Mild Hypoglycemia Research Articles

600: RETROSPECTIVE REVIEW OF OUTCOMES IN PEDIATRIC DKA: EARLY VERSUS LATE LONG-ACTING INSULIN

Introduction: In patients with diabetic ketoacidosis (DKA), the American Diabetes Association guidelines support administering long-acting insulin (LAI) at the time of conversion from IV insulin to subcutaneous rapid acting insulin (RAI). Challenges with LAI timing in children may complicate this transition, and LAI may be administered earlier in the DKA course at some institutions. Limited evidence currently exists assessing the value of this early LAI administration while the patients are still in DKA. The purpose of this study was to assess the benefit and safety of early LAI in pediatric DKA. Methods: This single-center retrospective cohort study included patients < 21 years old admitted to the PICU in DKA on an IV insulin drip. Patients meeting inclusion criteria were divided into two groups: early LAI (administered >4 hours prior to conversion to RAI) and late LAI (administered within 2 hours of RAI). Each group was subdivided into DKA severity (moderate vs severe) and new onset vs known diabetes. The primary outcome of the study was to compare the time to DKA resolution, and secondary outcomes evaluated the total IV insulin doses received, and incidence of adverse effects and complications: hypoglycemia, hypokalemia, cerebral edema, and recurrence of DKA. Results: A total of 372 encounters were included in the preliminary assessment (224 in early LAI and 148 in late LAI groups). Baseline characteristics were similar between both groups. The time to DKA resolution was significantly longer (13 vs. 9.6 hours, p< 0.0001) and total dose of IV insulin significantly higher (65.7 vs. 44 units, p=0.0018) in the early LAI group. Rates of mild hypoglycemia and hypokalemia were significantly higher in the early LAI groups (33.5% vs. 21.6%, p=0.0134 and 42.4% vs. 14.2%, p< 0.0001, respectively). The trends in longer duration of DKA and rates of these adverse effects for the early LAI were also seen in the subgroups of new onset patients and with both moderate vs severe DKA. No differences were observed with severe hypoglycemia or hypokalemia, rates of cerebral edema or recurrence of DKA. Conclusions: Use of early LAI in pediatric DKA demonstrated no reduction in the time to resolution of DKA or total IV insulin dose regardless of severity of presentation, and increased risk of mild hypoglycemia and hypokalemia.

Application of the screening test principles to screening for neonatal hypoglycemia.

Severe and prolonged neonatal hypoglycemia can cause brain injury, while the long-term consequences of mild or transitional hypoglycemia are uncertain. As neonatal hypoglycemia is often asymptomatic it is routine practice to screen infants considered at risk, including infants of mothers with diabetes and those born preterm, small or large, with serial blood tests over the first 12-24 h after birth. However, to prevent brain injury, the gold standard would be to determine if an infant has neuroglycopenia, for which currently there is not a diagnostic test. Therefore, screening of infants at risk for neonatal hypoglycemia with blood glucose monitoring does not meet several screening test principles. Specifically, the long-term neurodevelopmental outcomes of transient neonatal hypoglycemia are not well understood and there is no direct evidence from randomized controlled trials that treatment of hypoglycemia improves long-term neurodevelopmental outcomes. There have been no studies that have compared the long-term neurodevelopmental outcomes of at-risk infants screened for neonatal hypoglycemia and those not screened. However, screening infants at risk of hypoglycemia and treating those with hypoglycaemic episodes to maintain the blood glucose concentrations ≥2.6 mmol/L appears to preserve cognitive function compared to those without episodes. This narrative review explores the evidence for screening for neonatal hypoglycemia, the effectiveness of blood glucose screening as a screening test and recommend future research areas to improve screening for neonatal hypoglycemia. Screening babies at-risk of neonatal hypoglycemia continues to be necessary, but as over a quarter of all infants may be screened for neonatal hypoglycemia, further research is urgently needed to determine the optimal method of screening and which infants would benefit from screening and treatment.

