Rate Of Hypoglycemia Research Articles

IDF21-0409 Hypoglycemia and heart rate variability: synchronous detection by Holter and continuous glucose monitors

Background: Hypoglycemia is a notorious diabetic side effect leading to unwanted major vascular events and sudden cardiac death due to change in autonomic cardiac function. Previous studies have reported electrocardiographic (ECG) abnormalities such as QT interval prolongation in patients with hypoglycemia, so did heart rate variability (HRV). Aim: To document ECG and HRV changes during hypoglycemia and expect to establish a portable device to early detect hypoglycemia in the future. Method: Seventeen participants including ten poor controlled type 2 diabetes, six type 1 diabetes and one Latent autoimmune diabetes in adults (LADA) were enrolled in this study. There were six males and eleven females, aged from 37 to 77 (mean 50.3 ± 12.0) years old, with self-reported duration of diabetes from 6 to 33 (mean 20.8 ± 8.7) years. The mean HbA1c was 8.3 ± 1.4 % on the time of the examination. We used Holter- electrocardiogram (VitalSigns) and continuous glucose monitor (Medtronic) to record ECG waveform, heart rate variability and glucose level with synchronization of time for a duration of seven days. Results: Two of the seventeen participants did not experience hypoglycemia (≦70 mg/dL). The other participants who experienced hypoglycemia revealed, as a whole, a trend of correlation between blood glucose, corrected QT Interval (QTc), and HRV. When the participants experienced hypoglycemia were sub-divided into response and non-response groups according to the appearance of QTc prolongation, significant difference of age was found between two groups, most of them were type 1 diabetic patients. Among 90 events of hypoglycemia, 56 events (62%) presented with increased heart rate and/or Low Frequency/ High Frequency (LF/HF) ratio and /or decreased Root Mean Square of the Successive Differences (RMSSD). Besides, there were a trend of difference of glucose nadir, HRV include heart rate, RMSSD and LF/HF ratio between two groups. Discussion: In this study, Type 1 DM patient and younger age were easier to have QT interval prolongation during hypoglycemia. Besides, increased LF/HF ratio may represent that these group of patients have better regulation of autonomic nervous system. Heart rate variability can be seen during hypoglycemic events in both type 1 and type 2 diabetic patients especially in the response group.

Continuous glucose monitoring demonstrates low risk of clinically significant hypoglycemia associated with sulphonylurea treatment in an African type 2 diabetes population: results from the OPTIMAL observational multicenter study

IntroductionPeople living with diabetes in low-resource settings may be at increased hypoglycemia risk due to food insecurity and limited access to glucose monitoring. We aimed to assess hypoglycemia risk associated...

720 Intensive Insulin Therapy in the Burn Intensive Care Unit: A Systematic Review of Literature

IntroductionThe significant burden of burn-related morbidity and mortality is partly due to the complex pathophysiological derangements that occur in the acute post-burn period. Critical care literature has pushed for tighter glycemic control, but these studies often use heterogenous groups of medical and surgical patients. Furthermore, some of these studies present conflicting evidence of whether there is true mortality benefit. Providers must balance the risks associated with hyperglycemia such as infection, inflammation, and pour wound healing against the risks associated with severe hypoglycemia, most notably coma and death. This study aims to review the literature on outcomes in tight glucose control regimens (glucose < 150mg/dL) in the burn ICU population to help guide further research and practice guidelines.MethodsA systematic review of literature utilizing PubMed was conducted for any article published at any time. Searches used the AND function to identify articles with a burn term (burn injury OR burn care OR burn ICU OR burn OR thermal injury OR burned) and a glucose control related term (glucose control OR glycemic control OR glucose management OR insulin OR metformin OR glipizide). Inclusion criteria were English studies that describe intensive care unit (ICU) glucose management in adult burn patients. Exclusion criteria were involvement of children, animals, and settings outside of the ICU. Case reports, editorials, and position pieces were also excluded.ResultsThe search identified 2,154 articles. Full text review of 61 articles identified 8 that met inclusion criteria. Two randomized control trials, 3 retrospective case-control studies, 2 retrospective cohort studies, and 1 systematic literature review. Only 1 study showed mortality benefit of tighter glucose control (< 150 mg/dL) compared to controls (< 200 mg/dL), while 3 studies showed no difference in mortality between cases and controls. Three studies demonstrated a reduction in infectious complications including sepsis, pneumonia, urinary tract infection, and bacteremia. Nearly all studies (6/8) showed increased rates of hypoglycemia with tight control, but very few instances of adverse sequela following hypoglycemia were noted.ConclusionsLike the broader critical care population, tighter glucose control may be beneficial to burn patients but with some variability. Balancing the complications of hypoglycemia with hyperglycemia continues to be a challenge with no clear guidelines. Further research in a burn specific population would help create a safe and effective treatment algorithm which could be adapted widely.

