducted between 1973 and 2008, were obtained by the Blood Pressure Lowering Treatment Trialists’ Collaboration (Oxford University, Oxford, UK). We included all primary and secondary prevention trials that used a specific class or classes of antihypertensive drugs versus placebo or other classes of blood pressure lowering medications that had at least 1000 persons-years of follow-up in each randomly allocated arm. Participants with a known diagnosis of diabetes at baseline and trials conducted in patients with prevalent diabetes were excluded. For the one-stage individual participant data meta-analysis we used stratified Cox proportional hazards model and for the individual participant data network meta-analysis we used logistic regression models to calculate the relative risk (RR) for drug class comparisons.Findings145 939 participants (88 500 [60·6%] men and 57 429 [39·4%] women) from 19 randomised controlled trials were included in the one-stage individual participant data meta-analysis. 22 trials were included in the individual participant data network meta-analysis. After a median follow-up of 4·5 years (IQR 2·0), 9883 participants were diagnosed with new-onset type 2 diabetes. Systolic blood pressure reduction by 5 mm Hg reduced the risk of type 2 diabetes across all trials by 11% (hazard ratio 0·89 [95% CI 0·84–0·95]). Investigation of the effects of five major classes of antihypertensive drugs showed that in comparison to placebo, angiotensin-converting enzyme inhibitors (RR 0·84 [95% 0·76–0·93]) and angiotensin II receptor blockers (RR 0·84 [0·76–0·92]) reduced the risk of new-onset type 2 diabetes; however, the use of β blockers (RR 1·48 [1·27–1·72]) and thiazide diuretics (RR 1·20 [1·07–1·35]) increased this risk, and no material effect was found for calcium channel blockers (RR 1·02 [0·92–1·13]).InterpretationBlood pressure lowering is an effective strategy for the prevention of new-onset type 2 diabetes. Established pharmacological interventions, however, have qualitatively and quantitively different effects on diabetes, likely due to their differing off-target effects, with angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers having the most favourable outcomes. This evidence supports the indication for selected classes of antihypertensive drugs for the prevention of diabetes, which could further refine the selection of drug choice according to an individual's clinical risk of diabetes.FundingBritish Heart Foundation, National Institute for Health Research, and Oxford Martin School.

A guideline for the outpatient management of glycaemic control in people with cancer.

Individuals with cancer are at increased risk of developing new-onset diabetes mellitus and hyperglycaemia, and an estimated 20% of people with cancer already have an underlying diagnosis of diabetes mellitus. People with both cancer and diabetes may have an increased risk of toxicities, hospital admissions and morbidity, with hyperglycaemia potentially attenuating the efficacy of chemotherapy often secondary to dose reductions and early cessation. Numerous studies have demonstrated that hyperglycaemia is prognostic of worse overall survival and risk of cancer recurrence. These guidelines aim to provide the oncology/haemato-oncology and diabetes multidisciplinary teams with the tools to manage people with diabetes commencing anti-cancer/glucocorticoid therapy, as well as identifying individuals without a known diagnosis of diabetes who are at risk of developing hyperglycaemia and new-onset diabetes.

Multiomics Profiling Reveals Signatures of Dysmetabolism in Urban Populations in Central India

Background: Non-communicable diseases (NCDs) have become a major cause of morbidity and mortality in India. Perturbation of host–microbiome interactions may be a key mechanism by which lifestyle-related risk factors such as tobacco use, alcohol consumption, and physical inactivity may influence metabolic health. There is an urgent need to identify relevant dysmetabolic traits for predicting risk of metabolic disorders, such as diabetes, among susceptible Asian Indians where NCDs are a growing epidemic. Methods: Here, we report the first in-depth phenotypic study in which we prospectively enrolled 218 adults from urban and rural areas of Central India and used multiomic profiling to identify relationships between microbial taxa and circulating biomarkers of cardiometabolic risk. Assays included fecal microbiota analysis by 16S ribosomal RNA gene amplicon sequencing, quantification of serum short chain fatty acids by gas chromatography-mass spectrometry, and multiplex assaying of serum diabetic proteins, cytokines, chemokines, and multi-isotype antibodies. Sera was also analysed for N-glycans and immunoglobulin G Fc N-glycopeptides. Results: Multiple hallmarks of dysmetabolism were identified in urbanites and young overweight adults, the majority of whom did not have a known diagnosis of diabetes. Association analyses revealed several host–microbe and metabolic associations. Conclusions: Host–microbe and metabolic interactions are differentially shaped by body weight and geographic status in Central Indians. Further exploration of these links may help create a molecular-level map for estimating risk of developing metabolic disorders and designing early interventions.