Profile Of Type 2 Diabetes Mellitus Patients With Hypoglycemia Events In RSUD Dr. Soetomo Hospital, Surabaya from January 2019 - March 2021

Background: Hypoglycemia is a decrease in blood glucose levels which is the most common side effect of diabetes mellitus due to its treatment and is rarely a concern for patients and health workers. However, because the patient neglects the mild hypoglycemia symptoms, they cannot be immediately identified and treated. Each Type 2 diabetes mellitus (T2DM) patient with hypoglycemia has a different profile and manifestations. Objective: This study aims to identify the demography, clinical, and laboratory profiles of T2DM patients who experience hypoglycemia in the inpatient unit of RSUD Dr. Soetomo Surabaya from January 2019 - March 2021. Material and method: This study is a retrospective descriptive study. Medical record data were collected through total sampling, then processed descriptively, and presented as a frequency distribution table. Results: The samples of this study were 83 T2DM patients with hypoglycemia. The most age group was > 65 years, with 33 (39.8%) patients. The most gender group was female in 55 (66.3%) patients, the most common chief complaint was decreased consciousness in 47 (56.6%) patients, and the most common results of head physical examination were anemic conjunctiva in 43 (51.8%) patients. Extremity examination results 13 (15.7%) patients had wounds, and 10 (12.0%) patients had edema. The results of the random plasma glucose (RPG) examination <40 mg/dl in 62 (74.7%) patients, low Hb in 66 (79.5%) patients, high leukocytes in 47 (56.6%) patients, and high BUN in 52 (62.7%) patients. SK was high in 42 (50.6%) patients, and albumin was low in 56 (67.5%) patients. Conclusion: From this study, T2DM patients with hypoglycemia events were highly female and primarily found in patients over 65 years with severe hypoglycemia. The most common chief complaint was decreased consciousness, and the most common laboratory result was anemia, leukocytosis, high BUN, high SK, and hypoalbuminemia.

ODP219 Laparoscopic Gastrostomy tube (LGT) Placement for Management of Post Bariatric Surgery Hypoglycemia Syndrome (PBSHS).

Abstract Introduction Bariatric surgery is currently the most effective long term management for morbid obesity. Laparoscopic bariatric surgery whether gastric banding (LGB), sleeve gastrectomy (LSG) or gastric bypass (LRYGB) are now more commonly done. One major complication that can follow these procedures are the hypoglycemic syndromes; post bariatric surgery hypoglycemia syndrome (PBSHS). PBSHS is a spectrum ranging from mild reactive hypoglycemia to hypoglycemia with dumping syndrome to the most severe being post bariatric surgery nesidioblastosis (PBSN). Clinical case; The patient is a 33 yr old Caucasian lady with past history of morbid obesity who had LSG in 2012 with poor weight loss response. This was converted to LRYGB in 2016 with much better weight loss response. Within 1.5 yrs of the LRYGB however she started having recurrent hypoglycemic episodes which were initially mild and mostly postprandial (PP) but rapidly escalated to both fasting and PP states. Work up revealed that she had both reactive and fasting hypoglycemia and despite dietary interventions the episodes escalated and with "defensive eating" she progressively gained weight. Her hypoglycemic spells were confirmed as insulin mediated and consistent with PBSN. Medical therapy escalated to maximum dose acarbose, octreotide and high dose diazoxide. The frequency and severity of the hypoglycemic spells worsened and in 2021 she had over 7 hospital admissions from severe hypoglycemia with additional ED visits despite medication use including emergent glucagon use and CGMS monitoring with a DEXCOM device. She had hypoglycemia unawareness with progressively declining quality of life. Rather than possible attempted reversal of the LRYGB a LGT was placed to see if this would ameliorate her symptoms. She now drinks only non-caloric fluids per oral and all caloric intake is via the LGT. The clinical response has been swift and dramatic. Since LGT placement over 3 mths now she has had no symptomatic hypoglycemic episode and no ED nor hospital admissions. Post LGT placement CGMS profile demonstrated marked improvements in glycemic profile and post LGT mixed meal tests (MMT). A dichotomy was demonstrated between her glycemic profile on MMT for oral vs LGT caloric intake providing confirmation of the therapeutic effect of the LGT placement. Discussion With the increasing utilization of bariatric surgery for management of obesity and diabetes, the prevalence of PBSHS is expected to increase. This complication can be difficult and expensive to manage while negatively impacting weight loss and quality of life. Our case provides proof of principle evidence to suggest LGT placement as a management consideration in severe cases of PBSN. Conclusions LGT placement should be considered as an option in patients with severe PBSN that is poorly controlled with maximal medical and lifestyle interventions. Presentation: No date and time listed

Medical Nutrition Therapy and Other Approaches to Management of Post-bariatric Hypoglycemia: A Team-Based Approach.