Risk of Major Adverse Cardiovascular Events, Severe Hypoglycemia, and All-Cause Mortality in Postpancreatitis Diabetes Mellitus Versus Type 2 Diabetes: A Nationwide Population-Based Cohort Study.

Postpancreatitis diabetes mellitus (PPDM) is a frequent complication of pancreatitis and associates with poor glycemic control. We investigated the risk of adverse diabetes-related outcomes in PPDM compared with type 2 diabetes. In this Danish population-based cohort study, we included adults (>18 years) with incident PPDM or type 2 diabetes between 1998 and 2018 through national health registries. PPDM was further divided into acute (PPDM-A) and chronic (PPDM-C) subtypes. We ascertained risk of major adverse cardiovascular events (MACE), severe hypoglycemia, and all-cause mortality as well as incidence rates of severe hypoglycemia. We compared risk and incidence rates across diabetes subgroups using multivariate Cox and Poisson regression analyses. We identified 383,325 people with incident type 2 diabetes, 3,418 with PPDM-A, and 2,461 with PPDM-C. Compared with type 2 diabetes, PPDM-C was associated with increased risks of severe hypoglycemia (hazard ratio [HR] 5.27, 95% CI 4.62-6.00, P < 0.001) and all-cause mortality (HR 1.54, 95% CI 1.45-1.64, P < 0.001). Similar patterns were observed for people with PPDM-A. Incidence rate ratios (IRRs) for severe hypoglycemia were increased in both PPDM-C (IRR 7.38, 95% CI 6.75-8.08, P < 0.001) and PPDM-A (IRR 3.76, 95% CI 3.36-4.21, P < 0.001) compared with type 2 diabetes. Findings were consistent in an analysis restricted to people on insulin and in an analysis including pancreatitis patients without diabetes as comparator group. Compared with type 2 diabetes, PPDM is associated with excess risk of adverse diabetes-related outcomes. This has important implications for management.

Medication use to manage comorbidities in people with dementia: a systematic review

AbstractAimTo investigate physical health outcomes associated with medications prescribed to manage chronic physical conditions in people living with dementia; and determine whether a dementia diagnosis altered drug utilisation patterns for physical health conditions.Data sourcesMedline, Embase, Central and Scopus were searched 01/2011 to 12/2020.Study selectionExperimental and observational studies, where participants with dementia using medications prescribed by doctors to prevent or treat one or more chronic comorbid physical condition, were compared to no intervention, usual care, or a non‐dementia comparison group. The outcomes of interest were clinically meaningful physical outcomes, and medication utilisation patterns.ResultsTen studies met the inclusion criteria. All were of medium to high quality relative to their study design. Mixed findings were reported for ischemic stroke (n = 3), all‐cause mortality (n = 3) and bleeding‐related outcomes (n = 2). This is likely due to the heterogeneity in exposures reported. One study found that people with dementia, receiving antidiabetic management, had a higher rate of severe hypoglycaemia compared to people without dementia. Medication utilisation pattern outcomes included oral anticoagulant use before stroke‐related hospitalisation (n = 1), antithrombotic medication use before stroke‐related hospitalisation (n = 1), cardiovascular medication use for secondary prevention of ischemic heart disease (n = 1), antidepressant medication discontinuation (n = 1), osteoporosis treatment (n = 1), diabetic medication use (n = 2), and antihypertensive medication discontinuation (n = 1).ConclusionThis systematic review showed there is currently insufficient evidence to conclude that medication management in people with dementia should differ substantially to people without dementia. Comprehensive and high‐quality evidence is needed to improve confidence that medication prescribing achieves optimum clinical outcomes, quality of life, and benefit‐to‐risk determination in this vulnerable population.

