Lower Glucose Values Research Articles

7419 Navigating The Diagnostic Maze Of Pseudohypoglycemia In A Young Adult Male With Severe Hypertriglyceridemia: A Novel Case Report

Abstract Disclosure: C. Muojieje: None. M. Hotiana: None. Objective: This case report aims to shed light on the challenges of diagnosing and managing pseudohypoglycemia, particularly in the absence of Whipple's triad, and to explore its rare association with severe hypertriglyceridemia. Methods and Results: We present a 26-year-old Caucasian male with a history of depression, anxiety, and recently diagnosed hyperlipidaemia who presented to Cabell Huntington Hospital with intermittent chest pain and multiple episodes of syncope. Laboratory findings revealed low sodium (128 mmol/L) and significant discrepancies in blood glucose levels (52 mg/dL in laboratory tests vs. 93 mg/dL in point-of-care tests). The managing team initiated an evaluation for hypoglycaemia based on the low serum glucose values by ordering c-peptide, insulin and pro-insulin (normal findings). Endocrinology was consulted for further management of pseudo hypoglycaemia. Consultation led to further investigations, revealing severely elevated triglycerides (2,568 mg/dL), cholesterol (478 mg/dL), low HDL (26 mg/dL), and very low-density VLDL (514 mg/dL). The stat glucose test showed a level of 103 mg/dL, while the routine glucose test on the same sample was less than 10 mg/dL, and the point-of- care glucose test was 90 mg/dL. An A1c test returned normal at 4.9%, and the patient had no history of diabetes or insulin use. Conclusion: This case highlights the complexities in diagnosing pseudohypoglycemia, a condition that can present with falsely low glucose readings in the absence of clinical hypoglycemia symptoms. The significant hypertriglyceridemia observed in this patient suggests a potential novel association. The findings emphasize the need for comprehensive evaluation in cases of discordant glucose readings and suggest a potential new frontier in understanding and managing pseudohypoglycemia. Physicians should be aware of rare instances of in vitro glycolysis leading to pseudohypoglycemia and consider lipid profiles in their diagnostic process. Presentation: 6/3/2024

9337 Postprandial And “Fasting” Hypoglycemia In A Patient With A History Of Gastric Bypass Surgery And Carcinoid Syndrome

Abstract Disclosure: S. Ntelis: None. M. Pennant: None. Background: Hypoglycemia is an increasingly recognized complication of bariatric surgery that can occur years after the procedure. Episodes most commonly occur 1-3 hours after meals. Fasting hypoglycemia is not typical and raises concerns for other etiologies, including adrenal insufficiency and other causes of endogenous hyperinsulinism. Clinical Case: A 51-year-old woman with a history of carcinoid tumor of unknown origin with liver metastases, treated with monthly octreotide injections, and history of Roux-en-Y gastric bypass presented with multiple episodes of symptomatic hypoglycemia up to 24 mg/dl. Symptoms included tremor and diaphoresis and improved with juice. Morning cortisol was 22.7 mcg/dL (n > 19.4 mc/dL), ruling out adrenal insufficiency. A continuous glucose monitor (CGM) was placed, and she was advised to have frequent low-carbohydrate meals mixed with healthy fats and protein. She was also advised to add cornstarch to meals, until mixed-meal testing could be performed. She was hospitalized for a seizure provoked by hypoglycemia after a heavy high-carbohydrate meal, and treatment with acarbose 25 mg three times daily was started. Mixed-meal testing was consistent with post-prandial hyper-insulinemic hypoglycemia, with elevated insulin (58 mcIU/ml, n: 2.6-24.9 mcIU/ml) and c-peptide (11.2 ng/ml, n: 1.1-4.4 ng/ml) levels during an episode of symptomatic hypoglycemia (glucose 22 mg/dL) 2.5 hours after the patient’s meal. CGM showed hypoglycemia mostly occurring after meals and some episodes of hypoglycemia early in the morning, that occurred after late-night snacks. Clinical picture and laboratory testing were suggestive of post-bariatric surgery hypoglycemia. Poor hepatic glycogen reserve, secondary to the liver metastases, was considered a contributing factor. Interestingly, although hypoglycemia was mediated by hyperinsulinemia, treatment with a somatostatin analogue provided no benefit. The frequency of hypoglycemia decreased with adherence to a low-carbohydrate diet, and episodes mostly occurred when acarbose use was delayed. Octreotide was transitioned to lantreotide. Due to persistence of early-morning low glucose values on follow-up, further work-up was pursued to rule out etiologies of fasting hypoglycemia. Glucose values remained >70 mg/dl during 72 hours of fasting. IGF-I (115 ng/ml, n: 53-287 ng/ml) and IGF-II (608 ng/ml, n: 267-616 ng/ml) levels were normal, and insulin antibodies were undetectable. Post-bariatric surgery hypoglycemia was confirmed and acarbose dose was increased to 50 mg three times daily. Conclusion: Postprandial hypoglycemia is a late complication of bariatric surgery. Early-morning hypoglycemia can also be seen after bariatric surgery in patients who have late-night meals and snacks. Presentation: 6/1/2024