This manuscript provides a review of post-bariatric hypoglycemia (PBH) with a special focus on the role of the registered dietitian-nutritionist (RDN) and medical nutrition therapy (MNT) recommendations as foundational for management. As the number of bariatric surgeries rises yearly, with 256,000 performed in 2019, PBH is an increasingly encountered late complication. Following Roux-en-Y (RYGB) or vertical sleeve gastrectomy (VSG), about 1/3 of patients report symptoms suggestive of at least mild postprandial hypoglycemia, with severe and/or medically confirmed hypoglycemia in 1-10%. Anatomical alterations, changes in GLP1 and other intestinally derived hormones, excessive insulin response, reduced insulin clearance, impaired counterregulatory hormone response to hypoglycemia, and other factors contribute to PBH. MNT is the cornerstone of multidisciplinary treatment, with utilization of personal continuous glucose monitoring to improve safety when possible. While many individuals require pharmacotherapy, there are no currently approved medications for PBH. Increasing awareness and identification of individuals at risk for or with PBH is critical given the potential impact on safety, nutrition, and quality of life. A team-based approach involving the individual, the RDN, and other clinicians is essential in providing ongoing assessment and individualization of MNT in the long-term management of PBH.

Impact of tight glycemic control and hypoglycemia after pediatric cardiac surgery on neurodevelopmental outcomes at three years of age: Findings from a randomized clinical trial

BackgroundStudies examining the impact of randomization As per standard instruction, city is required for affiliations; however, this information is missing in affiliation 6. Please check if the provided city is correct and amend if necessary. to tight glycemic control (TGC) and resultant hypoglycemia on later neurodevelopmental outcomes have produced mixed results. Our study examined this association in children undergoing cardiac surgery.MethodsParticipants who were enrolled in the Safe Pediatric Euglycemia after Cardiac Surgery (SPECS) trial returned for neurodevelopmental (ND) follow-up between 30 to 42.5 months of age. ND outcomes were assessed using the Bayley Scales of Infant and Toddler Development, Third Edition. ND scores were compared between the TGC and standard care treatment groups and between patients with moderate to severe and no to mild hypoglycemia. As a secondary analysis, to increase sample size and power, we combined the three-year-old assessments with previously collected assessments done at < 30 months of age to further examine differences between groups longitudinally.ResultsAmong the 269 participants who completed neurodevelopmental evaluation (in-person testing or questionnaires) at three years of age (follow-up rate, 31%), there were no statistically significant differences in ND outcomes according to treatment group or hypoglycemia status. In the combined analysis of all evaluations (from 9 to 42.5 months of age), we found no treatment group differences. However, in these longitudinal analyses, children who experienced moderate to severe hypoglycemia had lower scores on the Bayley-III cognitive and motor domains compared to children with no to mild hypoglycemia.ConclusionsFor infants undergoing cardiac surgery, there was no impact of tight glycemic control on neurodevelopmental outcomes. Moderate to severe hypoglycemia was associated with worse ND outcomes in longitudinal analyses.Trial registrationClinicalTrials.gov NCT00443599. Registered: November 2016.

Interaction of ARRDC4 With GLUT1 Mediates Metabolic Stress in the Ischemic Heart.

An ancient family of arrestin-fold proteins, termed alpha-arrestins, may have conserved roles in regulating nutrient transporter trafficking and cellular metabolism as adaptor proteins. One alpha-arrestin, TXNIP (thioredoxin-interacting protein), is known to regulate myocardial glucose uptake. However, the in vivo role of the related alpha-arrestin, ARRDC4 (arrestin domain-containing protein 4), is unknown. We first tested whether interaction with GLUTs (glucose transporters) is a conserved function of the mammalian alpha-arrestins. To define the in vivo function of ARRDC4, we generated and characterized a novel Arrdc4 knockout (KO) mouse model. We then analyzed the molecular interaction between arrestin domains and the basal GLUT1. ARRDC4 binds to GLUT1, induces its endocytosis, and blocks cellular glucose uptake in cardiomyocytes. Despite the closely shared protein structure, ARRDC4 and its homologue TXNIP operate by distinct molecular pathways. Unlike TXNIP, ARRDC4 does not increase oxidative stress. Instead, ARRDC4 uniquely mediates cardiomyocyte death through its effects on glucose deprivation and endoplasmic reticulum stress. At baseline, Arrdc4-KO mice have mild fasting hypoglycemia. Arrdc4-KO hearts exhibit a robust increase in myocardial glucose uptake and glycogen storage. Accordingly, deletion of Arrdc4 improves energy homeostasis during ischemia and protects cardiomyocytes against myocardial infarction. Furthermore, structure-function analyses of the interaction of ARRDC4 with GLUT1 using both scanning mutagenesis and deep-learning Artificial Intelligence identify specific residues in the C-terminal arrestin-fold domain as the interaction interface that regulates GLUT1 function, revealing a new molecular target for potential therapeutic intervention against myocardial ischemia. These results uncover a new mechanism of ischemic injury in which ARRDC4 drives glucose deprivation-induced endoplasmic reticulum stress leading to cardiomyocyte death. Our findings establish ARRDC4 as a new scaffold protein for GLUT1 that regulates cardiac metabolism in response to ischemia and provide insight into the therapeutic strategy for ischemic heart disease.