Effective Overall Glycaemic Control with Fast-Acting Insulin Aspart Across Patients with Different Baseline Characteristics: A Post Hoc Analysis of the Onset 9 Trial

AimsTo investigate the efficacy and safety of fast-acting insulin aspart (faster aspart) compared with insulin aspart (IAsp) in participants with type 2 diabetes (T2D) across different subgroups.MethodsWe report on a post hoc analysis of onset 9, a 16-week trial of participants with T2D randomised to faster aspart (n = 546) or IAsp (n = 545). Participants were grouped by baseline HbA1c (< 7.0%, ≥ 7.0%), meal test bolus insulin dose (≤ 10 units [U], > 10 U to ≤ 20 U, > 20 U), body mass index (< 30 kg/m2, ≥ 30 to < 35 kg/m2, ≥ 35 kg/m2), and age (< 65 years, ≥ 65 years). Outcomes assessed were change from baseline in HbA1c and in 1-h postprandial glucose (PPG) increment, and severe or blood glucose (BG)-confirmed hypoglycaemia.ResultsFaster aspart provided reductions in HbA1c comparable to IAsp across all subgroups, with improved 1-h PPG control compared with IAsp in several subgroups. Faster aspart had comparable or improved rates of severe or BG-confirmed hypoglycaemia versus IAsp, particularly in participants with good glycaemic control (HbA1c < 7.0%), the elderly (≥ 65 years old), and those with insulin resistance (> 20 U meal test bolus insulin dose).ConclusionsFaster aspart provides effective overall glycaemic control, with improved early PPG control compared with IAsp across a range of patient characteristics.Clinical Trial RegistrationNCT03268005.Supplementary InformationThe online version contains supplementary material available at 10.1007/s13300-022-01213-3.

5 versus 10 Units of Intravenous Insulin for Hyperkalemia in Patients With Moderate Renal Dysfunction.

A reduced dose of 5 units of intravenous (i.v.) insulin has been widely accepted for treatment of hyperkalemia in those with end-stage renal dysfunction. However, there remains a dearth of data for patients with moderate renal dysfunction (estimated glomerular filtration rate 15-59 mL/min/m2). Describe the incidence of hypoglycemia and relative change in serum potassium when using 5 vs. 10 units of insulin for hyperkalemia in patients with moderate renal dysfunction. This was a single-center, retrospective study evaluating adult patients with moderate renal dysfunction who received i.v. insulin for treatment of hyperkalemia. Patients were analyzed based on whether they received 5 or 10 units of i.v. insulin. The primary outcome was the rate of hypoglycemia in each group. Secondary outcomes included rate of relative potassium-lowering effect and incidence of severe hypoglycemia. Hypoglycemia occurred in 12 patients who received 5 units of i.v. insulin and 16 patients who received 10 units of i.v. insulin (6.5% vs. 8.4%, p=0.476). Serum potassium was significantly reduced when utilizing 10 units over 5 units of i.v. insulin (-0.9 mmol/L vs. -0.63 mmol/L, p=0.001). Severe hypoglycemia was seen in two encounters in both the 5-unit and 10-unit groups (1.1% vs. 1.0%, p=0.979). There was no difference in hypoglycemic events among patients with moderate renal dysfunction receiving 5 vs. 10 units of i.v. insulin for hyperkalemia. However, 10 units of i.v. insulin lowered serum potassium significantly more than 5 units of i.v. insulin.

Abstract 6: Maternal efficacy, safety, and pregnancy outcomes with degludec versus detemir in the treatment of pregnant women with type 1 diabetes: An international, multicentre, randomised trial

