Quality Of Blood Glucose Control Research Articles

953-P: Sustainable Improvement in Quality of Blood Glucose Control in Users of mySugr’s Integrated Diabetes Management Solution

Objective: The mySugr App is the most widespread mobile health application in the diabetes industry, reaching 1.5M patients in 62 countries. mySugr’s Integrated Diabetes Management solution, the mySugr bundle, introduces unlimited test strip delivery and Certified Diabetes Educator-led coaching. In a previous retrospective study we looked at real world changes in blood glucose (BG) in a U.S. population of mySugr Bundle users. In this follow-up study we extended the observation period of intervention to further analyse the course of effect seen before. Method: We analyzed changes in BG control (mean±SD, tests in range (TIR), estimated A1c (eA1c)) and frequency of testing. Participants monitored BG ≥3 times/day during the observation period. Data from the first 2 weeks of use (t0), 8 weeks before (t1), 8 weeks after (t2) and 8 to 16 weeks after (t3) initiation of Bundle usage were aggregated and statistically compared using two-sided t-tests. Results: Study participants were 61 users; 59% with type 1 diabetes, 32.8% with type 2 diabetes, 6.6% with LADA and 1.6% with unreported diabetes type. Baseline BG was 152.0±56.0 mg/dl, eA1c 6.9% and TIR 65%. Significant (p<0.05) improvements were observed in mean BG (-11,8 mg/dl), standard deviation (-5,48 mg/dl), TIR (+6.8%), readings above target (-7.2%) and eA1c (-0.41%) between t0 and t3. A significant improvement was also observed in monitoring frequency (+21.4%) between t1 and t3. Conclusion: Our previous study suggested use of the mySugr Bundle triggered positive changes of glucose control at 8 weeks post intervention. We were now able to show a sustainable improvement in BG control over an extended time period of 16 weeks, indicating the potential benefits of mobile interventions that combine complementary treatment strategies for therapy adherence over longer time periods. Given that improvements were observed in well-controlled patients, findings support further studies in a wider study population range. Disclosure H. Mayer: Employee; Self; mySugr. R.P. Bankosegger: Employee; Self; mySugr. J. Kober: Employee; Self; mySugr.

Software-guided versus nurse-directed blood glucose control in critically ill patients: the LOGIC-2 multicenter randomized controlled clinical trial

BackgroundBlood glucose control in the intensive care unit (ICU) has the potential to save lives. However, maintaining blood glucose concentrations within a chosen target range is difficult in clinical practice and holds risk of potentially harmful hypoglycemia. Clinically validated computer algorithms to guide insulin dosing by nurses have been advocated for better and safer blood glucose control.MethodsWe conducted an international, multicenter, randomized controlled trial involving 1550 adult, medical and surgical critically ill patients, requiring blood glucose control. Patients were randomly assigned to algorithm-guided blood glucose control (LOGIC-C, n = 777) or blood glucose control by trained nurses (Nurse-C, n = 773) during ICU stay, according to the local target range (80–110 mg/dL or 90–145 mg/dL). The primary outcome measure was the quality of blood glucose control, assessed by the glycemic penalty index (GPI), a measure that penalizes hypoglycemic and hyperglycemic deviations from the chosen target range. Incidence of severe hypoglycemia (<40 mg/dL) was the main safety outcome measure. New infections in ICU, duration of hospital stay, landmark 90-day mortality and quality of life were clinical safety outcome measures.ResultsThe median GPI was lower in the LOGIC-C (10.8 IQR 6.2–16.1) than in the Nurse-C group (17.1 IQR 10.6–26.2) (P < 0.001). Mean blood glucose was 111 mg/dL (SD 15) in LOCIC-C versus 119 mg/dL (SD 21) in Nurse-C, whereas the median time-in-target range was 67.0% (IQR 52.1–80.1) in LOGIC-C versus 47.1% (IQR 28.1–65.0) in the Nurse-C group (both P < 0.001). The fraction of patients with severe hypoglycemia did not differ between LOGIC-C (0.9%) and Nurse-C (1.2%) (P = 0.6). The clinical safety outcomes did not differ between groups. The sampling interval was 2.3 h (SD 0.5) in the LOGIC-C group versus 3.0 h (SD 0.8) in the Nurse-C group (P < 0.001).ConclusionsIn a randomized controlled trial of a mixed critically ill patient population, the use of the LOGIC-Insulin blood glucose control algorithm, compared with blood glucose control by expert nurses, improved the quality of blood glucose control without increasing hypoglycemia.Trial registrationClinicalTrials.gov, NCT02056353. Registered on 4 February 2014.