Protecting against brain damage by improving treatment in neonates with hypoglycaemia: ProBrain-D—a study protocol of a prospective longitudinal study

IntroductionAlthough neonatal hypoglycaemia is the most common metabolic problem in neonates, there is no standard guideline for screening. Additionally, treatment of neonatal hypoglycaemia and glucose administration thresholds are discussed controversially....

Lifestyle Intervention Strategy to Treat Diabetes in Older Adults: A Randomized Controlled Trial.

Lifestyle intervention is recommended as first-line treatment of diabetes at all ages; however, little is known about the efficacy of lifestyle intervention in older adults with diabetes. We aimed to determine whether lifestyle intervention would improve glycemic control and age-relevant outcomes in older adults with diabetes and comorbidities. A total of 100 older adults with diabetes were randomly assigned to 1-year intensive lifestyle intervention (ILI) (diet and exercise at a facility transitioned into community-fitness centers and homes) or healthy lifestyle (HL) group. The primary outcome was change in HbA1c. Secondary outcomes included glucoregulation, body composition, physical function, and quality of life. Changes between groups were analyzed with mixed-model repeated-measures ANCOVA following the intention-to-treat principle. HbA1c improved more in the ILI than the HL group (mean ± SE -0.8 ± 0.1 vs. 0.1 ± 0.1%), associated with improved insulin sensitivity (1.2 ± 0.2 vs. -0.4 ± 0.2) and disposition (26.0 ± 8.9 vs. -13.0 ± 8.4 109 min-1) indices (between-group P < 0.001 to 0.04). Body weight and visceral fat decreased more in the ILI than HL group (-8.4 ± 0.6 vs. -0.3 ± 0.6 kg, P < 0.001, and -261 ± 29 vs. -30 ± 27 cm3, P < 0.001, respectively). Physical Performance Test score increased more in the ILI than HL group (2.9 ± 0.6 vs. -0.1 ± 0.4, P < 0.001) as did VO2peak (2.2 ± 0.3 vs. -1.2 ± 0.2 mL/kg/min, P < 0.001). Strength, gait, and 36-Item Short Form Survey (SF-36) Physical Component Summary score also improved more in the ILI group (all P < 0.001). Total insulin dose decreased in the ILI group by 19.8 ± 4.4 units/day. Adverse events included increased episodes of mild hypoglycemia in the ILI group. A lifestyle intervention strategy is highly successful in improving metabolic and functional health of older adults with diabetes.

Additional insulin dosing for fat and protein in children with type 1 diabetes using multiple daily injections

High-fat high-protein (HFHP) meals are associated with post-prandial hyperglycemia in type 1 diabetes (T1D), administration of additional insulin for such meals is recommended in order to optimize glucose levels. Optimal timing of additional insulin for HFHP meals in children and young people receiving multiple daily injections (MDI) remains unclear. To investigate the glycemic impact of additional insulin doses given before or after eating a HFHP meal in children with T1D using MDI. A randomized, controlled three period crossover trial of 27 participants aged 13 years (6.1-17.7) at two Pediatric Diabetes centers was conducted. Additional rapid-acting insulin for the fat-protein content of a standardized HFHP meal was given at three time points calculated using an algorithm extrapolated from current evidence base and clinical recommendations. Post-prandial glucose (PPG) parameters were calculated for 420minutes using continuous glucose monitoring. The primary outcome was mean PPG excursion. Secondary outcomes included peak glucose, time to peak and hypoglycemia incidence. There was no difference in post-prandial glucose parameters when additional HFHP insulin was administered at mean glucose excursion (mmol/L) (SE): 1.9(0.7), 1.2(0.7), 2.5(0.7); p= 0.5); mean peak glucose (mmol/L)(SE): 10.9(0.9), 11.5(0.8), 11.5(0.9); p= 0.9; time to peak glucose (mins)(SE): 82.3(35.4), 113.6(30.9), 95.1(32.1); p= 0.8. Mild hypoglycemia was common (55%) in all groups (p= 0.97). We found no benefit in giving additional insulin as a split dose for HFHP meals in children using MDI, mild hypoglycemia was common. Future studies would benefit from refinement of the insulin dose algorithm.