Background and Aims:To compare the efficacy and safety of insulin degludec (degludec) versus insulin detemir (detemir) in pregnant women with type 1 diabetes (T1D).Materials and Methods:EXPECT was an open-label, randomised trial of women aged ≥18 years with T1D and previously treated with insulin, who were at 8-13 weeks’ gestation or planned to become pregnant within 52 weeks. Women were randomised to degludec once daily or detemir 1- 2 times daily, both with insulin aspart 2-4 times daily. The primary analysis aimed to demonstrate the non-inferiority (margin of 0.4%) of degludec to detemir with respect to the last planned glycated haemoglobin (HbA1c) measurement prior to delivery (>16 weeks’ gestation) using ANCOVA. Secondary endpoints were maternal efficacy, safety, and pregnancy outcomes.Results:In total, 225 women (degludec: 111; detemir: 114) were randomised including 144 who were, and 81 who planned to become pregnant. Mean (±SD) HbA1c at treatment baseline was 6.8% (±0.7%) and 6.7% (±0.8%) with degludec and detemir, respectively. Over the trial, 188 women (degludec: 92; detemir: 96) with singleton pregnancies were included and there were 171 live-born infants (degludec: 86; detemir: 85), with no perinatal deaths (between ≥20 week's gestation and and <1 week after delivery). Estimated mean HbA1c prior to delivery was 6.23% with degludec and 6.34% with detemir (estimated treatment difference: −0.11% [−0.31; 0.08]95% CI, confirming non-inferiority). See Table for supportive maternal safety and pregnancy outcomes.TableSupportive maternal safely and pregnancy outcomes in women with type 1 diabetes randomised to degijdec or detemirDegludecDetemir n/N%EventsRalen/N%EventsRaleMaternal safer/ outcomosOverall hypoglycaemia89.’9197.8543111.84591/94968598213,401Nocturnal hypoglycaemia*71/9178.0712155369/9473.47591700Adjudicated severe hypoglycaemia‡6/916.68-3:943.24-Adverse events78/9185.742993676/9480.9328735Pre-edampsia12/8814.0--7/858.2--Pregnancy outcomesfctusevinfants with major abnormalities§8/928.7--8:968.3--Pre-teim delivery (<37 vreeks’ gestation)¶29/8633.7--19/85224--Infants born large for gestabonal age55/86840--4A8550.6--Infants with neonatal hypoglycaemia††20/8623.3--19/8522.4--Maternal safety outcomos were assessed over the pregnancy period and based on all randomised women who weie pregnant during the trial and received 21 dose of trial product. Additionally, tor pre-eciampsa. only women who delvered an infant at 220 weeks’ gestation were considered. Pregnancy outcomes were based on all randomised women who delivered an infant at ≤20 weeks’ gestation, except tor major abnormalities, where all randomised women who were pregnant during the trial were considered The analyses of maternal safety and pregnancy enidpoints were pre-specified to provide a descriptive summary only†Events occurhng between 00:01 and 05:59 (both inclusive): ‡events requiring third-party assistance; §UROCAT classified; ¶affer 20 weeks’ gestation: ††defined as blood glucose t .7 mmol/l (≤31 mg/dL) and assessed over the first 24 hours after birth.%. percentage of women with ≥ event: degludec. insulin degludec. detemir. insulin detemir; EUROCAT, European Concerted Action on Congenital Abnormalities and Twins; n, number of women with ≥1 event; N, total number of women In treatment group and analysis set: rate, rate of events per 100 years of exposure.Conclusion: In pregnant women with T1D, degludec was non-inferior to detemir with respect to HbA1c prior to delivery. Hypoglycaemia rates and pregnancy outcomes were comparable between insulins.

Continuous Glucose Monitor Use Prevents Glycemic Deterioration in Insulin-Treated Patients with Type 2 Diabetes.

Continuous glucose monitoring (CGM) is indicated in poorly controlled insulin-treated patients with type 2 diabetes (T2D) to improve glycemic control and reduce the risk of hypoglycemia, but the benefits of CGM for lower risk patients have not been well studied. Among 17,422 insulin-treated patients with T2D with hemoglobin A1c (HbA1c) <8% and no recent severe hypoglycemia (based on emergency room visits or hospitalizations), CGM initiation occurred in 149 patients (17,273 noninitiators served as reference). Changes in HbA1c and severe hypoglycemia rates for the 12 months before and after CGM initiation were calculated. CGM initiation was associated with decreased HbA1c (-0.06%), whereas noninitiation was associated with increased HbA1c (+0.32%); a weighted adjusted difference-in-difference model of change in HbA1c yielded a net benefit of -0.30%; 95% CI -0.50%, -0.10%; P = 0.004). No significant differences were observed for severe hypoglycemia. CGM may be useful in preventing glycemic deterioration in well-controlled patients with insulin-treated T2D.

Predicting Real-world Hypoglycemia Risk in American Adults With Type 1 or 2 Diabetes Mellitus Prescribed Insulin and/or Secretagogues: Protocol for a Prospective, 12-Wave Internet-Based Panel Survey With Email Support (the iNPHORM [Investigating Novel Predictions of Hypoglycemia Occurrence Using Real-world Models] Study)

