Mean Glucose Values Research Articles

Daily Inpatient Glycemic Survey (DINGS): A Process to Remotely Identify and Assist in the Management of Hospitalized Patients with Diabetes and Hyperglycemia

Hyperglycemia, hypoglycemia, and glycemic variability have been associated with increased morbidity, mortality, and overall costs of care in hospitalized patients. At the Stratton VA Medical Center in Albany, New York, a process aimed to improve inpatient glycemic control by remotely assisting primary care teams in the management of hyperglycemia and diabetes was designed. An electronic query comprised of hospitalized patients with glucose values <70 mg/dL or >350 mg/dL is generated daily. Electronic medical records (EMRs) are individually reviewed by diabetes specialist providers, and management recommendations are sent to primary care teams when applicable. Glucose data was retrospectively examined before and after the establishment of the daily inpatient glycemic survey (DINGS) process, and rates of hyperglycemia and hypoglycemia were compared. Patient-day mean glucose slightly but significantly decreased from 177.6 ± 64.4 to 173.2 ± 59.4 mg/dL (P<.001). The percentage of patient-days with any value >350 mg/dL also decreased from 9.69 to 7.36% (P<.001), while the percentage of patient-days with mean glucose values in the range of 90 to 180 mg/dL increased from 58.1 to 61.4% (P<.001). Glycemic variability, assessed by the SD of glucose, significantly decreased from 53.9 to 49.8 mg/dL (P<.001). Moreover, rates of hypoglycemia (<70 mg/dL) decreased significantly by 41% (P<.001). Quality metrics of inpatient glycemic control improved significantly after the establishment of the DINGS process within our facility. Prospective controlled studies are needed to confirm a causal association.

U-shaped relationship between early blood glucose and mortality in critically ill children.

BackgroundThe aims of this study are to evaluate the relationship between early blood glucose concentrations and mortality and to define a ‘safe range’ of blood glucose concentrations during the first 24 h after pediatric intensive care unit (PICU) admission with the lowest risk of mortality. We further determine whether associations exist between PICU mortality and early hyperglycemia and hypoglycemia occurring within 24 h of PICU admission, even after adjusting for illness severity assessed by the pediatric risk of mortality III (PRISM III) score.MethodsThis retrospective cohort study included patients admitted to PICU between July 2008 and June 2011 in a tertiary teaching hospital. Both the initial admission glucose values and the mean glucose values over the first 24 h after PICU admission were analyzed.ResultsOf the 1349 children with at least one blood glucose value taken during the first 24 h after admission, 129 died during PICU stay. When analyzing both the initial admission and mean glucose values during the first 24 h after admission, the mortality rate was compared among children with glucose concentrations ≤65, 65-90, 90–110, 110–140, 140–200, and >200 mg/dL (≤3.6, 3.6–5.0, 5.0–6.1, 6.1–7.8, 7.8–11.1, and >11.1 mmol/L). Children with glucose concentrations ≤65 mg/dL (3.6 mmol/L) and >200 mg/dL (11.1 mmol/L) had significantly higher mortality rates, indicating a U-shaped relationship between glucose concentrations and mortality. Blood glucose concentrations of 110–140 mg/dL (6.1–7.8 mmol/L), followed by 90–110 mg/dL (5.0–6.1 mmol/L), were associated with the lowest risk of mortality, suggesting that a ‘safe range’ for blood glucose concentrations during the first 24 h after admission in critically ill children exists between 90 and 140 mg/dL (5.0 and 7.8 mmol/L). The odds ratios of early hyperglycemia (>140 mg/dL [7.8 mmol/L]) and hypoglycemia (≤65 mg/dL [3.6 mmol/L]) being associated with increased risk of mortality were 4.13 and 15.13, respectively, compared to those with mean glucose concentrations of 110–140 mg/dL (6.1–7.8 mmol/L) (p <0.001). The association remained significant after adjusting for PRISM III scores (p <0.001).ConclusionsThere was a U-shaped relationship between early blood glucose concentrations and PICU mortality in critically ill children. Both early hyperglycemia and hypoglycemia were associated with mortality, even after adjusting for illness severity.