Beyond Proteinuria: Apoptosis and Vitamin D3 State in Children with Diabetic Nephropathy

Diabetic nephropathy (DN) is the leading cause of death in patients with diabetes mellitus type I (T1D). Formation of diabetic nephropathy depends on the quality of blood glucose control. The aim of the study was to investigate the level of metabolic-hypoxic disorders, condition of apoptosis controlling system and Vitamin D3 levels in children with diabetic nephropathy. The study involved 36 children with type I diabetes and diabetic nephropathy (aged 6 to 17 years). The affinity of haemoglobin to oxygen determined by spectrophotometric method. The levels of the marker of cellular hypoxia HIF-1alfa, levels of the apoptotic factor caspase-3 studied by Western Blotting, Vitamin D3 levels were analyzed using ELISA assay. In the group of children with newly diagnosed T1D an increased rate of dissociation of oxygen and haemoglobin compared to the control group was detected. Children with DN the levels of this index were significantly lower than the control group. We show stage-dependent manner in increase of the cellular hypoxia and apoptotic effector caspase-3 levels. Both markers detected at significantly higher rate in DN patients as compared to T1D. Vitamin-D3 deficiency is documented in patients with DN. Thus, the development of DN in children is associated with violation of Hb/oxygen dissociation, a sign of the high degree of the Hb glycosylation resulting to the formation of cellular hypoxia and activation of apoptosis, as one of the basic mechanisms of cell damage kidneys in DN. All mentioned above disorders accompanied by Vitamin D3 deficiency.

Ingredients for adequate evaluation of blood glucose algorithms as applied to the critically ill

The article by Eslami and colleagues provides an overview of the indicators used to measure the quality of blood glucose control in patients admitted to the intensive care unit. Each indicator can be related to one or more of the following categories: blood glucose zones, blood glucose levels, time intervals, and features of the insulin titration algorithm. Some important issues (for instance those concerning the clarity of definitions used for glycaemic thresholds) are raised. This systematic review calls for a practical guide to advise the clinician how different blood glucose signals should (ideally) be evaluated and which steps should to be undertaken.

Tight blood glucose control: What is the evidence?

In two large, randomized studies, maintenance of normoglycemia with intensive insulin therapy largely prevented morbidity and reduced mortality of critically ill patients. Recently, questions have been raised about the efficacy and safety of this therapy. These issues are systematically addressed and discussed with the evidence available from these and other studies. The available studies show that an absolute reduction in risk of hospital death of 3% to 4% is to be expected from intensive insulin therapy in an intention-to-treat analysis. Future studies designed to confirm a statistically significant survival benefit should be adequately powered, with inclusion of >or=5,000 patients. When patients are treated with intensive insulin therapy for >3 days, the absolute reduction in the risk of death increases to approximately 8%. Insulin therapy also improves morbidity, more so when continued for >3 days. Strict blood glucose control to normoglycemia (<110 mg/dL) is required to obtain the most clinical benefit, but this inherently increases the risk of hypoglycemia. It remains unclear whether short hypoglycemic episodes are truly harmful for these patients. In conclusion, demonstration of the clinical benefits of intensive insulin therapy depends on the quality of blood glucose control and the statistical power of the studies.

Fungal foot infections in patients with diabetes mellitus – results of two independent investigations