BackgroundHypoglycemia prognostic models contingent on prospective, self-reported survey data offer a powerful avenue for determining real-world event susceptibility and interventional targets.ObjectiveThis protocol describes the design and implementation of the 1-year iNPHORM (Investigating Novel Predictions of Hypoglycemia Occurrence Using Real-world Models) study, which aims to measure real-world self-reported severe and nonsevere hypoglycemia incidence (daytime and nocturnal) in American adults with type 1 or 2 diabetes mellitus prescribed insulin and/or secretagogues, and develop and internally validate prognostic models for severe, nonsevere daytime, and nonsevere nocturnal hypoglycemia. As a secondary objective, iNPHORM aims to quantify the effects of different antihyperglycemics on hypoglycemia rates.MethodsiNPHORM is a prospective, 12-wave internet-based panel survey that was conducted across the United States. Americans (aged 18-90 years) with self-reported type 1 or 2 diabetes mellitus prescribed insulin and/or secretagogues were conveniently sampled via the web from a pre-existing, closed, probability-based internet panel (sample frame). A sample size of 521 baseline responders was calculated for this study. Prospective data on hypoglycemia and potential prognostic factors were self-assessed across 14 closed, fully automated questionnaires (screening, baseline, and 12 monthly follow-ups) that were piloted using semistructured interviews (n=3) before fielding; no face-to-face contact was required as part of the data collection. Participant responses will be analyzed using multivariable count regression and machine learning techniques to develop and internally validate prognostic models for 1-year severe and 30-day nonsevere daytime and nocturnal hypoglycemia. The causal effects of different antihyperglycemics on hypoglycemia rates will also be investigated.ResultsRecruitment and data collection occurred between February 2020 and March 2021 (ethics approval was obtained on December 17, 2019). A total of 1694 participants completed the baseline questionnaire, of whom 1206 (71.19%) were followed up for 12 months. Most follow-up waves (10,470/14,472, 72.35%) were completed, translating to a participation rate of 179% relative to our target sample size. Over 70.98% (856/1206) completed wave 12. Analyses of sample characteristics, quality metrics, and hypoglycemia incidence and prognostication are currently underway with published results anticipated by fall 2022.ConclusionsiNPHORM is the first hypoglycemia prognostic study in the United States to leverage prospective, longitudinal self-reports. The results will contribute to improved real-world hypoglycemia risk estimation and potentially safer, more effective clinical diabetes management.Trial RegistrationClinicalTrials.gov NCT04219514; https://clinicaltrials.gov/ct2/show/NCT04219514International Registered Report Identifier (IRRID)DERR1-10.2196/33726

Safety and Effectiveness of the Use of an Electronic Glucose Monitoring System Versus Weight-Based Dosing Nomogram for Treatment of Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar Syndrome in a VA Hospital.

The objective of this study is to assess the safety and effectiveness of an electronic glucose monitoring system (eGMS) versus paper-based protocols (PBPs) to manage diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar syndrome (HHS) within the VA setting. This study is a retrospective chart review of patients on an insulin drip, treated in the emergency department (ED) or intensive care unit (ICU) at Veteran Health Indiana for DKA or HHS. The primary outcome was evaluating the percentage of patients with hypoglycemia (blood glucose [BG] level <70 mg/dL) in patients admitted with DKA and HHS comparing an eGMS versus a PBP. A total of 168 patients were included in the analysis, with 84 patients in each group. The primary outcome comparing rates of hypoglycemia in the eGMS group versus the PBP group showed a lower rate of hypoglycemia in the eGMS group (0.024%) compared with the PBP group (0.060%); however, this difference was not found to be statistically significant (P = .90). Statistically significant secondary outcomes include the percentage of glucose checks drawn within the protocol recommendation (80.7% vs 52.6%, P = .02). While the primary endpoint of decreased hypoglycemia was not found to be statistically significant, it did reduce the overall number of hypoglycemia events in the eGMS group compared with the PBP group which may be clinically significant. This demonstrates that eGMS use has the potential to minimize hypoglycemia and glycemic variability in a critically-ill Veteran population by individualizing insulin drip titration based on a variety of patient-specific factors and providing reminders for staff to obtain BG checks in a timely manner.

The Benefits of Utilizing Continuous Glucose Monitoring of Diabetes Mellitus in Primary Care: A Systematic Review.

Continuous glucose monitoring (CGM) and intermittently scanned CGM (is-CGM) have shown to effectively manage diabetes in the specialty setting, but their efficacy in the primary care setting remains unknown. Does CGM/is-CGM improve glycemic control, decrease rates of hypoglycemia, and improve staff/physician satisfaction in primary care? If so, what subgroups of patients with diabetes are most likely to benefit? A comprehensive search in seven databases was performed in June 2021 for primary studies examining any continuous glucose monitoring system in primary care. We excluded studies with fewer than 20 participants, specialty care only, or hospitalized participants. The National Heart, Lung and Blood Institute and Grading of Recommendations Assessment, Development and Evaluation were used for the quality assessment. The weighted mean difference (WMD) of HbA1c between CGM/is-CGM and usual care with 95% confidence interval was calculated. A narrative synthesis was conducted for change of time in, above, or below range (TIR, TAR, and TBR) hypoglycemic events and staff/patient satisfaction. From ten studies and 4006 participants reviewed, CGM was more effective at reducing HbA1c compared with usual care (WMD -0.43%). There is low certainty of evidence that CGM/is-CGM improves TIR, TAR, or TBR over usual care. The CGM can reduce hypoglycemic events and staff/patient satisfaction is high. Patients with intensive insulin therapy may benefit more from CGM/is-CGM. Compared with usual care, CGM/is-CGM can reduce HbA1c, but most studies had notable biases, were short duration, unmasked, and were sponsored by industry. Further research needs to confirm the long-term benefits of CGM/is-CGM in primary care.