Stress Interpretation by Using Blood Glucose levels, blood pressure and pulse rate measurement in Patients attending Oral and Maxillofacial Clinic in College of Dentistry at University of Sulaimani

Objective: Based on specific parameters such as blood glucose levels, blood pressure, and pulse rate, a prospective randomized case-control study was conducted to determine the stress during minor oral surgical procedures. &#x0D; Methods: A total of 200 patients who underwent minor oral surgical procedures were randomly assigned into two groups: group (1) received 2% lignocaine with adrenaline, while group (2) received the same plus an oral intake of 10 mg glucose in 200 mL water after administration of local anesthesia. Before starting the operation and after the procedure was completed, the blood glucose level, blood pressure, and pulse rate were taken at the chairside, with the time difference for each phase noted. &#x0D; Results: In group (1), blood glucose levels were found to decrease before operations and then increase to a value higher than the preoperative value, while in group (2), blood sugar levels remained constant before eventually rising to a higher postoperative value. Blood pressure increased gradually in all classes, and a rise in pulse rate was observed. &#x0D; Conclusions: We found a temporary decrease in blood glucose levels preceding an increase in blood glucose levels, lasting no more than four or five minutes in minor intraoral operations under local anesthesia. Mild hypoglycemia may trigger episodes of psychogenic syncope, so this brief hypoglycemia is of great clinical importance. At the same time, pulse rate and blood pressure gradually increase with the procedures' progress, which is due to sympathetic nervous system excitation that promotes norepinephrine-induced changes in many systems.

237-OR: Platelet-Derived Protein Responses Differ According to Severity of Hypoglycemia

Introduction: Severe hypoglycemia is associated with an increased risk of cardiovascular (CV) death, and platelet responses to hypoglycemia (hypo) have been described. The impact of a transient severe hypo versus prolonged less severe hypo is unclear. Methods: 2 hypo studies were compared; firstly, in 18 subjects (type 2 diabetes (T2D) : 8 controls) blood glucose lowered to 3.5mmoL/L (90mg/dL) for 1-hour; secondly, in 46 subjects (23 T2D: 23 controls) blood glucose lowered to &amp;lt;2.2mmoL/L (&amp;lt;40mg/dL) transiently. The platelet-related protein (PRP) responses from baseline to after 1-hour of hypo (study-1) or at severe transient hypo (study-2) were compared, and at 24-hours post-hypo. Slow Off-rate Modified Aptamer (SOMA) -scan plasma protein measurement was used to determine platelet-related protein changes for 13 proteins. Results: In T2D, from baseline to hypo, differences were seen for 4 PRPs, three showing increased percent change in study-2 (plasminogen activator inhibitor-1 (PAI-1) , platelet glycoprotein VI (PGVI) and Tissue factor) , one showing increased percent change in study-1 (CD40 ligand (CD40LG)) ; at 24-hours in T2D, percent change for CD40LG remained increased, together with von Willebrand factor (vWF) , in study-2. In controls, from baseline to hypo, differences were seen for four PRPs, three showing increased percent change in study-2 (PAI-1, CD40LG and Protein S) , one showing increased percent change in study-1 (vWF) ; at 24-hours in controls, percent change for Protein S remained increased in study-2, whilst percent change for vWF and plasminogen were increased in study-1. Conclusion: Thrombogenic potential was enhanced in T2D versus controls, as evidenced by an increased thrombogenic protein expression profile in both mild and severe hypoglycemia, that showed persistent changes at 24-hours in severe hypo. Disclosure A. Moin: None. H. Kahal: None.