In diabetic patients, mycotic infections may increase the risk of developing diabetic foot syndrome. However, little data are available on the prevalence of fungal foot infections in patients with diabetes. In a first study published using data obtained during a conference attended by patients with long-term diabetes mellitus type 1 (DM1), 78/95 patients (82.1%) showed probable pedal fungal infections, of which 84.6% (66/78) were mycologically confirmed by direct microscopy and/or culture. The dermatophyte Trichophyton rubrum was the most common (69.2% of isolates). Significant correlation was found between infection and the gender (men more frequently affected) and the age of the patients. Marked mycoses on the soles of the feet were often considered to be dry skin by the patients. In a second study, 174 [31 DM1, 112 DM2 and 29 healthy accompanying persons (HAP), family members without DM] participants at a regional patients' symposium on diabetes took part in an examination for fungal infections and neuropathy of the feet. In addition to the items of the first study, we gathered data on the quality of blood glucose control (HbA1c), peripheral neuropathy (neuropathy symptome and deficit score) and measurement of sudomotoric activity by Neuropad. Mean duration of disease was 23.6 (DM1) and 11.2 (DM2) years, mean HbA1c 7.56% (DM1) and 6.89% (DM2) and fungal foot infections were confirmed at 35.5% (DM1), 53.1% (DM2) and 37.9% (HAP) respectively. In DM2, the prevalence of positive fungal samples is significantly higher for participants with less controlled blood glucose (higher HbA1c) (P = 0.04). Mycotic foot infection is also correlated with age, gender and duration of diabetes disease. Of special interest is the finding of relatively high numbers of black fungi ('Dematiaceae') (n = 10), Phialophora europea (n = 3) being the most common one. The sudomotoric activity was impaired in a very high number of participants [107/171 (61.5%)], and was found positively correlated with the prevalence of fungal foot infection in DM2 but not in DM1 and HAP. The high prevalence of fungal infections detected in DM1 as well as in DM2 diabetics is remarkable, especially considering this highly motivated collective. Therefore, it appears that the feet of diabetics require more diagnostic, therapeutic and preventive care in terms of mycotic infections and sudomotoric dysfunction than previously thought.

Carotid intima-media thickness and stiffness in relation to type 2 diabetes in Chinese

We investigated carotid intima-media thickness (IMT) and quantitative carotid stiffness (QCS) index in relation to plasma glycosylated hemoglobin A(1C) (HbA(1C)) and duration of diabetes mellitus in 337 Chinese diabetic patients. In categorical analyses, carotid IMT was 710 mum in subjects with a duration of diabetes mellitus < or = 2 years, 760 micorm in subjects with a duration of diabetes mellitus more than two years and with plasma HbA(1C) < 6.5% (P < 0.05), and 790 microm in subjects with a duration of diabetes mellitus more than two years but with plasma HbA(1C) > or = 6.5% (P < 0.01). The corresponding values for QCS values were 4.5, 4.6 and 5.1 (P < 0.05), respectively. In multiple stepwise regression analyses carotid IMT was significantly associated with the duration of diabetes mellitus, systolic blood pressure and serum concentration of total cholesterol, whereas QCS was significantly associated with age, HbA(1C), systolic and diastolic blood pressure (P < 0.05). In conclusion, carotid IMT as a structural measure of arterial wall is increased in patients with a longer history of diabetes mellitus, whereas QCS as functional index is mainly influenced by the quality of blood glucose control.

Self-monitoring of blood glucose and type 2 diabetes mellitus

Self-monitoring of blood glucose (SMBG) in management of type 2 diabetes mellitus continues to be debated. However, SMBG is recognized as being useful (professional agreement) in three situations: sensitizing the type 2 diabetic patient to the advantages of diet control and physical exercise, determining and adapting the dosage of oral antidiabetic medication at the beginning of treatment or during a dosage change, and monitoring plasma glucose during intercurrent disease or during a treatment that may lead to acute blood glucose imbalance. However, the frequency, the timing of blood glucose monitoring, and the target blood glucose values remain poorly defined. It is well known that the postprandial period covers approximately 50% of the day, and several recent studies have shown the respective role of fasting, pre- and postprandial glucose levels in overall diurnal hyperglycemia in the type 2 diabetic and their respective contribution to the mean HbA1c level depending on how well blood glucose levels are controlled. Based on these studies, it is now possible to propose a SMBG scheme, specific to a given patient and for a defined therapeutic objective, taking the three physiological periods into account: postprandial, postabsorptive, and fasting. However, the optimal use of SMBG requires patient education and training. Using a specific, adapted, and optimal SMBG is only advantageous if the results are usable, and used, by the patient and healthcare professionals to improve the quality of blood glucose control (as shown by the HbAlc level) and the safety of intensified oral antidiabetic treatments (minimal risk of hypoglycemia).

Screening for people with diabetes mellitus for poor blood glucose control in an ophthalmological laser clinic

Purpose: The study was performed to test the effect of a structured intervention in diabetic patients with poor glycaemic control in an ophthalmological department. Patients and methods: All the patients attending the ophthalmological out-patient department with the need for laser therapy due to diabetic retinopathy were investigated from January to March 1998 (Type 1: n=20, Type 2: n=144). If an HbA 1c-level higher than 9.0% was found the patient was informed within 1 week and a standardised letter was sent to the primary care physician and the local ophthalmologist. Over the first 3 months of 1999 the effect was evaluated. Results: HbA 1c values higher than 9.0% were found in eight/20 of the patients (40%) with Type 1 diabetes and in 61/144 of the patients (54%) with Type 2 diabetes. In 55% this new information in the context of the need for laser therapy resulted in the acceptance of a structured intervention by the patient. This led to an improvement of the HbA 1c in the people with Type 1 diabetes. Conclusion: Patients with poor blood glucose control can be identified in an ophthalmological department. The need for laser therapy can be used to motivate the patients for a significant improvement of the quality of blood glucose control.