Effects of blood glucose control on glucose variability and clinical outcomes in patients with severe acute pancreatitis in intensive care unit

To explore the effects of blood glucose control on glucose variability and clinical outcomes in patients with severe acute pancreatitis in intensive care unit (ICU). A total of 72 ICU patients with severe acute pancreatitis were recruited and divided randomly into observation and control groups (n = 36 each). Both groups were treated conventionally. And the observation group achieved stable blood glucose at 6.1-8.3 mmol/L with intensive glucose control. The length of ICU and hospital stays, ICU mortality rate, transit operative rate, concurrent infection rate, admission blood glucose, glycosylated hemoglobin, mean insulin dose, mean blood glucose, blood glucose value standard deviation (GLUSD), glycemic liability index (GLUGLI) and mean amplitude of glycemic excursion (GLUMAGE) of two groups were compared. At the same time, the relationship between blood glucose variability, ICU mortality rate and its predictive value were analyzed by correlation analysis and receiver operating characteristic curve (ROC). The lengths of ICU and hospital stays of observation group were all significantly less than those of the control group [(11.7 ± 9.9) vs (15.9 ± 8.02) days, (21.8 ± 10.8) vs (28.2 ± 12.7) days, P < 0.05]. In observation group, the rates of pulmonary infection (27.78%) and hematogenous infection (5.56%) were all significantly lower than those of control group (72.22%, 38.89%, P < 0.05). The values of mean blood glucose value and GLUSD of observation group were significantly lower than those of control group [(7.4 ± 1.1) vs (9.6 ± 1.2), (1.8 ± 1.0) vs (2.5 ± 1.3) mmol/L]. The differences were statistically significant (P < 0.05). While the dose of insulin [(70.2 ± 47.6) vs (34.4 ± 38.6) U/d] was significantly higher than that of control group (P < 0.05). Bivariate correlation analysis showed that ICU mortality rate was positively correlated with GLUGLI (r = 0.368, P < 0.05). ROC curve analysis showed that, AUC of GLUGLI was 0.748 and 95% CI 0.551-0.965 (P < 0.05). Intensive glucose control in patients with severe acute pancreatitis helps reduce the blood sugar fluctuations, lower the risks of infectious complications and promote the patient rehabilitation. And GLUGLI is positively correlated with ICU mortality rate. It has good predictive values.

Continuous postoperative insulin infusion reduces deep sternal wound infection in patients with diabetes undergoing coronary artery bypass grafting using bilateral internal mammary artery grafts: a propensity-matched analysis.

Deep sternal wound infection (DSWI), especially in patients with diabetes mellitus (DM), is a major concern after coronary artery bypass grafting (CABG) with bilateral internal mammary artery (BIMA) grafts. We evaluated the risk of DSWI and other clinical outcomes between continuous insulin infusion therapy (CIT) and insulin sliding scale therapy (IST) in a cohort of DM patients who underwent CABG with BIMA. The clinical records of DM patients who underwent isolated CABG with BIMA were retrospectively reviewed. The study population consisted of 95 patients who received CIT and 126 patients who received IST. Furthermore, a one-to-one matched analysis based on estimated propensity scores for patients who received CIT or IST yielded two groups comprising 58 patients each. The proportion of patients with DSWI, overall survival rates and major adverse cardiac events were compared between the two groups in the overall and the propensity-matching cohort. The prevalence of DSWI requiring debridement and closure was significantly reduced in the CIT group compared with that in the IST group [1/95 (1.1%) vs 9/126 (7.1%), P = 0.031]; these results were not attenuated even after propensity-matching analysis [0/58 (0%) vs 6/58 (10.3%), P = 0.031]. The mean preoperative glucose levels were similar between the two groups (157.5 ± 54.6 vs 176.1 ± ±70 mg/dl, P = 0.063), whereas the mean glucose values were significantly lower on the first and second operative days in the CIT group than in the IST group (132.9 ± 44.1 vs 197.8 ± 78.6 mg/dl, P < 0.0001; 153.5 ± 58.8 vs 199.6 ± 89.1 mg/dl, P < 0.0001, respectively). The glucose variability levels within 24 h postoperatively were significantly higher in the IST group (46.1 ± 19.4 vs 66.4 ± 26.8 mg/dl, P < 0.0001). The 30-day and 1-year survival rates were similar between the two groups (100 vs 99.2%, P = 0.384; 96.6 vs 94.4%, P = 0.454). No results were changed in the propensity-matching models. The CIT approach reduced the variability in glucose concentration and resulted in fewer instances of DSWI after CABG with BIMA grafts.