Oppurtunistic completion of the 9 diabetic care processes during inpatient admission to a mental health hospital: an audit of local practice

AimsDiabetes is more prevalent in people with mental illness than in the general population. Those with both mental illness and diabetes are more likely to have poor glycaemic control. Clients with mental illness and diabetes are less likely to receive the 9 NICE recommended annual diabetic care processes than the general population. In 2017, the Joint British Diabetes Societies for Inpatient Care (JBDS-IP) and the Royal College of Psychiatrists released guidance recommending that inpatient psychiatric admissions should be used as an opportunity to complete diabetic care processes, and a named staff member should be responsible for this.We aimed to review local compliance with this JBDS-IP guidance, increase knowledge and improve local care for clients living with both mental illness and diabetes.MethodWe reviewed the notes of all current inpatients to general, forensic or learning disability wards at our centre and identified all patients with a known diagnosis of Diabetes. We identified which of the 9 care processes had been completed (or had the most recent result documented, or had a plan made for completion) during this admission. We identified if a named staff member was responsible for completing processes on each ward, and whether the care processes were documented in the patients’ notes.ResultWe identified 18 current diabetic inpatients at our centre (14% of inpatients). We found that none of these patients had a diabetic care processes review documented and none of these patients had had a foot check and urinary albumin performed during admission, or had the last community result identified and documented. We found that less than 15% of patients had a documented plan concerning the completion of retinal screening. One ward had a named staff member responsible for reviewing their diabetic patients’ screening. However, 6/9 care processes had been completed in the significant majority of patients (&gt;75%).ConclusionOur centre is not compliant with the guideline audited. We have implemented a plan to increase awareness of care processes through posters, teaching (at junior and consultant level), creating documentation templates and ensuring wards nominate a staff member to review care processes. We have organised a re-audit. Organising foot examination, renal function testing and retinal screening during admission for clients who may have complicated social situations and may not be aware of (or be non adherent with) the long term management of their diabetes has the potential to significantly reduce morbidity in this client subgroup.

Abstract P690: Conversion From Prediabetes to Diabetes After Ischemic Stroke

Introduction: Type II diabetes mellitus is an established risk factor for ischemic stroke. Prediabetes, defined as hemoglobin A1C from 5.7 to 6.4%, is a significant and under-recognized contributor to stroke risk. Based on meta-analyses in the general population, the risk of progression from prediabetes is roughly 11%/year. To date, there has been only one prospective cohort study of 26 acute stroke patients which found a progression rate of 19% in 3 months. Methods: We conducted a retrospective chart review of acute ischemic stroke patients from 2013 to 2018 with prediabetes (A1C 5.7-6.4%) during hospitalization, as well as a follow up A1C at least 3 months later. Patients were excluded if they had a known diagnosis of diabetes or were on antidiabetic medication. Our primary outcome was incident diabetes (A1c&gt;6.4). We evaluated potential predictors in logistic regression models and used a stepwise interactive process to create a final model, for which we report the area under the receiver operating curve (AUC). Results: We included 74 patients with a mean age of 66.1 years, 54% male, at a mean of 1.6 days from stroke onset to first A1c measurement, and a mean of 386 days to the follow-up A1c measurement. The conversion rate to diabetes was 10.8% (8/74) and 36.5% (27/74) of patients had an increase in A1c. The final predictive model for incident diabetes included discharge to home (vs. facility), 90-day mRS ≥2, baseline A1c ≥6, and median income by zip code of &lt;$50,000/year, which yielded an AUC of 0.85. Conclusion: In this preliminary cohort, acute ischemic stroke patients with prediabetes have a rate of conversion to diabetes that is comparable to the general population. However, given that diabetes increases risk for stroke and recurrent stroke has significantly higher morbidity and mortality than primary stroke, this patient population warrants targeting to prevent conversion to diabetes. Further research into a predictive model such as ours, with an AUC of 0.85, could improve patient selection for diabetes prevention after acute ischemic stroke.

Casual blood glucose and subsequent cardiovascular disease and all-cause mortality among 159 731 participants in Cohort of Norway (CONOR)

IntroductionOur aim was to assess the association between casual blood glucose level and subsequent cardiovascular disease (CVD) and mortality among community-dwelling adults without a diagnosis of diabetes.Research design and methodsIn...