Clinico-epidemiological profile of 75 cases of TB meningitis in children and adoloscents

BackgroundNeurological involvement is one of the deadliest forms of tuberculosis especially in pediatric population. AimTo study the clinico-epidemiological profile of 75 cases of pediatric TB meningitis and its co-relation with CBNAAT/TRUENAT positivity. Study designProspective study in children and adolescents less than 18 years in Tertiary Health care centre in New Delhi. Subjects and methods75 Children and adolescents less than 18 years with Probable TBM as per NTEP guidelines were enrolled. Clinical, Radiological and CSF analysis were carried out in all the patients. Results75 children were enrolled out of which 61% were females. The most common symptom at presentation was fever followed by loss of appetite and weight loss. Neck rigidity was present in 66% cases followed by posturing in 25% cases. 46% patients presented in Stage 2. Tuberculin skin test was positive in 16% cases and 20% patients had evidence of pulmonary TB on chest Xray. Hydrocephalous was the most common finding in neuroimaging present in 61% cases. In majority of the cases, CSF analysis revealed pleocytosis with lymphocyte predominance, low glucose and high protein values. Nucleic amplification tests (CBNAAT/TRUENAT) were positive in 33% cases and 4 out of 75 were detected to have rifampicin resistance. There was no co-relation identified between Stage at presentation, tuberculin positivity and CSF analysis with CBNAAT/TRUENAT positivity. Six patients expired within 2 weeks of presentation. ConclusionThe diagnosis of TBM is a composite of clinical, radiological and CSF analysis parameters. Being a paucibacillary sample, the yield of TB bacilli in NAAT studies remains moderately low. Moreover, detection of TB bacilli in CBNAAT/TRUENAT is independent of the CSF cytological and biochemical profile, and is also independent of the Stage of TBM.

Real-world data analysis for the association of glucose control and mortality in critically ill patients.

Existing results regarding the usage of glycemic control in critically ill patients for reduced morbidity and mortality have been based on clinical studies but could not be reproduced in large prospective studies. Current guidelines for glycemic control suggest a target blood glucose of 140-180mg/dL, with lower targets being appropriate for some patients. The current study aims to provide additional evidence to this area, through the usage of real-world retrospective data of everyday clinical practice. We have used the large, credentialed access database MIMIC-IV to assess the effect of glycemic control to patient mortality. Glycemic control has been characterized by the percentage of time that the glucose measurements fall within pre-specified glucose bands. Results from logistic regression and survival analysis are reported, along with visualizations based on methods from the machine learning literature, which all suggest that increased time in low and high glucose values is related to increased ICU mortality and decreased survival.

430-P: Glycemic Control Assessed by Continuous Glucose Monitoring among Dialysis Patients With and Without Diabetes Mellitus