Cytological and Biochemical Profile of Cerebrospinal Fluid from Meningitis Patients

BACKGROUND: The term Meningitis is used to describe an inflammatory infection of the membranes surrounding the brain and spinal cord, which occurs as either a primary disease or secondarily to disease in some other part of the body. The diagnosis is primarily confirmed by analyzing cerebrospinal fluid (CSF). Early diagnosis of the cause may be based on the cytological and biochemical parameters. Our objective was to determine the cytological and biochemical profile of CSF from meningitis patients. METHODS: In this cross sectional study, a total of 356 CSF specimens were collected from patients suspected of meningitis and processed microscopically and microbiologically by standard microbiological methods in Emergency Lab of Tribhuvan University Teaching Hospital (TUTH) Kathmandu, Nepal, over a period of six months, from March to August 2014 to determine cytological and biochemical parameters. RESULTS: Out of the 13 confirmed bacterial meningitis cases from 356 processed CSF samples, the mean value of total leukocytes count (TLC) was found to be 337.3 cells/mm3 with predominant neutrophils (73.8%). The mean value of glucose and protein was 28.8 mg/dL and 89.4 mg/dL respectively in the cases of bacterial meningitis. Among the three confirmed cases of fungal meningitis, the mean value of TLC was 11.7 cells/mm3 with lymphocytic predominance. In fungal meningitis glucose level was found to be normal (45.0 mg/dL) with slight increase in protein (48.7 mg/dL). CONCLUSIONS: Bacterial meningitis is generally characterized by increased TLC with predominance of neutrophils, decreased glucose and increased protein levels whereas fungal meningitis displays decreased TLC predominance of lymphocytes, normal or reduced glucose and slight increased protein level. DOI: http://dx.doi.org/10.3126/acclm.v1i1.12305 Ann. Clin. Chem. &amp; Lab. Med. 1(1) 2015: 2-5

Hyperglycemia is a predictor of prognosis in traumatic brain injury: Tertiary intensive care unit study

Background:Hyperglycemia is frequently encountered in critically ill patients and has been shown to contribute to both morbidity and mortality. We aimed to study the predictive role of blood glucose level in clinical outcomes of mechanically ventilated patients with traumatic brain injury during intensive care unit (ICU) stay and to explore its relationship with Glasgow coma scale (GCS) and acute physiology and chronic health examination (APACHE) II scores that are used in the evaluation of ICU patients as predictor.Materials and Methods:A total of 185 patients with craniocerebral trauma who were hospitalized in the ICU were included in the study. Comparisons of mean glucose values (MGVs) and APACHE II scores between survivors and nonsurvivors were made with Student's t-test and chi-square test. Survival analysis was performed with log rank (Mantel-Cox) test and Cox regression was used for mortality risk factors analysis.Results:MGVs at the initial, last, and all measurements were significantly higher for nonsurvivors than for survivors. Hazard rate at any given time point for patients with mean glucose value (MGV) between 150 and 179 was found to be 3.691 times that of patients with MGV values between 110 and 149. The hazard rate at any given time point for patients with MGV values ≥180 was found to be 6.571 times that of patients with MGV values between 110 and 149.Conclusion:High glucose level is an independent risk factor for mortality in mechanically ventilated ICU patients with traumatic brain injury.

A simple score to predict fetal outcomes in gestational diabetes mellitus.

Strict glycemic control is critical in preventing adverse maternal and fetal outcomes with gestational diabetes mellitus (GDM), but frequently results in recurrent maternal hypoglycemia and is often impracticable. This study was done to determine whether a more lenient strategy might provide satisfactory outcomes and to formulate a glycemic score for prognostication of fetal outcomes. A prospective non-interventional study was conducted on consecutive patients admitted with GDM between May 2007 and August 2009. Patients with pre-gestational diabetes were excluded. All patients received treatment at the discretion of treating consultants. Glycemic control was estimated by recording mean values of all glucose profiles performed. Fasting and postprandial blood glucose levels below 95 mg/dl and 120 mg/dl, respectively, were considered controlled. A glycemic score was calculated based on the number of mean blood glucose values controlled. Fetal outcomes were noted. Ninety-four patients with GDM were included. The glycemic score was significantly predictive of adverse fetal outcomes (p < 0.001). Analysis by receiver operating characteristic (ROC) curve showed good sensitivity and specificity for macrosomia (78.3% and 81.8%, respectively) and congenital anomalies (73.9% and 66.7%, respectively) with a glycemic score of 2 or less [area under curve (AUC) 0.768; odds ratio (OR), 11.17; 95% Confidence Interval (CI), 2.58-48.35; p < 0.001; and AUC 0.765; OR, 2.22; 95% CI, 0.71-6.92; p = 0.055, respectively]. Binomial logistic regression confirmed the glycemic score to be independently predictive of fetal outcome (p = 0.015). The glycemic score is a sensitive and specific prognostic marker. Tight control of three of four values of blood glucose within the glucose profile appears sufficient to prevent adverse fetal outcomes.