Prevalence of Hypoglycemia in Patients of Type 2 Diabetes Mellitus

Objective: Aim of current study is to evaluate the frequency of hypoglycemia in patients of type-2 diabetes mellitus. Study Design:Cross-sectional Place and Duration: King Salman Armed Forces Hospital Tabuk KSA and Muhammed Medical College &amp; Hospital, Mirpurkhas, Sindh during from June, 2020 to Dec, 2020. Methods: There were 115 patients of both genders had type-2 diabetes mellitus were presented.Patients ranged in age from 20 to 60 years old. Individuals participated in the study were asked to sign a permission form acknowledging they had read the information and understood its significance before having their demographic data collected. Frequency of hypoglycemia was recorded by Whipple’s triad questionnaire based information. Symptoms of hypoglycemia were also recorded. SPSS 23.0 was used to analyze all data. Results:Among 115 patients, majority of the patients 65 (56.5%) were males and 50 (43.5%) were females. Mean age of the patients was 51.6±11.54 years and had mean BMI 27.5±8.34 kg/m2. There were 70 (60.9%) cases had rural residency and 45 (39.1%) patients had urban residency.Most common symptoms were dizziness, weakness and sweating among all cases. Metformin was the most common treatment used among all cases, followed by glynase and insulin. We found frequency of hypoglycemia among 50 (43.5%) in which majority of the cases were females. Among 50 cases of hypoglycemia, 11 cases had severe hypoglycemia, 20 cases had moderate and 19 cases had mild hypoglycemia. Conclusion: In this research, we found that type-2 diabetic patients, most of whom were female and rural, had a high incidence of hypoglycemia. The high incidence requires primary care doctors to ask for hypoglycemia symptoms at each diabetes patient visit. It's also crucial to educate patients about hypoglycemic symptoms and the need of reporting them to alter dosage and avoid recurrence bouts. Keywords:Type 2-diabetes Mellitus, Hypoglycemia, Dizziness, Glynase

Un unexpected cause of mild hypoglycaemia in an adult

Un unexpected cause of mild hypoglycaemia in an adult

Severe iatrogenic hypoglycaemia modulates the fibroblast growth factor protein response.

There is evidence that fibroblast growth factor (FGF) levels may be implicated in hypoglycaemia, with FGF19 being a potential contributor to insulin-independent pathways driving postprandial hypoglycaemia following bariatric surgery and basic FGF (FGF2) being elevated following mild hypoglycaemia occurring after the glucose tolerance test. However, their response following severe iatrogenic hypoglycaemia is unknown and therefore this pilot exploratory study was undertaken. A case-control study of aged-matched type 2 diabetes (T2D; n=23) and control (n=23) subjects who underwent a hyperinsulinaemic clamp, initially to euglycaemia in T2D (5 mmol/L; 90 mg/dl), and then to hypoglycaemia (<2 mmol/L; <36 mg/dl) with subsequent follow-up time course to 24 h. FGF and FGF receptor proteins were determined by Slow Off-rate Modified Aptamer (SOMA)-scan plasma protein measurement. At baseline, FGF12 (p= .006) was higher and FGF20 (p= .004) was lower in T2D versus controls. At hypoglycaemia, FGF7 was lower in T2D. Post-hypoglycaemic levels of FGF18, FGF19, FGF20 and FGF23 were lower while FGF12 and FGF16 were higher in T2D versus control at different time points. No differences between T2D and controls were seen for FGF1, FGF2, FGF4, FGF6, FGF8, FGF9, FGF10, FGF21 or any of the FGF receptors. At 24 h post-hypoglycaemia, FGF20 (p= .01) differed between controls and T2D, while the levels for the other proteins measured returned to baseline. None of the FGF proteins altered from baseline to euglycaemia when clamped in T2D subjects. FGF23 negatively correlated with fasting blood glucose, but no FGFs correlated with body mass index in T2D. Severe transient hypoglycaemia modulated FGF7, 16, 19, 20 and 23 (known to be associated with diabetes), together with FGF18 and 12, not previously reported to be associated with diabetes but that may be important in the pathophysiology of hypoglycaemia; FGF20 remained low at 24 h. Taken together, these data suggest that recurrent hypoglycaemia may contribute to the development of complications through changes in FGF proteins.

Comparable Triglyceride Reduction With Plasma Exchange and Insulin in Acute Pancreatitis - A Randomized Trial.