Development and validation of a machine learning model for classification of next glucose measurement in hospitalized patients.

SummaryBackgroundInpatient glucose management can be challenging due to evolving factors that influence a patient's blood glucose (BG) throughout hospital admission. The purpose of our study was to predict the category of a patient's next BG measurement based on electronic medical record (EMR) data.MethodsEMR data from 184,361 admissions containing 4,538,418 BG measurements from five hospitals in the Johns Hopkins Health System were collected from patients who were discharged between January 1, 2015 and May 31, 2019. Index BGs used for prediction included the 5th to penultimate BG measurements (N = 2,740,539). The outcome was category of next BG measurement: hypoglycemic (BG 70 mg/dl), controlled (BG 71–180 mg/dl), or hyperglycemic (BG > 180 mg/dl). A random forest algorithm that included a broad range of clinical covariates predicted the outcome and was validated internally and externally.FindingsIn our internal validation test set, 72·8%, 25·7%, and 1·5% of BG measurements occurring after the index BG were controlled, hyperglycemic, and hypoglycemic respectively. The sensitivity/specificity for prediction of controlled, hyperglycemic, and hypoglycemic were 0·77/0·81, 0·77/0·89, and 0·73/0·91, respectively. On external validation in four hospitals, the ranges of sensitivity/specificity for prediction of controlled, hyperglycemic, and hypoglycemic were 0·64–0·70/0·80–0·87, 0·75–0·80/0·82–0·84, and 0·76–0·78/0·87–0·90, respectively.InterpretationA machine learning algorithm using EMR data can accurately predict the category of a hospitalized patient's next BG measurement. Further studies should determine the effectiveness of integration of this model into the EMR in reducing rates of hypoglycemia and hyperglycemia.

Metabolic characteristics and adverse pregnancy outcomes for women with hyperglycaemia in pregnancy as a function of insulin resistance

Aim. Recent studies have shown that women with hyperglycaemia in pregnancy and insulin resistance have a greater risk of adverse pregnancy outcomes than women with normoglycaemic pregnancies. This study aimed to determine adverse pregnancy outcomes of women with hyperglycaemia in pregnancy only as a function of insulin resistance.Methods. From a prospective cohort study, we included 1,423 women with hyperglycaemia in pregnancy whose insulin resistance was evaluated using homoeostatic model assessment for insulin resistance (HOMA-IR) when care was first provided for this condition. We compared the adverse pregnancy outcomes for different tertiles of HOMA-IR (intertertile range 1.9 and 3.3).Results. Increasing HOMA-IR tertiles were positively associated with the rate of insulin therapy (tertile 1, 2 and 3: 32.7, 47.0 and 58.7%, P < 0.0001), caesarean section (23.7, 26.0 and 32.2%, respectively, P < 0.01), gestational hypertension (1.3, 2.8 and 5.4% respectively, P < 0.01), preeclampsia (1.5, 2.8 and 4.5% respectively, P < 0.05), large-for-gestational-age infant (13.3, 10.4 and 17.6% respectively, P < 0.05), and neonatal hypoglycaemia (0.8, 1.5 and 3.2% respectively, P < 0.05). Women in the 3rd HOMA-IR tertile were more likely to have insulin therapy (odds ratio 2.09 (95% interval confidence 1.61–2.71)), hypertensive disorders (2.26 (1.42–3.36)), and large-for-gestational-age infant (1.42 (1.01–1.99)) than those in the 1st and 2nd tertiles combined in multivariable logistic regression analyses adjusted for gestational age at HOMA-IR measurement, glycaemic status, age, body mass index, family history of diabetes, parity and ethnicity.Conclusion. Despite suitable care and increased rates of insulin therapy during pregnancy, higher insulin resistance in women with hyperglycaemia in pregnancy was associated with a greater risk of adverse pregnancy outcomes.

Monitoring Glucose Concentrations in Children with Epilepsy on a Ketogenic Diet.