Introduction: Glycemic control for dialysis patients with diabetes mellitus (DM) is challenging due to limitations of HbA1c, risk of hypoglycemia, and fewer options for glucose-lowering agents. We sought to comprehensively describe glycemic patterns among dialysis patients using continuous glucose monitoring (CGM). Methods: The Blood Sugar Sensing On Maintenance Dialysis (BLOSSOM) study is a prospective community-based cohort of people treated with dialysis, with or without DM, designed to assess the prevalence, causes, and consequences of dysglycemia. Each participant wore a Dexcom G6 CGM for 10 days. This interim analysis examined the first 153 BLOSSOM dialysis participants. Results: Dialysis participants had a mean (SD) age of 61 (14) years, 132 (86%) underwent hemodialysis, and 21 (14%) were treated with peritoneal dialysis (PD). Among 90 dialysis participants with DM, mean (SD) glucose management indicator (GMI) was 7.9% (1.2%), time in range (TIR) (70-180 mg/dL) was 50% (29%) and 27 (30%) participants achieved TIR ≥70%. Mean (SD) time high (>180 mg/dL), very high (>250 mg/dL), low (<70 mg/dL) and very low (<54 mg/dL) was 49% (29%), 21% (23%), 2% (11%) and 1% (11%), respectively. Of 63 dialysis participants without DM, mean (SD) GMI was 6.2% (0.4%), and time in normal range (70-140 mg/dL) 75% (18%). Mean (SD) time low and very low were 2% (8%) and 0% (3%), with low and very low sensor glucose values seen in 38 (60%) and 23 (37%) participants, respectively. PD patients without known DM (n=9) had a mean (SD) GMI of 6.6% (0.3%) and spent mean (SD) 54% (21%) of time in normal range. Conclusions: In this community-based sample of maintenance dialysis patients, uncontrolled hyperglycemia was highly prevalent among patients with DM. PD patients without DM were in normal range less than half of the time. Hypoglycemia was seen in patients with and without DM. Our findings warrant additional investigation into causes and consequences of glycemic patterns in patients on dialysis. Disclosure L.Mayeda: None. L.Zelnick: None. S.Trikudanathan: Research Support; Insulet Corporation, Bionic pancreas. I.B.Hirsch: Consultant; Abbott Diabetes, Lifecare, Inc., Hagar, Research Support; Beta Bionics, Inc., Insulet Corporation, Dexcom, Inc. S.Watnick: None. I.De boer: Advisory Panel; AstraZeneca, Boehringer Ingelheim and Eli Lilly Alliance, Boehringer Ingelheim International GmbH, Otsuka America Pharmaceutical, Inc., Bayer Inc., Consultant; George Clinical, Gilead Sciences, Inc., Medscape, Research Support; Dexcom, Inc. Funding National Institute of Diabetes and Digestive and Kidney Diseases (R01DK126373)

932-P: Impact of a Titration App for Basal Insulin on Glycaemic Outcomes in People with Type 2 Diabetes on an Oral-Basal Insulin Regimen—Results of an RCT

A multicenter RCT analyzed the efficacy of a basal insulin titration app (myDose Coach; MDC) in people with type 2 diabetes and newly initiated or existing basal insulin treatment. We randomized 251 participants in a 1:1 ratio to either the intervention arm (insulin titration with MDC) or the control arm (insulin titration without App). The primary outcome was A1c reduction after 3-month. Baseline data (median age 60.0 years IQR 56.0 - 66.5; HbA1c 8.2 IQR 7.7 - 9.1%) showed no significant differences. After a median follow-up of 91.0 days, the intervention group showed a reduction in HbA1c of 0.93, IQR 0.40 - 1.57 percentage points compared to the control group (0.6; IQR 0.10 -1.40); adjusted difference between groups 0.35; 95% CI 0.35 0.01 - 0.69; p=0.0064. Improvements in follow-up A1c were evident across the range of A1c values (Figure 1). The respective differences between groups in glucose level (19.3; 95% CI 9.10 - 29.97 mg/dl; p=0.0012), fasting glucose (10.5; 95% CI 1.5 - 19. 0 mg/dl) and % < 180 mg/dl (12.2; 95% CI 3.8 - 20.5; p=0.0065) all favored the intervention group, while % < 70 mg/dl (−0.2; 95% CI −1.0 - 0.6; p=0.8778) did not differ substantially. Titration of basal insulin with the MDC app significantly improved glycemic management, without increasing exposure to low glucose values substantially. Thus, titration with the MDC app has a medical benefit beyond usual care. Disclosure N.Hermanns: Advisory Panel; Insulet Corporation, Research Support; Sanofi-Aventis Deutschland GmbH, Roche Diagnostics, Becton, Dickinson and Company, Speaker's Bureau; Dexcom, Inc., Berlin-Chemie AG. D.Ehrmann: Advisory Panel; Roche Diabetes Care, mySugr, Dexcom, Inc., Speaker's Bureau; Berlin-Chemie AG, Dexcom, Inc. T.Roos: None. K.Finke-groene: None. B.Kulzer: Advisory Panel; Berlin-Chemie AG, Abbott Diabetes, Bayer Inc., Dexcom, Inc., Novo Nordisk, Insulet Corporation, embecta, Research Support; Sanofi, Roche Diabetes Care. Funding Sanofi

The Official Journal of ATTD Advanced Technologies & Treatments for Diabetes Conference 22‐25 February 2023 I Berlin & Online

The Official Journal of ATTD Advanced Technologies & Treatments for Diabetes Conference 22‐25 February 2023 I Berlin & Online