Blood glucose fluctuations in hemodialysis patients with end stage diabetic nephropathy

ObjectiveTo characterize blood glucose fluctuation during hemodialysis in patients with end stage diabetic nephropathy (ESDN) by a continuous glucose monitoring system (CGMS), and aim to improve blood glucose control in this patient population. MethodsForty-six patients with or without type 2 diabetes mellitus (T2DM), receiving hemodialysis, were recruited in this study. Thirty-six patients had end stage diabetic nephropathy (ESDN group), the other ten patients had end stage renal disease without diabetes (ESRD group). A continuous glucose monitoring system (CGMS) was employed to monitor glycemic fluctuation for 72hours. Blood samples were collected and analyzed. ResultsMean, standard deviation (SD), maximum, and mean amplitude glycemic excursion (MAGE) of blood glucose and the ratio of blood glucose readings that was greater than 13.9mmol/L of ESDN group, were significantly greater than those of ESRD group (p<0.01 for all) during 72hours of observation. The mean blood glucose was significantly lower, while SD and MAGE were significantly higher in ESDN group on hemodialysis day than on days off hemodialysis (p<0.05), while these were not been observed in ESRD group. Though mean, SD, and MAGE of blood glucose during hemodialysis were significantly lower than those of peri-hemodialysis in both groups (p<0.01 or p<0.05, respectively), they were significantly higher in ESDN group than that in ESRD group (p<0.05). The mean blood glucose value calculated from HbA1c did not reflect the actual mean blood glucose measured by CGM in both groups, and gave an inaccurate impression of a significantly lower mean glucose. ConclusionsESDN patients had larger glycemic fluctuations as compared with ESRD patients. Hemodialysis caused reduction in mean, SD, and MAGE, which in turn caused bigger glycemic fluctuations on hemodialysis day. The HbA1c in ESDN patients gave an inaccurate value, which did not truly reflect blood glucose status for a prolonged period.

Resultados de un programa de telemedicina para pacientes con diabetes tipo 2 en atención primaria

ObjectiveTo evaluate the impact of a telemedicine program on self-perceived health in patients with type 2 diabetes in primary care, as well as patient acceptance of and satisfaction with this program. MethodWe conducted an 18-month follow-up through telemedicine in 52 diabetic patients. The study design was non-experimental (before and after). In addition to weekly electronic transmission of fasting glucose levels, we regularly provided advice to patients about healthy habits. ResultsNo statistically significant differences were observed when mean blood glucose values were compared during follow-up. However, at the end of participation, the mean score in self-perceived health was significantly higher than at the initial assessment (70.5±12.8 vs. 62.8±15.0, p=0.02). After 18 months of participation in the telemedicine program, 57.7% of patients were satisfied and 38.5% were very satisfied. ConclusionsAlthough glycemic control did not improve during the follow-up, electronic transmission of information was found to be feasible and satisfactory for patients. The patients reported a higher level of self-perceived health.

Comparison of glycemic and surgical outcomes after change in glycemic targets in cardiac surgery patients.

To compare perioperative glycemic and long-term surgical outcomes in patients undergoing cardiac surgery before and after the recommended 2009 changes in inpatient glycemic targets. We performed a retrospective review of patients who underwent cardiac surgery between 4 September 2007 and 30 April 2011. Comparison was made of blood glucose (BG) outcomes 3 days after surgery, and 30-day cardiac outcomes before and after a change in insulin protocol that took place on 1 September 2009, which consisted of raising the glycemic targets during intravenous insulin infusions from 80-110 mg/dL (80-110 group) to 110-140 mg/dL (110-140 group). When compared with the 80-110 group (n = 667), the 110-140 group (n = 658) had higher mean postoperative BG levels during the intravenous insulin infusion (141 ± 15 vs. 121 ± 15 mg/dL, P < 0.001) and the subcutaneous insulin period (134 ± 24 vs. 130 ± 23 mg/dL, P < 0.001), and for 3 days postoperatively (141 ± 17 vs. 127 ± 15 mg/dL, P < 0.001). Fewer patients in the 110-140 mg/dL group experienced moderate hypoglycemia (BG <70 mg/dL) (177 vs. 73, P = 0.04). Severe hypoglycemia (BG <40 mg/dL) occurred in only one patient in the 80-110 group and three patients in the 110-140 group. There were no significant differences in mortality or surgical complication rates (with the exception of reintubation) between the groups. The higher glycemic target of 110-140 mg/dL resulted in similar mean glucose values, with significantly less hypoglycemia and no significant differences in mortality/morbidity compared with the more strict target of 80-110 mg/dL.