Diabetic Emergencies: Experience of a Tertiary Endocrine Center

Purpose: In this study, we aimed to retrospectively evaluate the demographic data, clinical features, laboratory data, precipitating causes of diabetic emergencies, complications in the follow-up of adult patients who applied to our hospital due to diabetic emergencies. Methods: The study included patients aged 18 years and older referred to a tertiary endocrine center with diabetic ketoacidosis (DKA), hyperosmolar hyperglycemic state (HHS) hypoglycemia between January 2010 and May 2018. Results: The study was carried out with 165patients, 69(41.8%) males, and 96(58.2%) females. The mean age of the patients was 43.8±20.4(18- 88). Of these patients, 77% (n=127) had DKA, 17% (n=28) had HHS and 6% (n=10) had hypoglycemia. Of the patients 55.2% (n=91) were type 1 DM, 44.8% (n=74) were type 2DM. When the precipitating causes of diabetic emergencies were examined, 32.7%(n=54) poor adherence to treatment and 32.1%(n=53) infection of the patients were involved. The new diagnosis was DM in 10.9% of the patients (n=18). The most common complication after treatment was hypopotassemia with 38.7% (n=60), but no complication was observed in the majority of patients (54.8%). In our study, total mortality was 1.8% and 11.1% in HHS patients. No mortality was found in DKA and hypoglycemia patients. Conclusion: Diabetic ketoacidosis is more common in DM patients than in other diabetic emergencies. Approximately 11% of patients do not have a known diagnosis of diabetes. Poor adherence to treatment and infection are the most important precipitating causes of the diabetic emergency. The mortality rate is very low with early diagnosis and correct treatment.

Blood Glucose Levels Combined with Triage Revised Trauma Score Improve the Outcome Prediction in Adults and in Elderly Patients with Trauma.

This study was aimed to assess if combining the evaluation of blood glucose level (BGL) and the Triage Revised Trauma Score (T-RTS) may result in a more accurate prediction of the actual clinical outcome, both in general adult population and in elderly patients with trauma. This is a retrospective cohort study, conducted in the emergency department (ED) of an urban teaching hospital, with an average ED admission rate of 75,000 patients per year. Those excluded: known diagnosis of diabetes, age <18 years old, pregnancy, and mild trauma (classified as isolate trauma of upper or lower limb, in absence of exposed fractures). A combined Revised Trauma Score Glucose (RTS-G) score was obtained adding to T-RTS: two for BGL <160mg/dL (8.9mmol/L); one for BGL ≥160mg/dL and < 200mg/dL (11.1mmol/L); and zero for BGL ≥ 200mg/dL. The primary outcome was a composite of patient's death in ED or admission to intensive care unit (ICU). Receiver Operating Characteristic (ROC) curve analysis was used to evaluate the overall performance of T-RTS and of the combined RTS-G score. Among a total of 68,933 traumas, 9,436 patients (4,407 females) were enrolled, aged from 18 to 103 years; 4,288 were aged ≥65 years. A total of 577 (6.1%) met the primary endpoint: 38 patients died in ED (0.4%) and 539 patients were admitted to ICU. The T-RTS and BGL were independently associated to primary endpoint at multivariate analysis. The cumulative RTS-G score was significantly more accurate than T-RTS and reached the best accuracy in elderly patients. In general population, ROC area under curve (AUC) for T-RTS was 0.671 (95% CI, 0.661 - 0.680) compared to RTS-G ROC AUC 0.743 (95% CI, 0.734 - 0.752); P <.001. In patients ≥65 years, T-RTS ROC AUC was 0.671 (95% CI, 0.657 - 0.685) compared to RTS-G ROC AUC 0.780 (95% CI, 0.768 - 0.793); P <.001. Results showed RTS-G could be used effectively at ED triage for the risk stratification for death in ED and ICU admission of trauma patients, and it could reduce under-triage of approximately 20% compared to T-RTS. Comparing ROC AUCs, the combined RTS-G score performs significantly better than T-RTS and gives best results in patients ≥65 years.

Management of hyperglycaemia and steroid (glucocorticoid) therapy: a guideline from the Joint British Diabetes Societies (JBDS) for Inpatient Care group.