Ketogenic diet (KD) and pulsatile dexamethasone therapy (PDT) are commonly used in the treatment of children with drug resistant epilepsy. Potential side effects of the KD are hypoglycemia, whereas PDT might lead to hyperglycemia. One practical option to measure glucose concentrations regularly is the flash glucose monitoring system (FGM). In this single-center study in Germany, two pediatric patients with epilepsy (age: 6.0 and 6.8 years) received FGM from the beginning of the KD over six months, in the year 2020, and one patient (9.8 years) was observed for one month on PDT and switched to the KD thereafter. Glucose concentrations were measured by using an FGM system and capillary blood measurement. Seizure frequency, changes in cognition, motor performance, social behavior, and sleep quality were evaluated. The mean hypoglycemia rate per day (65 mg/dL and lower) declined significantly in patient 1 and 2 after three months. Patient 3 showed in total seven hyperglycemic events during PDT. Patient 1 became seizure free. Improvement of attention and memory performance were reported. FGM during the KD as a treatment for drug resistant epilepsies in childhood is a practical option to explore and to avoid hypoglycemia during the KD and hyperglycemia during PDT.

Association of Area-Level Socioeconomic Deprivation With Hypoglycemic and Hyperglycemic Crises in US Adults With Diabetes

Social determinants of health play a role in diabetes management and outcomes, including potentially life-threatening complications of severe hypoglycemia and diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar state (HHS). Although several person-level socioeconomic factors have been associated with these complications, the implications of area-level socioeconomic deprivation are unknown. To examine the association between area-level deprivation and the risks of experiencing emergency department visits or hospitalizations for hypoglycemic and hyperglycemic crises (ie, DKA or HHS). This cohort study used deidentified administrative claims data for privately insured individuals and Medicare Advantage beneficiaries across the US. The analysis included adults with diabetes who met the claims criteria for diabetes between January 1, 2016, and December 31, 2017. Data analyses were performed from November 17, 2020, to November 11, 2021. Area deprivation index (ADI) was derived for each county for 2016 and 2017 using 17 county-level indicators from the American Community Survey. ADI values were applied to patients who were living in each county based on their index dates and were categorized according to county-level ADI quintile (with quintile 1 having the least deprivation and quintile 5 having the most deprivation). The numbers of emergency department visits or hospitalizations related to the primary diagnoses of hypoglycemia and DKA or HHS (ascertained using validated diagnosis codes in the first or primary position of emergency department or hospital claims) between 2016 and 2019 were calculated for each ADI quintile using negative binomial regression models and adjusted for patient age, sex, health plan type, comorbidities, glucose-lowering medication type, and percentage of White residents in the county. The study population included 1 116 361 individuals (563 943 women [50.5%]), with a mean (SD) age of 64.9 (13.2) years. Of these patients, 343 726 (30.8%) resided in counties with the least deprivation (quintile 1) and 121 810 (10.9%) lived in counties with the most deprivation (quintile 5). Adjusted rates of severe hypoglycemia increased from 13.54 (95% CI, 12.91-14.17) per 1000 person-years in quintile 1 counties to 19.13 (95% CI, 17.62-20.63) per 1000 person-years in quintile 5 counties, corresponding to an incidence rate ratio of 1.41 (95% CI, 1.29-1.54; P < .001). Adjusted rates of DKA or HHS increased from 7.49 (95% CI, 6.96-8.02) per 1000 person-years in quintile 1 counties to 8.37 (95% CI, 7.50-9.23) per 1000 person-years in quintile 5 counties, corresponding to an incidence rate ratio of 1.12 (95% CI, 1.00-1.25; P = .049). This study found that living in counties with a high area-level deprivation was associated with an increased risk of severe hypoglycemia and DKA or HHS. The concentration of these preventable events in areas of high deprivation signals the need for interventions that target the structural barriers to optimal diabetes management and health.

Expert consensus on standard clinical management of neonatal hypoglycemia in China (2021).

There are many high-risk factors for neonatal hypoglycemia, and persistent severe hypoglycemia can lead to irreversible neurological damage and bring a great burden to family and society. Early standardized prevention and clinical management can effectively reduce the incidence rate of neonatal hypoglycemia and brain injury induced by hypoglycemia; however at present, there is still a lack of unified clinical management guidelines for neonatal hypoglycemia in China, and different medical institutions follow different clinical guidelines developed by other countries for the management of neonatal hypoglycemia. In order to further standardize the clinical management of neonatal hypoglycemia, this consensus is developed by the Group of Neonatology, Pediatric Society, Chinese Medical Association. This consensus provides 21 recommendations to address related clinical issues in the prevention, monitoring, and management of hypoglycemia in neonates with a gestational age of ≥35 weeks.