Niacin increased glucose, insulin, and C-peptide levels in sedentary nondiabetic postmenopausal women.

The current study examined the effects of niacin and a single bout of aerobic exercise on plasma glucose, insulin, and C-peptide in sedentary, nondiabetic postmenopausal women. As a crossover design, 17 participants underwent four different trials: rest during the no-niacin condition (R), exercise during the no-niacin condition (E), rest during the with-niacin condition (RN), and exercise during the with-niacin condition (EN). All participants took 1,000 mg/day of extended-release niacin for 4 weeks during the with-niacin conditions (RN and EN). The exercise treatment consisted of a single bout of treadmill walking at 60% heart rate reserve until 400 kcal were expended. Blood samples were collected at 24 hours after each trial and analyzed for changes in plasma glucose, insulin, and C-peptide. A two by two analysis of variance was used to examine the changes in dependent variables, and the Bonferroni adjustment was employed as the post hoc test. The level of statistical significance was set at P<0.05. There was no significant interaction between exercise and niacin, nor was there a main effect of exercise for changes in glucose, insulin, or C-peptide. However, there was a significant main effect for niacin as mean glucose, insulin, and C-peptide values significantly increased with niacin; glucose increased 10.6% (P=0.001), from 95.03±10.67 mg/dL to 105.07±13.56 mg/dL; insulin increased 61.8% (P=0.001), from 16.98±12.49 μU/mL to 27.48±14.84 μU/mL; and C-peptide increased 46.1% (P=0.001), from 1.65±0.75 ng/mL to 2.41±0.97 ng/mL. Although niacin was generally well tolerated, given its adverse effects on glucose, insulin, and C-peptide profiles, the use of niacin should be done so with caution and under medical supervision.

Effect of Aegle marmelos fruit pulp powder on glycemic status of type 2 diabetic patients

Plant materials are considered to be attractive potential sources of alternate agents in the prevention and management of type 2 diabetes mellitus (T2DM). Different parts of Aegle marmelos have been claimed to possess anti-glycemic property. The present study was conducted at Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM), Dhaka, Bangladesh from July 2010 to June 2011 to determine the anti-glycemic effect of A. marmelos unripe fruit pulp in T2DM patients. The experiment was conducted under a crossover design and the effects were analyzed during the 0-21 as well as 28-49 days with 7 days wash out period. The data were then pooled and the baseline versus endpoint values was also compared. The mean fasting blood glucose (FBG) values did not significantly differ between the two groups at any time points. No significant difference between the baseline and end point values regarding FBG. The effect on blood glucose was not significant in any of the analysis. This study did not reveal any antiglycemic effect of A. marmelos fruit pulp in T2DM patients. DOI: http://dx.doi.org/10.3329/imcj.v7i2.20109 Ibrahim Med. Coll. J. 2013; 7(2): 35-37

Using the glucometrics website to benchmark ICU glucose control before and after the NICE-SUGAR study.

Prior to 2009, intensive glycemic control was the standard in main intensive care units (ICUs). Glucose targets have been recalibrated after publication of the NICE-SUGAR study in that year, followed by updated guidelines that endorsed more moderated control. We sought to determine if the prevalence of hyperglycemia in US ICUs had increased after the NICE-SUGAR study's results were reported. We used data from hospitals submitted to the Yale Glucometrics™ website to assess mean blood glucose values, percentage of blood glucose within various ranges, and the prevalence of hypo- and hyperglycemic excursions, based on the patient-day method, comparing the pre- to post-NICE-SUGAR time period. Among more than a total of 2 million blood glucose determinations, comprising 408 790 patient-days, median patient-day blood glucose decreased from 144 mg/dL to 141 mg/dL (P < .001) in the pre- versus post-NICE-SUGAR time period. The percentage of patient days with a mean blood glucose of 110-179 mg/dl increased from 58.3 to 63.6%. The percentage of patient-days with either hypoglycemia (<70 mg/dl) or severe hyperglycemia (≥300 mg/dl) decreased during this time. Our results suggest that glycemic control in US ICUs has improved when comparing time periods before versus after publication of the NICE-SUGAR study. We found no evidence that fewer hypoglycemic events were achieved at the expense of more hyperglycemia.