743: EVALUATION OF REGULAR INSULIN 10 UNITS VERSUS 5 UNITS FOR THE TREATMENT OF HYPERKALEMIA

Introduction: Hyperkalemia is a common problem faced in the intensive care unit (ICU) and emergency department. Traditionally, regular insulin 10 units IV has been used in combination with dextrose to shift potassium intracellularly to prevent cardiac abnormalities. Available literature supports the use of different insulin regimens based on a patient’s weight, renal function, and diabetes status. Currently, our institution has a hyperkalemia order set that includes varying regular insulin doses, dextrose, and scheduled lab draws for potassium and glucose. The purpose of this study was to compare the efficacy and safety of regular insulin 5 units and 10 units for the treatment of hyperkalemia. Methods: This was a single-center, retrospective, cohort study of ICU and emergency department patients who received regular insulin 10 units or 5 units IV push for hyperkalemia treatment. The primary outcome was the decrease in potassium in mmol/L after insulin administration. Secondary outcomes included the incidence of hypoglycemia, rate of order set utilization, and incidence of inappropriate omission of dextrose. Results: Forty-three patients were included in the study, with 21 receiving 10 units and 22 receiving 5 units. Patients who received 5 units of insulin had worse renal function (serum creatinine 5.6 mg/dL vs 3.5 mg/dL) and lower glucose values prior to insulin (glucose 133.7 mg/dL vs 184.8 mg/dL) compared to those who received 10 units. Both groups had similar potassium levels upon presentation, 6.19 mmol/L in insulin 5 unit group compared to 6.20 mmol/L in the 10 unit group. Average decrease in potassium levels was 1.1 mmol/L with 5 units and 1.0 mmol/L with 10 units. Two patients in each group experienced hypoglycemia after insulin administration. Both groups had similar rates of dextrose orders omitted and need for additional units of insulin within 24 hours. Conclusions: The potassium lowering effects were not different between groups based on the units of insulin received. Regular insulin 10 units did not result in a higher incidence of hypoglycemia or a need for less additional insulin orders. This study demonstrated that the use of regular insulin 5 units had similar outcomes compared to the use of 10 units for the treatment of hyperkalemia.

User Performance Evaluation and System Accuracy Assessment of Four Blood Glucose Monitoring Systems With Color Coding of Measurement Results.

Blood glucose monitoring systems (BGMSs) are a cornerstone in diabetes management. They have to provide sufficiently accurate results in the hands of lay users, particularly in insulin-treated patients. The aim of this study was user performance evaluation and system accuracy assessment of four BGMSs with color coding of results. Study procedures were based on ISO 15197:2013. User performance evaluation included data from 100 participants, each of whom used every system with one reagent lot. Study personnel observed user techniques. For the system accuracy assessment, 100 capillary samples were obtained for measurement in duplicate with each of three reagent system lots per system, resulting in 600 results per system. All assessed BGMSs exhibited a sufficient level of accuracy, with small differences between them. In the user performance evaluation, study personnel observed the smallest total number of user errors with Contour Next (Ascensia), followed by Accu-Chek Instant (Roche), Medisafe Fit Smile (Terumo), and OneTouch Ultra Plus Reflect (LifeScan). Approximately 90% of participants stated that a consistent color scheme, eg, for low blood glucose (BG) values, should be used across all BGMSs. There was no clear preference among the four tested BGMSs regarding the specific way of displaying color coding. The four BGMSs assessed in this study showed only small differences in an overall sufficient level of accuracy. User handling errors, as observed by study personnel, differed between the systems.

Effect of process production on antinutritional, nutrition, and physicochemical properties of modified sorghum flour

Increasing wheat flour consumption makes increasing of wheat import value in Indonesia. Wheat flour has good nutritions, sufficient gluten compound, high glucose and high glycemic index. Therefore, substituting wheat with sorghum (local crop) which has gluten free, a low glucose and glycemic index value, can overcome food security problem in Indonesia. However, it has a high phytic acid and tannin (antinutrients). This study focuses on the reduction of antinutrients by three processes (fermentation treatment using lactic acid bacterias (LAB), including Lactobacillus bulgaricuss, Lactobacillus casei, and Lactobacillus brevis (1); NaOH solution submersion (2); and combining NaOH solution submersion followed by fermentation (3)). It was found that combining NaOH solution submersion and fermentation resulted in reduction of antinutrient contents (phytic acid decreased from 11.9% to 0.117% and the tannin decreased from 6.16% to 0.063%) and improved nutrition composition (such as protein content increased from 8.59% to 14.67%) on sorghum so that sorghum could be feasible to be an alternative source of wheat substitution in flour production. Moreover, the glucose content and glycemic Index (GI) of modified sorghum flour was decreased from 2.75 to 1.83%, and decreased from 40.79 to 36.33, respectively.