Glucocorticoids (steroids) are widely used across many medical specialities for their anti-inflammatory and immunosuppressive properties. However, one of their major side effects is the development of hyperglycaemia. It is well recognized that high glucose levels in people with diabetes in hospital are associated with harm and increased lengths of hospital stay. The use of glucocorticoid (steroid) treatment in people with pre-existing diabetes will undoubtedly result in worsening glucose control, and this may be termed 'steroid-induced hyperglycaemia', and will warrant temporary additional, and more active, glycaemic management. A rise in glucose may occur in people without a known diagnosis of diabetes, and this may be termed 'steroid-induced diabetes'. There is a lack of evidence to guide how people with hyperglycaemia should be managed, and much of the guidance given here is a consensus based on best practice collated from around the United Kingdom. Where evidence is available, this is referenced. These guidelines on the management of people with diabetes treated with steroids has been adapted specifically for Diabetic Medicine. The full version of the guidelines can be found on line at: www.diabetes.org.uk/joint-british-diabetes-society or https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group.

Routine HbA1c Testing in Women Undergoing Major Gynecologic Surgery to Detect Prevalence of Glucose Intolerance [20Q

INTRODUCTION: Determine the prevalence of undiagnosed diabetes, prediabetes and overall incidence of glucose intolerance in women undergoing major surgical procedures on the gynecologic oncology service. METHODS: Retrospective review of preoperative HbA1c levels obtained at preadmission testing in women scheduled for major gynecologic surgery at NYU Winthrop Hospital by gynecologic oncologists between July 2014 and July 2016. Exclusion criteria were lack of HbA1c within 90 days of scheduled surgery and all women undergoing minor surgical procedures. Diabetes was defined either by established diagnosis or with HbA1c ≥6.5, and prediabetes if HbA1c ranged 5.7- 6.4. Value less than 5.7 was considered normal. RESULTS: 343 women underwent major procedures and had HbA1c levels obtained. Fifty-eight (16.9%) had a known diagnosis of diabetes, and 285 (83.1%) were presumed non-diabetics. Majority (182, 63.9%) had normal HbA1c, 86 (30.2%) were prediabetic and 17 (6%) met criteria for diabetes, for a 36.2% prevalence of abnormal glucose tolerance in presumed non-diabetics. When all 343 women were considered, the diagnosis of glucose intolerance was present in 161 (46.9%), 64.0% of whom were previously undiagnosed. CONCLUSION: Nearly half of the women undergoing major gynecologic surgery procedures on the oncology service had impaired glucose tolerance. The diagnosis was previously not established in 64.0%. Pre-surgical assessment of HbA1c is warranted in this high risk population.

Long-term use of angiotensin-converting enzyme inhibitors protects against bone loss in African-American elderly men.

There is evidence of bone mass preservation in patients receiving ACEis, commonly used to treat hypertension. However, limitations of previous studies include being cross-sectional or only including a short-term follow-up of patients using ACEi and including patients with diabetes, which affects bone metabolism. None of the previous studies described effects of ACEi stratified by race. The objective of this study was to investigate differences in changes in bone mineral density (BMD) in older adults who suffer from hypertension and had reported ACEi use during each study visit for at least 9years during the study, stratified by gender and race. We used data from the Dynamics of Health, Aging and Body Composition (HABC) study, which enrolled 3075 community-dwelling older white and black individuals. We compared changes in femoral neck, total hip, and whole-body BMD after either no use of ACEi (n=580) or long-term use (at least 9years) of ACEi (n=239) in HABC participants with hypertension and no known diagnosis of diabetes mellitus. Overall, BMD values significantly decreased for all subgroups over time. In the stratified multivariate analysis, long-term use of ACEi was associated with a reduced rate of decline for all three BMD measures among black men, but no significant effect was observed in the other subgroups. Our findings show a gender- and race-specific effect of ACEi in the prevention of age-associated bone loss that warrants further evaluation.

Leptin-adiponectin ratio in pre-diabetic patients undergoing percutaneous coronary intervention.