The Acute Effects of Interval- Vs Continuous-Walking Exercise on Glycemic Control in Subjects With Type 2 Diabetes: A Crossover, Controlled Study

Glycemic control improves with physical activity, but the optimal exercise mode is unknown. The objective of the study was to determine whether interval-based exercise improves postprandial glucose tolerance and free-living glycemia more than oxygen consumption- and time duration-matched continuous exercise. This was a crossover, controlled study with trials performed in randomized order. The study was conducted in hospitalized and ambulatory care. PATIENTS diagnosed with type 2 diabetes mellitus (n=10, no withdrawals) participated in the study. Subjects performed three 1-hour interventions: 1) interval walking (IW; repeated cycles of 3 min of slow and fast walking); 2) continuous walking (CW); and 3) control (CON). Oxygen consumption (VO2) was measured continuously to match mean VO2 between exercise sessions (∼75% VO2peak). A mixed-meal tolerance test (MMTT; 450 kcal, 55% carbohydrate) with stable glucose isotopic tracers was provided after each intervention, and glucose kinetics were measured during the following 4 hours. Free-living glycemic control was assessed for approximately 32 hours after the MMTT using continuous glucose monitoring. VO2 was well matched between the exercise interventions. IW decreased the mean and maximal incremental plasma glucose during the MMTT when compared with the CON (mean 1.2 ± 0.4 vs 2.0 ± 0.5 mmol/L, P < .001; maximal 3.7 ± 0.6 vs 4.6 ± 0.7 mmol/L, P = .005) and mean when compared with CW (1.7 ± 0.4 mmol/L, P = .02). No differences in the mean or maximal incremental plasma glucose values were seen between the CW and CON. The metabolic clearance rate of glucose during the MMTT was increased in the IW compared with CW (P = .049) and CON (P < .001). Continuous glucose monitoring mean glucose was reduced in IW compared with CW for the rest of the intervention day (8.2 ± 0.4 vs 9.3 ± 0.7 mmol/L, P = .03), whereas no differences were found between IW and CW the following day. One interval-based exercise session improves glycemic control in type 2 diabetes mellitus subjects when compared with an oxygen consumption- and time duration-matched continuous exercise session.

English

Diabetes mellitus (DM) &nbsp;has been reported to be associated with derangement of micronutrients. This study was to investigate the plasma levels of antioxidant elements (zinc, selenium, copper) haemopoeitic elements (chromium and iron) and magnesium in female type 2 diabetes mellitus (DM) patients. Fifty (50) female type 2 DM patients (test subjects) aged 20 to 50 years and 35 healthy, non-diabetic age-matched females (control subjects) were recruited for the study. Fasting blood plasma levels of the elements were determined using atomic absorption spectrophotometer (AAS) after acid digestion. Blood glucose level was determined by glucose oxidase/peroxidase method to confirm the status of the test and the control subjects. Body mass index was determined from weight and height of the subjects. The mean values of plasma zinc, selenium, magnesium and chromium were significantly lower in the diabetic patients than in non-diabetics (P&lt;0.002, P&lt;0.001, P&lt; 0.001 and P&lt;0.001 respectively). The mean values of glucose, BMI, iron and copper was observed to be significantly higher in diabetic patients than control subjects (P&lt;0.002, P&lt;0.05, P&lt;0.002 and P&lt;0.001 respectively). A significant positive correlation existed between glucose and BMI, copper and iron (r=0.717; P&lt;0.0001, r=0.717; P&lt;0.05, r=0.721; P&lt;0.05) whereas an inverse relationship was observed between iron and chromium, selenium and magnesium (r =-0.448, -0.703 and -0.651; p&lt;0.004, 0.000, 0.000 respectively). Negative association was also observed between copper and zinc (r=-0.716; P&lt;0.01). These findings revealed that DM is associated with significant alteration in the concentrations of essential trace metals and significant increase in BMI. This may contribute to various metabolic complications and increased mortality from cardiovascular diseases in DM patients in the rural locality as it as observed among diabetics in urban settings. &nbsp; Key words: Trace metals, diabetes mellitus, copper, chromium, Ekiti state.