Father newborn skin-to-skin wheelchair transfer from delivery room to neonatal care unit: Possible change in practices

ObjectiveTo evaluate the transfer of newborns from the delivery room to the neonatal care unit with their fathers on wheelchairs in terms of the safety of the procedure and paternal anxiety. MethodsA prospective observational single-center before-and-after pilot study was conducted from February to May 2018 at the University Maternity Hospital of Nantes. Safe transfer was judged on the basis of episodes of hypothermia or hypoglycemia. Paternal anxiety was assessed with the State–Trait Anxiety Inventory (STAI) scale after newborn transfer. ResultsOverall, 70 preterm newborns were enrolled, 44 were carried in wheelchairs in the father's arms (target group) and 26 were transferred in an incubator (control group). After adjusting for gestational age and birthweight, there were no statistically significantly differences between the target and the control group in the rates of hypothermia (43.9% vs 30.8%, p = 0,59) and hypoglycemia (9.52% vs 19.23%, p = 0,19). The STAI scale score was not significantly different between groups after incubator transfer or wheelchair transfer, at 35 ± 8.2 and 38 ± 10.2, respectively (p = 0.07). ConclusionTransferring a newborn to the neonatal care unit via wheelchair with the father is a safe alternative to incubator transfer.

Nocturnal Hypoglycemia Associated with Bedtime Administration of Premixed Insulin Preparations in Hospitalized Patients.

Patients with diabetes mellitus for whom premixed insulin preparations (PMIPs) are ordered in the hospital setting may be at risk of hypoglycemia if the PMIP is incorrectly administered at bedtime (instead of suppertime). The primary objective was to determine, retrospectively, the incidence of bedtime administration of PMIPs at a tertiary teaching hospital. The secondary objective was to investigate whether bedtime administration of PMIPs led to an increase in nocturnal hypoglycemia. Inpatient PMIP orders for the period April 1, 2013, to March 31, 2017, were extracted from the pharmacy information system of the Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia. Two hundred randomly selected inpatient admissions were audited, and instances of PMIP administration after 2000 (8 pm) were recorded. Data from an additional random sample of inpatient admissions, from January 1, 2016, to December 31, 2017, were reviewed to determine whether bedtime administration of PMIPs was associated with increased incidence of nocturnal hypoglycemia, relative to suppertime administration. In the randomly selected sample of 200 inpatient admissions, a PMIP was administered at bedtime at least once during 47 admissions (24%). In the additional sample of 123 inpatient admissions during which a PMIP had been administered, the mean nocturnal hypoglycemia rate was 4.15% for suppertime administration and 14.85% for bedtime administration (p = 0.13). For a substantial proportion of patients, PMIPs were inappropriately ordered and administered at bedtime in this hospital setting and may have been associated with nocturnal hypoglycemic events. Recommendations to reduce this practice include ongoing education and a review of preprinted order sets.

Characteristics of severely malnourished under-five children immunized with Bacillus Calmette-Guérin following Expanded Programme on Immunization schedule and their outcomes during hospitalization at an urban diarrheal treatment centre, Bangladesh.

BackgroundBacillus Calmette-Guérin (BCG) vaccination has recently been found to have beneficial effects among children infected other than Mycobacterium tuberculosis. Due to the paucity of data on the outcomes of children who had successful BCG vaccination following Expanded Programme on Immunization (EPI) schedule, we aimed to investigate the characteristics of such children and their outcomes who were hospitalized for severe malnutrition.MethodsA prospective observational study was conducted to determine the viral etiology of pneumonia in severely malnourished children those were admitted to the Dhaka Hospital of International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) between April 2015 and December 2017, constituted the study population. Using a case-control design for the analysis, children having BCG vaccination prior hospital admission were treated as cases (n = 611) and those without vaccination, constituted as controls (n = 83). Bi-variate analysis was conducted using socio-demographic, clinical, laboratory, and treatment characteristics on admission and outcomes during hospitalization. Finally, log-linear binomial regression analysis was done to identify independent impact of BCG vaccination.ResultsThe cases more often presented with older age, have had lower proportion of maternal illiteracy, higher rate of breastfeeding, severe wasting and lower rate of hypoglycemia, compared to the controls. The cases were also found to have lower risk of severe sepsis and deaths, compared to the controls (for all, p<0.05). However, in log-linear binomial regression analysis, after adjusting for potential confounders, BCG vaccination following EPI schedule (RR:0.54; 95%CI = 0.33–0.89; p = 0.015) and breastfeeding (RR:0.53; 95%CI = 0.35–0.81; p = 0.003) were found to be protective for the development of severe sepsis.ConclusionBCG vaccination and breastfeeding were found to be protective for the development of severe sepsis in hospitalized severely malnourished under-five children which underscores the importance of continuation of BCG vaccination at birth and breastfeeding up to two years of age.