Background and AimsBoth insulin and plasma exchange (PE) are used in hypertriglyceridemic acute pancreatitis (HTG-AP). Our aim was to compare the efficacy of both treatments.MethodsA randomized, parallel group study performed in a tertiary hospital in 22 HTG-AP patients with non-severe prognosis and triglycerides between 15 and 40 mmol/L. Patients were randomized to daily PE or insulin infusion until triglycerides were <10 mmol/L. Primary outcome was % reduction in triglycerides within 24 h. Secondary outcomes were days needed to lower triglycerides <10 mmol/L, highest CRP and percentage of patients with a severe course of pancreatitis.ResultsThere was a trend toward a greater decrease in triglycerides within the first 24 h in the PE group (67 ± 17% vs. 53 ± 17%, p = 0.07), but the absolute difference was modest [mean difference of 6 mmol/L (14% of initial value)]. Triglycerides fell below 10 mmol/L in a median (IQR) of 1 (1–2) and 2 (1–2) days, respectively (p = 0.25). Secondary outcomes related to disease severity were also comparable: highest CRP 229 vs. 211 mg/L (p = 0.69) and severe course of pancreatitis in 2/11 cases in both groups (p = 1.0). Regarding treatment complications, there was one mild hypoglycemia and one allergic reaction during PE. Survival was 100% in both groups.ConclusionThere was no significant difference, but only a trend toward a greater decrease in triglycerides with PE, and the clinical course was also comparable. These results do not support universal use of PE in patients with HTG-AP.Clinical Trial Registration[ClinicalTrials.gov], identifier [NCT02622854].

Higher HbA1c was observed in young people with diabetes who fasted during COVID-19 pandemic lockdown of 2020 Ramadan in Bangladesh – A Post Ramadan survey

ObjectiveMuslim people with T1DM should be actively discouraged from fasting during the COVID-19 pandemic, as diabetes has emerged as a significant risk factor for adverse outcomes of COVID-19 infection. We report the experience of young patients with type 1, type 2 and other types diabetes who fasted during Ramadan 2020 at the time of the COVID-19 pandemic time lockdown.Research Design and Methods.A Post- Ramadan survey was designed for young patients who fasted during Ramadan in 2020 during COVID pandemic time. The study was conducted to compared the basal characteristics and other parameters in children and adolescents (<18 years), with young adults (≥18 years) with diabetes at Paediatric Diabetes Center in BIRDEM in Bangladesh. ResultsAmong the study participants, a significantly higher number of participants were in older age group who fasted for more than 15 days (p = 0.045). A considerable proportion (30.7%) of patients developed mild hypoglycaemia, and only eight patients (2.6%) developed moderate to severe hypoglycemia. There was significant reduction of post Ramadan basal insulin dose in both groups (p = 0.001). Although increased bolus insulin dose requirements were observed in older age group, but decreased requirement was observed in younger age group during Ramadan (p = 0.001). Post Ramadan median HbA1C in both groups was increased with marked increase in older age group compared to younger age group though it did not reach the statistical significance. (p = 0.239) ConclusionsCOVID-19 pandemic had minor impact on fasting during Ramadan in our cohort, they could fast safely with less complications during Ramadan. Our data supports Ramadan focused diabetes education with ample self-care, young people with diabetes can fast safely during Ramadan.

Evaluating the Incidence and Risk Factors Associated With Mild and Severe Hypoglycemia in Insulin-Treated Type 2 Diabetes

ObjectivesThis study to assess the incidence rates and risk factors of hypoglycemia in a wide real-life sample of patients with insulin-treated type 2 diabetes mellitus. MethodsIn a prospective epidemiological study, data from 817 subjects were collected from medical records and via interviews. Over a 3-month period, hypoglycemic episodes were recorded via self-measurement of glucose levels at least twice daily. Cox proportional and negative binomial multivariable models were applied to estimate adjusted and unadjusted hazard ratios and incidence rate ratios of hypoglycemic events. ResultsOf the 817 patients, 52.9% experienced hypoglycemia, 38.1% had only nonsevere episodes, and 14.8% had at least 1 severe episode. Total events per patient-year were estimated at 13.3 (±24.8), with 11.8 (±21.6) and 1.4 (±4.7) being nonsevere and severe, respectively. History of hypoglycemia and severe hypoglycemia were consistent risk factors of hypoglycemia. Intensification of therapy was associated with higher incidence rates, whereas the effect on the hazard rates was more moderate. Longer duration of insulin therapy and the presence of congestive heart failure were associated with a higher risk of developing and frequency of hypoglycemia. Hypoglycemia awareness was found to independently affect only mild hypoglycemia. ConclusionsHypoglycemia is a common complication in patients with insulin-treated type 2 diabetes mellitus. The risk factors of developing hypoglycemia are to some extent different from those of the frequency of hypoglycemic episodes. Particular attention is required for patients with recurrent hypoglycemic events and on intensive antidiabetic therapy.