Glycemic Control in a Medical Intensive Care Setting

The purpose of this study was to determine whether the addition of rapid-acting insulin bolus for enteral feed coverage and a reduction in basal insulin improve glycemic control and decrease hypoglycemia in a medical intensive care unit. A quasi-experimental posttest design assessing glucose control postimplementation of a revised nurse-driven ICU hyperglycemia protocol was conducted on a 16-bed medical intensive care unit at a multicenter hospital system. A daily report of all patients on the ICU hyperglycemia protocol was automated for the inpatient diabetes management team, and pertinent data were collected. Univariate statistics were conducted for all variables. The variability in blood glucose based on different clinical variables was compared using t tests. The hypoglycemic rate was only 0.72%, and no glucose value was less than 40 mg/dL. In addition, the mean glucose value throughout the study was 160.9 ± 35.6 mg/dL. Findings from this study will hopefully provide insight on an effective way to control glucose within a medical intensive care unit as well as reduce hypoglycemia rates within this setting.

Gestational Diabetes Mellitus in Primi Gravida of Bangladesh in Different Trimesters

Background: Gestational Diabetes Mellitus is defined as any degree of glucose intolerance with onset or first recognition during pregnancy. It is an important dimension of the syndrome of Diabetes Mellitus. Similar to other members of the Asian race, Bangladeshi women are also considered to be at a high risk for developing gestational diabetes. Materials and Methods: In order to better understand whether this heightened risk attributed to race really exists even in primi gravida of Bangladesh, what is the percentage of the disease among them and whether there is any association of classical risk factors of the disease, a hospital based observational study was performed and the glycemic status of the primi gravida women presenting to Chittagong Medical College Hospital were assessed. Results: A total of 117 primi gravida women, 39 in each of the three trimesters of pregnancy were selected as study subjects during the study period on the basis of set criteria and a 2 h, 75 g OGTT was performed over them. The mean age of the subjects enrolled was 21.1 ± 2.29 years, mean BMI was 21.6 ± 2.72 kg/m2, the mean fasting serum glucose values in mmol/l were 4.5 ± 0.63, 4.6 ± 0.62 and 4.7 ± 0.56 in 1st, 2nd and 3rd trimesters and the 2 h post 75 g glucose load serum glucose values in mmol/l were found 6.1 ± 1.08, 6.6 ± 1.76 and 7.0 ± 1.42 respectively. Using the cut-off value mentioned in the operational definition of GDM, 13.7% of the subjects were found to have the disease. Among them, 12.5% were in first trimester, 31.2% were in second trimester and 56.3 % were in third trimester of pregnancy. Maternal obesity/over-weight and a family history of diabetes, not the maternal older age, have shown statistically significant association with GDM. Prevalence of GDM has been noted in clinically non-risk group of subjects also. Conclusion: From the above study, the inference could be drawn that, screening for GDM should be done as early as possible during pregnancy, even at first trimester, irrespective of presence or absence of established risk factors. But larger trials are needed to truly assess the disease burden of gestational diabetes among primi gravida women.

Residual dysglycemia when at target HbA1c of 7% (53 mmol/mol) in persons with type 2 diabetes

AimsTo understand the composition of the residual dysglycemia when HbA1c is between 6.5% (48mmol/mol) and 7% (53mmol/mol), representing the definition of diabetes and the recommended treatment goal, respectively. MethodsOne hundred persons with type 2 diabetes and a HbA1c<7% (53mmol/mol), treated with diet alone and/or oral hypoglycemic agents underwent continuous glucose monitoring (CGM) and were further divided into two subgroups 1 (n=50) and 2 (n=50) according to whether the HbA1c was <6.5% (48mmol/mol) or 6.5–6.9% (48–52mmol/mol), respectively. A similar analysis was performed in those on diet alone: subgroups A (n=34, HbA1c<6.5%, 48mmol/mol) and B (n=10, HbA1c 6.5–6.9%, 48–52mmol/mol). The residual dysglycemia determined from the CGM was assessed using glucose exposures defined as areas under curves (AUCs) and mean glucose values. ResultsAveraged 2-h postprandial glucose value (averaged PPG, mmol/L, mean±SD) and postprandial glucose exposure (AUCpp, mean±SD, mmol·L−1·h) were significantly higher in subgroup 2 (mean HbA1c=6.7%, 50mmol/mol) than in subgroup 1 (mean HbA1c=6.0%, 42mmol/mol): averaged PPG=8.1±1.3 versus 7.3±1.3mmol/L (p<0.002); AUCpp=23.5±8.6 versus 16.2±8.6 (p<0.0001). The percentages of persons with averaged PPG≥7.8mmol/L were 52% and 24% (p<0.01) in subgroups 2 and 1, respectively. Similar results were observed in those (subgroups A and B) who were on diet alone. ConclusionsThe residual dysglycemia in type 2 diabetes with HbA1c between 6.5 and 6.9% (48–52mmol/mol) inclusive is mainly due to remnant abnormal postprandial glucose excursions. Consequently, HbA1c<6.5% (48mmol/mol) is an achievable goal with therapeutic measures aimed at reducing postmeal glucose when the HbA1c is at 7% (53mmol/mol).