Fetal size at birth in relation to quality of blood glucose control in pregnancies complicated by pregestational diabetes mellitus: Persson B.; Hanson U. SWE Br J Obstet Gynaecol 1996 103/5 (427–433)

International Journal of Gynecology & ObstetricsVolume 55, Issue 2 p. 192-193 Citations from the literature perinatology Fetal size at birth in relation to quality of blood glucose control in pregnancies complicated by pregestational diabetes mellitus Persson B.; Hanson U. SWE Br J Obstet Gynaecol 1996 103/5 (427–433) First published: November 1996 https://doi.org/10.1016/S0020-7292(96)80196-2AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume55, Issue2November 1996Pages 192-193 RelatedInformation

Fetal size at birth in relation to quality of blood glucose control in pregnancies complicated by pregestational diabetes mellitus

To determine the relation between maternal levels of blood glucose and glycated haemoglobin (HbA1c) and infant size at birth in pregestational diabetes. Longitudinal study from 6 to 14 weeks gestation. Women were treated intensively with insulin, aiming at normoglycaemia but avoiding hypoglycaemia. Blood glucose was determined six times daily, HbA1c every four weeks. Individual mean fasting and postprandial glucose levels were calculated for three-week periods of gestation. Birthweight > 2 SD or within +/- 2 SD for gestational age and gender was classified as large (LGA) or appropriate (AGA), respectively. Birthweight ratio was calculated as the ratio of birthweight to normal mean birthweight after correction for gestational age and gender. One hundred and thirteen consecutive pregnant women with pregestational diabetes and their newborn infants. Perinatal mortality was nil, the rates of spontaneous preterm delivery (8.9%) and severe maternal hypoglycaemia (4.4%) were low. Mothers with LGA infants (26%) had a significantly higher fasting glucose between weeks 27 and 32 than mothers of AGA infants (P < 0.01). Relative birthweight was significantly and independently associated with pre-pregnancy bodyweight (r = 0.24, P < 0.05) and fasting glucose at weeks 27 to 29 (r = 0.27, P < 0.01) but together could only explain 12.3% of the variation in birthweight (mult. r = 0.35, P < 0.01). HbA1c correlated with glucose levels but was unrelated to birthweight ratio. The fasting glucose level between weeks 30 and 32 was significantly interrelated with the fasting glucose level from each of the six preceding three-week periods. Near normoglycaemia cannot be obtained in all patients, presumably due to intrinsic differences in glucoregulatory ability between individuals. The incidence of LGA infants was unexpectedly high. The modest abnormality in glycaemic control in mothers with LGA infants could only partly explain fetal oversize, suggesting that other factors must be implicated to explain fetal growth acceleration.

Intensive Insulin Therapy—Effects on M‐Value and Frequency of Hypoglycemia—

AbstractThe frequency of hypoglycemia and M‐values were measured on 11 intensively treated insulin dependent diabetic children separated into three groups of once‐daily, twice‐daily and multiple daily insulin injection regimens. Despite a similar quality of blood glucose control (Hb Al (%): 10.0 ± 1.5, 10.4 ± 2.6, 10.6 ± 2.5) in each of the above regimens, the M‐values were 26.2 ± 11.7 in the once‐daily, 34.9 ± 17.9 in the twice‐daily and 47.7 ± 14.7 in the multiple daily injection regimen (M ± SD), respectively. A mild biochemical hypoglycemia was found more often in the patients under treatment with twice‐daily and multiple daily injections. Further, though the mean blood glucose profiles in the patients treated with once‐daily and multiple daily injections were very good, marked hypoglycemic blood glucose levels were seen prior to meals, especially before lunch.

Does pregnancy influence the prognosis of uncomplicated insulin-dependent diabetes mellitus?

To evaluate the effect of one or two pregnancies on the prevalence and severity of late diabetic complications, 22 pairs (44 patients) of female insulin-dependent diabetic (IDDM) patients were examined. Each pair consisted of one patient who had completed one or two pregnancies and one who had not. The two groups were carefully matched with respect to age, duration of disease, endogenous insulin secretory capacity, quality of blood glucose control, insulin requirement, hospitalization, and social status. No differences in prevalence or severity of retinopathy, nephropathy, and neuropathy were found.