Screening for sleep-disordered breathing in people with type 1 diabetes by combining polysomnography with glucose variability assessment

AimsThere are few published data on sleep-disordered breathing (SDB) in type 1 diabetes (T1DM). Here, we used a combination of polysomnography and glucose variability assessment to screen for SDB. MethodsIn a prospective, single-centre study, adults with T1DM underwent polysomnography and continuous glucose monitoring during a single night. We measured high glucose variability and the occurrence of a low or very low glucose level. Mild and moderate-to-severe SDB were defined as an apnoea-hypopnoea index above 5/h and 15/h, respectively. ResultsWe studied 46 patients (25 men; median age: 42 [35–54]; diabetes duration: 18 years [13–29]; body mass index (BMI): 24.8 kg/m2 [23.0–28.9]). SDB was present in 17 patients (37.0%) overall (mild SDB: n = 9; moderate-to-severe SDB; n = 8). When compared with the absence of SDB or mild SDB, moderate-to-severe SDB was associated with a higher BMI (29.8 kg/m2 [27.8–31.1]) and a longer diabetes duration (26 years [18–31]) but not with above-target glucose variability or more sleep disorder symptoms. Conversely, sleep disorder symptoms were not more frequent in patients with above-target glucose variability. ConclusionSDB was highly prevalent and associated with obesity. According to the methods used here, sleep disorders were not associated with above-target glucose variability or low glucose values.

Hypoglycaemia in the Early Neonatal Period in Newborns

Neonatal hypoglycaemia is a topical problem in neonatology and paediatric endocrinology. In recent years, problems of glycaemia monitoring during first days of life have been discussed as well as the strategy for management of newborns with the syndrome of hypoglycemia and evaluation of metabolism in brain neurons has been a matter of scientific research. Scientific publications regarding the detection rate and duration of low glucose values in the early neonatal period as well as means of their correction and conducted therapy results are very scarce and ambiguous, which determines the necessity of new modern data regarding the problem considered. Purpose of the study: to study the detection rate and dynamics of clinical and laboratory manifestations of hypoglycaemia in children in the early neonatal period in order to optimise observation of newborns at the risk of developing this condition. Materials and methods: an open, retrospective, continuous, single-centre study was conducted to obtain preliminary data important for development of monitoring strategies for newborns at the risk of hypoglycaemia (neonates with high birth weight, children born to mothers with diabetes, newborns with intrauterine growth restriction). The target studied group was constituted by 522 newborns of both genders in the early neonatal period (aged 0 to 7 days). Results: the paper presents data on hypoglycaemia detection rate in newborns with risk factors for hypoglycaemia development, clinical and laboratory features of this condition, dynamics of glycaemia during the early neonatal period as well as the timing of blood glucose stabilisation (the age of normoglycaemia achievement).

Low glucose at 3-hour 100 gram oral glucose tolerance test: implications for glucose control

Objective To assess the clinical significance of a low 180-minute glucose value in a 100 g oral glucose tolerance test (OGTT) and a single high abnormal value. Methods A retrospective cohort study. The study group included women with 180-minute plasma glucose levels of ≤60 mg/dL and one abnormal value in the OGTT. The control group was comprised of women with one abnormal value in the OGTT and normal 180-minute glucose value. The primary outcome was glycemic control, defined as fasting blood glucose measurements > 90 mg/dL or post-prandial glucose values >140 mg/dL or 120 mg/dL (one-hour and two-hour post-prandial, respectively) in >30% of the measurements. Secondary outcomes were the rate of insulin treatment and the perinatal outcome consisting of birthweight, large-for-gestational-age, and polyhydramnios. Results Three hundred and one women were included, 143 in the study group and 158 in the control group. Pre-pregnancy BMI, first trimester fasting glucose levels, previous GDM, and familial diabetes were similar for both groups. Suboptimal glycemic control was more prevalent among the women in the study group (14% vs. 5.1%, respectively, p= .01). The need for insulin treatment was similar in both groups. Conclusions Women with one abnormal value and a 180-minute hypoglycemia in the OGTT are at increased risk for suboptimal glycemic control.