Influence of Dialysis on the Glucose Profile in Patients with Diabetes: Usefulness of Continuous Glucose Monitoring

We sought to investigate the impact of dialysis on glucose profiles of diabetic patients using continuous glucose monitoring (CGM). The study included 33 hemodialyzed patients with diabetes (14 females and 19 males; mean age: 66±8 years; patients with type 2 diabetes: 30; mean duration of dialysis: 3.8±2.6 years) who were under insulin treatment. After a run-in period, CGM was performed for 48 h, including a dialysis session. Three CGM sessions were proposed for each patient over a 3-month period. CGM results were analyzed during and after dialysis at 6 different time points. Moreover, data were analyzed in 7 different day periods according to meals. Of the 99 CGM available, 21 were excluded because of technical issues or patient refusal. The CGM results indicated that mean glucose values (7.5±2.5 mmol/l vs. 9.4±1.9 mmol/l; p<0.001) and variability indices (p<0.001) were lower, whereas the frequency of hypoglycemia (4.4±9.6% vs. 2.1±7.9%; p<0.001) was higher during hemodialysis sessions. Significant differences were observed in glucose values only before and 2 h after breakfast (p<0.001). Compared with other day periods, glucose values were lower during the second half of the night and higher before and after dinner (p<0.001). In summary, CGM allows the identification of a particular glucose profile in hemodialyzed diabetic patients. CGM seems feasible and clinically useful for the analysis of glucose profiles in this group of patients.

Glycaemic Control and Long-Term Outcomes following Transition from Modified Intensive Insulin Therapy to Conventional Glycaemic Control

This retrospective observational cohort study compared glycaemic control and long-term outcomes following transition from a modified intensive insulin therapy (mIIT) regimen to conventional glycaemic control (CGC) in adult patients admitted to a tertiary adult general intensive care unit, during two 24-month periods, before and after the publication of the Normoglycemia in Intensive Care Evaluation and Surviving Using Glucose Algorithm Regulation (NICE-SUGAR) trial. The before NICE-SUGAR cohort received mIIT (target glycaemic ranges 4.4 to 7.0 mmol/l), while the after NICE-SUGAR cohort received CGC (target glycaemic range 7.1 to 9.0 mmol/l). A total of 5202 patients were included in the study. With transition from mIIT to CGC, the mean time-weighted glucose increased from 6.94 mmol/l to 8.2 mmol/l (P <0.0001). A similar increase was observed in other glycaemic indices (mean, highest and lowest glucose values, P <0.0001 for all). The adjusted 90-day odds ratio for mortality decreased by 47% with transition from mIIT to CGC (odds ratio 1.47 (95% confidence interval, 1.22 to 1.78) (P <0.0001). The rate of severe and moderate hypoglycaemia also decreased from 1.2 to 0.4% (P=0.004) and from 23.3 to 5.9% (P <0.0001), respectively. mIIT was associated with an increased risk of moderate and severe hypoglycaemia compared to CGC (odds ratio 3.1 (1.51 to 6.39) (P=0.002), 6.29 (5.1 to 7.75) (P <0.0001)). Changes in recommended glycaemic control were translated into practice, with increased glycaemic indices and decreased rates of severe and moderate hypoglycaemia after the introduction of CGC. The associated decrease in 90-day mortality suggests mIIT was not superior to CGC, despite a lower hypoglycaemia rate than in previous IIT trials. Our findings support the continued use of CGC.