The Relationship between Hypoglycaemic Episodes and Arrhythmias in Type 2 Diabetes Subjects after Acute Myocardial Infarction with ST-Segment Elevation—A Case Series

Background and Aims: Several studies have shown that hypoglycaemia, especially a severe episode is associated with an increased mortality rate in diabetes mellitus subjects with previous cardiovascular disease or acute coronary syndrome. One of the presumed mechanisms is the proarrhythmic effect of hypoglycaemia related to the prolongation of the action potential, or the catecholamine surge that follows an episode. The aim of this case series analysis was to investigate the relationship between hypoglycaemia and glucose variability with arrhythmic events in type 2 diabetes patients who suffered an acute myocardial infarction. Materials and Methods: We selected patients admitted consecutively to the cardiology department of Clinical Emergency Hospital in Bucharest for a period of three months with acute myocardial infarction and previously diagnosed type 2 diabetes. For each patient, a retrospective continuous glucose monitoring system (CGMS) or glucose sensor (Medtronic&#174 Enlite, USA) and a dual electrocardiograph and blood pressure monitor for 24 hours were available. Also, patients had an oscillometric device (Arteriograph&#174 TensioMed Ltd) for 24 hours or non-invasive monitoring of central blood pressure, pulse wave velocity and augmentation index. The data were analysed using Medtech&#174, TensioWin&#174 and Carelink iPro&#174 softwares. We used SPSS&#174 version 20.0 (IBM) for the statistical analysis. The results are presented as median and interquartile range (IQR). Results and Discussion: Ten type 2 diabetes patients (4 males, 6 females) with anterior (4/10) and inferior acute myocardial infarction (6/10) were included. They were treated with insulin (3/10), sulphonylurea (Gliclazide) plus Metformin (4/10), Metformin monotherapy (2/10), or all three (1/10). The patients had a median age of 67.5 (3.25) years with a median disease duration of 8 (7.75) years. The median body mass index was 29.54 (5.65) kg/m2. The median HbA1c was 7.9% (3.15) % and C-peptide 3.3 (2.66) ng/ml. There were no significant differences regarding the number of atrial or ventricular premature beats, ventricular or atrial tachycardia or fibrillation, the duration of QT interval, systolic and diastolic blood pressure, aortic pressure, augmentation index, pulse wave velocity between subjects with hypoglycaemia and those without. There was a negative correlation between QTc and glucose values in patients with hypoglycaemia (Spearman coefficient correlation r = -0.232; p Conclusion: Mild hypoglycaemia in type 2 diabetes patients with systolic dysfunction after ST-elevated myocardial infarction did not increase the number of supraventricular premature beats and QTc duration. We suggest that non-severe hypoglycaemia does not increase the risk of arrhythmias in patients with type 2 diabetes.

Comparison of Efficacy of Detemir and Degludec Insulin in the Management of Children and Adolescents with Type 1 Diabetes

Aims and Objectives: Despite the advantages offered by current basal analogs, the management of type 1 diabetes (T1D) in children and adolescents is a great challenge till now. Insulin degludec (IDeg) is alternative basal insulin to be used in persons not responding to other basal insulins. The aim of the study was to compare the efficacy of IDeg (once daily) and insulin detemir (IDet) in children and adolescents with T1D in Bangladesh. Materials and Methods: In this retrospective analysis, we included T1D patients who were treated with IDet or IDeg in CDiC Diabetes Center, BIRDEM Hospital from January to June 2018. Thirty patients with IDeg were compared with 30 patients who were taking IDet; patients were randomly selected from the data set. Insulin dose requirement, weight, body mass index, fasting plasma glucose (FPG), and HbA1c were compared at the base level and at three and six months after treatment. Results: While comparing between two groups, the median FPG was high, 15.0 (13.6–18.3) vs. 14.4 (10.5–16.9), in both groups at the base level. Over the six months, FPG was gradually reduced in both groups but significantly reduced in IDeg patients (P = 0.03), although median HbA1c was higher, 9.9 (8.4–12.0), in IDeg patients than in IDet patients, 9.3 (8.1–10.4), at the base level but reduced significantly in IDeg patients, 8.4 (7.6–9.0), compared with IDet patients, 9.0 (8.1–9.7), after six months (P = 0.042). Though mild hypoglycemia was documented, there was no incidence of severe hypoglycemia in IDet or IDeg groups. Conclusion: In conclusion, in our study population, the IDeg group had more improvement in glycemic control, reducing FPG, than the IDet group. Moreover, there was more reduction of basal insulin dose in IDeg than in IDet after six months of starting the therapy.