Sleep apnoea-hypopnoea syndrome in the obese and non-obese: Clinical, polysomnographical and clinical characteristics

IntroductionSleep apnoea-hypopnoea syndrome (SAHS) and childhood obesity are two high prevalence conditions that represent a public health challenge. ObjectiveTo analyse the association between both and comparing child groups that had or did not have both conditions. Patients and methodsA prospective study in children (3–14 years), referred to the “Multidisciplinary Sleep Unit” due to suspected SAHS, between 1 November 2015 and 1 August 2017. The following parameters were evaluated: anthropometry, symptoms, blood pressure, ear, nose, and throat examination, polysomnography (nocturnal PSG) and laboratory tests. ResultsA total of 67 children were evaluated (64% non-obese (NOb) and 36% obese (Ob). It was observed that the Ob were older (P < .001), slept less hours (P = .028), did less physical exercise (P = .029), ate less in the school dining room (P = .009), had la lower sleep efficiency, and had abnormal values in carbohydrate and lipid metabolism.The children with SAHS were younger (P = .010), a high percentage of daytime sleepiness (P = .001), and breathing through the mouth (P = .006), greater percentile of diastolic blood pressure (P = .019) and a lower IGF-1 (P = .003) than those that did not have SAHS. The comparison of the SAHS NOb and SAHS Ob groups, showed that the first group were younger (P = .010), snored more (P = .012), had a more severe SAHS (IAH 13.1 vs 5.4, P = .041), and a higher GOT (P < .001). In the second group, they slept less hours P = .038) and showed lower values of glucose (P = .039), insulin (P < .001), and HOMA (P < .001). ConclusionThe behaviour of SAHS is different in obese children and non-obese children, with differences in age, clinical characteristics, severity of SAHS, and metabolic changes. The children diagnosed with SAHS were in the higher percentile of diastolic blood pressure. Obesity was associated with worse sleep quality, and changes in carbohydrate and lipid metabolism.

558-P: Association between Glucose Levels and Diabetes Symptoms

Low and high glucose levels can cause diabetes-specific aversive symptoms. These symptoms can be a direct marker of the impact of diabetes on living with the disease. We used Ecological Momentary Analysis (EMA) in combination with a flash glucose meter (Freestyle Libre, Abbott) to assess the impact of glucose levels on symptoms. We selected symptoms typically associated with high and low glucose levels, as well as control symptoms. In the DIA-LINK study, 203 people with type 1 diabetes were asked to rate the severity of diabetes symptoms on a “0” to “10” scale four times a day over a two-day period. Two measurement points were fixed (morning and evening) and two were randomly assigned. Glucose data from the 2-hour period before each symptom assessment were extracted. Multilevel regression analysis was used to determine the difference between 2-hour periods with low or high glucose values (glucose value 250 mg/dl, respectively) and without such hypoglycemic or hyperglycemic periods. Figure shows T values (values > 1.96 = p Disclosure N. Hermanns: Advisory Panel; Self; Abbott, Research Support; Self; Berlin-Chemie AG, Roche Diabetes Care, Sanofi-Aventis Deutschland GmbH. A. J. Schmitt: None. B. Kulzer: Advisory Panel; Self; Berlin-Chemie AG, Roche Diabetes Care, Sanofi-Aventis Deutschland GmbH, Research Support; Self; Berlin-Chemie AG, Novo Nordisk, Speaker’s Bureau; Self; Berlin-Chemie AG, Dexcom, Inc., Novo Nordisk. L. Priesterroth: None. D. Ehrmann: Speaker’s Bureau; Self; Berlin-Chemie AG. Funding German Center for Diabetes Research (DZD)

Hypoglycemia is an early, independent predictor of bacteremia and in-hospital death in patients with cirrhosis.

Bacteremia is a common cause of death in patients with cirrhosis and early antimicrobial therapy can be life-saving. Severe liver disease impairs glucose metabolism such that hypoglycemia may be a presenting sign of infection in patients with cirrhosis. We explored this association using granular retrospective data. We conducted a case-control analysis from 1 January 2008 to 31 December 17 in the University of Pennsylvania Health System. We identified the first blood culture results from all cirrhosis hospitalizations and obtained detailed vital sign and laboratory data in the 24-72 h prior to culture results. We used multivariable logistic regression to develop models predicting blood culture positivity and in-hospital mortality. We repeated these analyses restricted to normothermic individuals. Restricted cubic splines were used to model nonlinearity in the glucose variable. We identified 1274 cirrhosis admissions with blood culture results (52.7% positive). In adjusted models, minimum glucose 24-72 h prior to blood culture result date was a significant predictor of blood culture positivity. In particular, glucose levels below 100 mg/dL significantly increased the probability of subsequent positive blood culture (e.g. odds ratio 1.89 for 50 mg/dL vs. 100 mg/dL, P = 0.004). This relationship persisted when restricting the cohort to normothermic individuals. Glucose levels <100 mg/dL in patients with bacteremia were also positively associated with in-hospital mortality. Early hypoglycemia is predictive of subsequently documented bacteremia and in-hospital mortality in patients with cirrhosis, even among normothermic individuals. In patients without other overt signs of infection, low glucose values may serve as an additional data point to justify early antibiosis.