The obesity-related hormones leptin and adiponectin are independently and oppositely associated with insulin resistance, which is an important risk factor for coronary artery disease (CAD) and restenosis after coronary intervention. In this report, we set out to determine the role of the leptin-adiponectin ratio (LAR) in non-diabetic patients with or without impaired glucose tolerance undergoing a percutaneous coronary intervention. 300 PCI patients were enrolled in this prospective single-centre study. Patients with known diagnosis of diabetes (n = 50) and newly diagnosed diabetes (2h OGTT > 200 mg/dL, n = 25) were excluded. In both stable and acute subjects, assessment was done on the day of discharge and included a fasting glucose level, leptin, adiponectin and an oral glucose tolerance test (OGTT). LAR was significantly higher in diabetic (7.2 ± 0.7) than in non-diabetic patients (3.9 ± 0.3, P = 0.001), and even higher in newly diagnosed diabetics (9.8 ± 1.5, P < 0.001). Likewise, among non-diabetic patients, LAR was significantly higher in patients with impaired glucose tolerance. LAR was significantly higher in pre-diabetic (4.57 ± 0.48) versus normoglycaemic patients (3.45 ± 0.33, P = 0.05). LAR was found to be numerically higher in pre-diabetic versus normoglycaemic patients with two- and three-vessel disease (VD), but not in patients with single VD. In pre-diabetic patients, LAR was found to be significantly increased with more advanced CAD (P = 0.021), independent of stable versus unstable presentation. LAR is related to the extent of CAD in pre-diabetic patients but not in normoglycaemic patients. This finding might in part explain the poorer outcome in revascularized patients with impaired glucose tolerance compared to normoglycaemic patients.

Glycated haemoglobin (HbA1c ) and fasting plasma glucose relationships in sea-level and high-altitude settings.

AimHigher haemoglobin levels and differences in glucose metabolism have been reported among high‐altitude residents, which may influence the diagnostic performance of HbA1c. This study explores the relationship between HbA1c and fasting plasma glucose (FPG) in populations living at sea level and at an altitude of > 3000 m.MethodsData from 3613 Peruvian adults without a known diagnosis of diabetes from sea‐level and high‐altitude settings were evaluated. Linear, quadratic and cubic regression models were performed adjusting for potential confounders. Receiver operating characteristic (ROC) curves were constructed and concordance between HbA1c and FPG was assessed using a Kappa index.ResultsAt sea level and high altitude, means were 13.5 and 16.7 g/dl (P > 0.05) for haemoglobin level; 41 and 40 mmol/mol (5.9% and 5.8%; P < 0.01) for HbA1c; and 5.8 and 5.1 mmol/l (105 and 91.3 mg/dl; P < 0.001) for FPG, respectively. The adjusted relationship between HbA1c and FPG was quadratic at sea level and linear at high altitude. Adjusted models showed that, to predict an HbA1c value of 48 mmol/mol (6.5%), the corresponding mean FPG values at sea level and high altitude were 6.6 and 14.8 mmol/l (120 and 266 mg/dl), respectively. An HbA1c cut‐off of 48 mmol/mol (6.5%) had a sensitivity for high FPG of 87.3% (95% confidence interval (95% CI) 76.5 to 94.4) at sea level and 40.9% (95% CI 20.7 to 63.6) at high altitude.ConclusionThe relationship between HbA1c and FPG is less clear at high altitude than at sea level. Caution is warranted when using HbA1c to diagnose diabetes mellitus in this setting.

Does a Large Fetal Abdominal Circumference in Women Without Diabetes Predict Adverse Outcomes? [5P

INTRODUCTION: We sought to determine if fetuses that have a large abdominal circumference (AC) have an increase in adverse outcomes. METHODS: This is a retrospective cohort study conducted via chart review of women seen for ultrasound at 28-32 weeks gestation with fetal AC measuring &gt;90th percentile during the study period of 1/1/2014 through 12/31/2015. Women with a known diagnosis of diabetes were excluded. Multivariate logistic regressions were conducted to determine relationships between fetal AC and neonatal and maternal outcomes: neonatal hypoglycemia, birth weight, NICU admission, 5-minute Apgar scores, mode of delivery, development of gestational diabetes, and polyhydramnios. These outcomes were adjusted for presence or absence of gestational diabetes, race, maternal age, and gravidity. RESULTS: 1715 women were included. Mean gestational age was 31 weeks. Increasing fetal AC is predictive of primary cesarean delivery (OR 1.486, p=0.0023). Fetuses with larger abdominal circumferences on antenatal ultrasounds are more likely to be macrosomic with birth weight &gt;4000 grams (OR 2.496, p &lt; 0.0001). Increasing fetal AC is associated with the later development of gestational diabetes (OR 2.343, p=0.0023) and polyhydramnios (OR 2.938, p=0.0003). Fetal AC does not predict lower Apgar score (OR 0.615, p=0.416), NICU admission (OR 0.824, p=0.167), or neonatal hypoglycemia (OR 1.047, p=0.852). Though none of the patients in this study were initially diagnosed with diabetes, 220 (12.8%) were found to have gestational diabetes by the time of delivery. CONCLUSION: Women should be counseled about the increased risks of primary cesarean delivery, polyhydramnios, macrosomia, and gestational diabetes when a large fetal AC is found.