Programming of an open-loop system for i.v. insulin infusion in insulin-dependent diabetes.

The blood glucose of 10 stable unstressed uncomplicated insulin-dependent diabetics (age: 39 ± 4 years; duration of diabetes: 11 ± 1 years) was controlled by a preprogrammed open-loop system of i.v. insulin infusion during two randomized consecutive days. Individual constant basal insulin rates were determined by adapting the rate of the pump to obtain normoglycemia during an overnight infusion. The post-prandial doses of insulin, given as square waves (12 U/h) or boluses (120 U/h), were calculated on one day (type I programme) from the fractional individual insulin requirements during a previous external artificial pancreas run, and on the other day (type II programme), from the formula: constant basal rate (U/h) × amount of carbohydrates (g) × 0.4 if for breakfast, on × 0.15 if for midday and evening meal. Blood glucose control, which was similar for the two methods, was identical to that provided by the artificial pancreas closed-loop system for correction of post-prandial glycemic excursions (mean peak values: 7.0 ± 0.4, 7.2 ± 0.1, 7.0 ± 0.1 mmol/l for type I, type II and closed-loop programmes). Basal blood glucose was significantly higher with the open-loop system (7.2 ± 1.1, 6.8 ± 0.8, 4.8 ± 0.3 mmol/l for type I, type II and closed-loop programmes) because of a drift of the values during the first half of the night. Boluses gave a slightly better post prandial control than square waves but produced a late hyperglycemic rebound. Daily insulin doses required by type I, type II and closed-loop programmes were respectively 75 ± 7, 64 ± 5 and 80 ± 7 U. Individual basal rate was uniform (1.1 ± 0.1 U/h). From these results it is concluded: (1) the quality of blood glucose control obtained from open-loop and closed-loop systems of insulin infusion is remarkably similar; (2) our formula is adequate for preprogramming insulin for the prandial periods, but careful individual determination of the basal rate by use of a closed-loop system is required.

Long-Term Continuous Intravenous Insulin Therapy with a Portable Insulin Dosage-regulating Apparatus

A portable insulin dosage-regulating apparatus (PIDRA) was used with five volunteer diabetic subjects for periods ranging from 1 wk to more than 3 months to explore the possibilities of achieving near normoglycemic control over long time periods with such an apparatus. PIDRA consists of a matchbox size pump with insulin reservoir and a pocket size electronic control box. It can infuse a preprogrammed basal rate of insulin plus externally manipulated supplementary doses in rectangular profiles. The quality of blood glucose control was monitored with the Miles Biostator and through self-testing by the patient in the outpatient phases. Under inpatient conditions, the relatively simple PIDRA insulin administration profile was almost as effective in achieving normoglycemia as the Biostator, and good control could be maintained over long periods of time. The apparatus allows considerably greater ease in variation of insulin dosage with less risk of hypoglycemic epidoses as compared with conventional subcutaneous injections. Several technical problems remain to be solved, but it is concluded that PIDRA represents a viable alternative as a means of achieving tight control, at least as a step toward the goal of an implanted glucose-contingent insulin infusion system.

Analysis of variance applied to blood glucose values for assessing insulin preparations and state of lability in diabetes.

A method for numerical evaluation of the quality of blood glucose control in diabetes mellitus is presented. Blood glucose values were obtained 4–9 times daily during periods of 5 days. By analysis of variance estimates were obtained for 1. Blood glucose variations during the day, used as a parameter for assessment of the efficiency of a given insulin preparation in an individual patient, and also for comparison of different insulin preparations in a group of patients. — 2. The variation of the mean blood glucose levels from day to day, influenced a.o. by the lability of the diabetes. — 3. The constancy of the pattern of the blood glucose curves during different days, influenced by the lability of the disease. The two latter factors were combined to give a parameter which under controlled conditions may be used for classification of the lability of diabetes. — The method is exemplified by application to different types of diabetes disease and treatment. Pour insulin preparations were compared in a group of patients. A change of insulin in several cases caused fairly great changes in the parameter measuring the efficiency of the insulin preparation. The parameter measuring lability of diabetes showed a characteristic level for each patient, with only small changes throughout the experimental periods. — In our experience, the present method has proved to be useful and has the advantage of being derived from a well defined statistical analysis.