Glycemic Patterns Are Distinct in Post-Bariatric Hypoglycemia After Gastric Bypass (PBH-RYGB).

Severe hypoglycemia with neuroglycopenia, termed post-bariatric hypoglycemia (PBH). typically occurs postprandially, but it is also reported after activity or mid-nocturnally. To quantify glycemia, glycemic variability, and magnitude/duration of low sensor glucose (SG) values in patients with PBH after Roux-en-Y gastric bypass (PBH-RYGB). This retrospective analysis of data from an academic medical center included individuals with PBH-RYGB (n = 40), reactive hypoglycemia without gastrointestinal surgery (Non-Surg Hypo, n = 20), prediabetes (Pre-DM, n = 14), newly diagnosed T2D (n = 5), and healthy controls (HC, n = 38). Masked continuous glucose monitoring (Dexcom G4) was used to assess patterns over 24 hours, daytime (6 am-midnight) and nighttime (midnight-6 am). Prespecified measures included mean and median SG, variability, and percent time at thresholds of sensor glucose. Mean and median SG were similar for PBH-RYGB and HC (mean: 99.8 ± 18.6 vs 96.9 ± 10.2 mg/dL; median: 93.0 ± 14.8 vs 94.5 ± 7.4 mg/dL). PBH-RYGB had a higher coefficient of variation (27.3 ± 6.8 vs 17.9 ± 2.4%, P < 0.0001) and range (154.5 ± 50.4 vs 112.0 ± 26.7 mg/dL, P < 0.0001). Nadir was lowest in PBH-RYGB (42.5 ± 3.7 vs HC 49.0 ± 11.9 mg/dL, P = 0.0046), with >2-fold greater time with SG < 70 mg/dL vs HC (7.7 ± 8.4 vs 3.2 ± 4.1%, P = 0.0013); these differences were greater at night (12.6 ± 16.9 vs 1.0 ± 1.5%, P < 0.0001). Non-Surg Hypo also had 4-fold greater time with SG < 70 at night vs HC (SG < 70: 4.0 ± 5.9% vs 1.0 ± 1.5%), but glycemic variability was not increased. Patients with PBH-RYGB experience higher glycemic variability and frequency of SG < 70 compared to HC, especially at night. These data suggest that additional pathophysiologic mechanisms beyond prandial changes contribute to PBH.

Metabolic Parameters in Patients with Suspected Reactive Hypoglycemia.

Background: It remains unclear whether reactive hypoglycemia (RH) is a disorder caused by improper insulin secretion, result of eating habits that are not nutritionally balanced or whether it is a psychosomatic disorder. The aim of this study was to investigate metabolic parameters in patients admitted to the hospital with suspected RH. Methods: The study group (SG) included non-diabetic individuals with symptoms consistent with RH. The control group (CG) included individuals without hypoglycemic symptoms and any documented medical history of metabolic disorders. In both groups the following investigations were performed: fasting glucose and insulin levels, Homeostatic Model Assessment for Insulin Resistance (HOMA-IR), 75 g five-hour Oral Glucose Tolerance Test (OGTT) with an assessment of glucose and insulin and lipid profile evaluation. Additionally, Mixed Meal Tolerance Test (MMTT) was performed in SG. Results from OGTT and MMTT were analyzed in line with the non-standardized RH diagnostic criteria. Results: Forty subjects have been enrolled into SG. Twelve (30%) of those patients had hypoglycemic symptoms and glucose level ≤55 mg/dL during five-hour OGTT and have been diagnosed with RH. Ten (25%) subjects manifested hypoglycemic like symptoms without significant glucose decline. Patients with diagnosed RH had statistically significantly lower mean glucose at first (92.1 ± 37.9 mg/dL vs. 126.4 ± 32.5 mg/dL; LSD test: p < 0.001) and second (65.6 ± 19.3 mg/dL vs. 92.6 ± 19.3 mg/dL; LSD test: p < 0.001) hour of OGTT and insulin value (22.7 ± 10.9 lU/mL vs. 43.4 ± 35.0 lU/mL; LSD test: p < 0.001) at second hour of OGTT compared to the patients who did not meet the criteria of RH. Seventeen (43%) subjects from SG reported symptoms suggesting hypoglycemia during MMTT but none of them had glucose value lower than ≤55 mg/dL (68.7 ± 4.7 mg/dL). From the entire lipid profile, only mean total cholesterol value was significantly higher (p = 0.024) in SG in comparison with CG but did not exceed standard reference range. Conclusions: No metabolic disturbances have been observed in patients with diagnosed reactive hypoglycemia. Hyperinsulinemia has not been associated with glycemic declines in patients with this condition. Occurrence of pseudohypoglicemic symptoms and lower glucose value was more common after ingestion of glucose itself rather than after ingestion of a balanced meal. This could suggest an important role that nutritionally balanced diet may play in maintaining correct glucose and insulin levels in the postprandial period.

Hypoglycaemia detection and prediction techniques: A systematic review on the latest developments

The main objective of diabetes control is to correct hyperglycaemia while avoiding hypoglycaemia, especially in insulin‐treated patients. Fear of hypoglycaemia is a hurdle to effective correction of hyperglycaemia because it promotes under‐dosing of insulin. Strategies to minimise hypoglycaemia include education and training for improved hypoglycaemia awareness and the development of technologies to allow their early detection and thus minimise their occurrence. Patients with impaired hypoglycaemia awareness would benefit the most from these technologies. The purpose of this systematic review is to review currently available or in‐development technologies that support detection of hypoglycaemia or hypoglycaemia risk, and identify gaps in the research. Nanomaterial use in sensors is a promising strategy to increase the accuracy of continuous glucose monitoring devices for low glucose values. Hypoglycaemia is associated with changes on vital signs, so electrocardiogram and encephalogram could also be used to detect hypoglycaemia. Accuracy improvements through multivariable measures can make already marketed galvanic skin response devices a good noninvasive alternative. Breath volatile organic compounds can be detected by dogs and devices and alert patients at hypoglycaemia onset, while near‐infrared spectroscopy can also be used as a hypoglycaemia alarms. Finally, one of the main directions of research are deep learning algorithms to analyse continuous glucose monitoring data and provide earlier and more accurate prediction of hypoglycaemia. Current developments for early identification of hypoglycaemia risk combine improvements of available ‘needle‐type’ enzymatic glucose sensors and noninvasive alternatives. Patient usability will be essential to demonstrate to allow their implementation for daily use in diabetes management.

Síndrome de apneas-hipopneas durante el sueño en obesos y no obesos: características clínicas, polisomnográficas y metabólicas

IntroductionSleep apnoea-hypopnoea syndrome (SAHS) and childhood obesity are la high prevalence conditions that represent a public health challenge. ObjectiveTo analyse the association between both and comparing child groups that had or did not have both conditions. Patients and methodsA prospective study in children (3-14 years), referred to the “Multidisciplinary Sleep Unit” due to suspected SAHS, between 1 November 2015 and 1 August 2017. The following parameters were evaluated: anthropometry, symptoms, blood pressure, ear, nose, and throat examination, polysomnography (nocturnal PSG) and laboratory tests. ResultsA total of 67 children were evaluated (64% non-obese and 36% obese.It was observed that the obese were older (P<.001), slept less hours (P=.028), did less physical exercise (P=.029), ate less in the school dining room (P=.009), had la lower sleep efficiency, and had abnormal values in carbohydrate and lipid metabolism.The children with SAHS were younger (P=.010), a high percentage of daytime sleepiness (P=.001), and breathing through the mouth (P=.006), greater percentile of diastolic blood pressure (P=.019) and a lower IGF-1 (P=.003) than those that did not have SAHS.The comparison of the SAHS non-obese and SAHS obese groups, showed that the first group were younger (P=.010), snored more (P=.012), had a more severe SAHS (IAH 13.1 vs. 5.4, P=.041), and a higher GOT (P<.001). In the second group, they slept less hours P=.038) and showed lower values of glucose (P=.039), insulin (P<.001), and HOMA (P<.001). ConclusionThe behaviour of SAHS is different in obese children and non-obese children, with differences in age, clinical characteristics, severity of SAHS, and metabolic changes. The children diagnosed with SAHS were in the higher percentile of diastolic blood pressure. Obesity was associated with worse sleep quality, and changes in carbohydrate and lipid metabolism.