Single Blood Glucose Research Articles

Velagliflozin, a once-daily, liquid, oral SGLT2 inhibitor, is effective as a stand-alone therapy for feline diabetes mellitus: the SENSATION study.

To investigate safety and effectiveness of velagliflozin oral solution as sole therapy in naïve and previously insulin-treated diabetic cats. 252 client-owned cats receiving ≥ 2 doses of velagliflozin; 214 (85%) naïve diabetics and 38 (15%) insulin-treated diabetics. Prospective, baseline-controlled, open-label clinical field trial. Cats received velagliflozin orally, once daily. Physical examinations and blood collections were performed days 0, 3, 7, 30, 60, 120, and 180. Data are median (range). Screening blood glucose (BG) was 436 mg/dL (272 to 676 mg/dL). On days 30, 60, 120, and 180, single BG after receiving velagliflozin was 153 mg/dL (62 to 480 mg/dL), 134 mg/dL (64 to 414 mg/dL), 128 mg/dL (55 to 461 mg/dL), and 125 mg/dL (77 to 384 mg/dL), respectively. Screening fructosamine was 538 µmol/L (375 to 794 µmol/L). On the same recheck days, fructosamine was 310 µmol/L (204 to 609 µmol/L), 286 µmol/L (175 to 531 µmol/L), 269 µmol/L (189 to 575 µmol/L), and 263 µmol/L (203 to 620 µmol/L). At day 180, 81% of 158 cats remaining had BG and/or fructosamine within reference ranges; 88.6% (124 of 140) and 87.7% (121 of 138) showed improvement in polyuria and polydipsia, respectively. Ketonuria developed in 35 cats (13.9%), including 18 (7.1%) that had ketoacidosis. Ketoacidosis was less common in naïve diabetic cats (11 of 214 [5.1%]) compared to insulin-treated diabetic cats (7 of 38 [18.4%]). At ketoacidosis diagnosis, 14 of 18 cats (77.8%) were euglycemic (ie, BG < 250 mg/dL). Most episodes of ketosis or ketoacidosis (30 of 35 [85.7%]) occurred within the first 14 days of treatment. Insulin-treated diabetic cats were less likely to complete the trial. No clinical hypoglycemia occurred. Velagliflozin improved glycemic parameters and clinical signs in diabetic cats. Velagliflozin provides an alternative to insulin as a stand-alone treatment of diabetic cats.

Glucose-Responsive Injectable Thermogels via Dynamic-Covalent Cross-Linking of Pluronic Micelles.

Stimuli-responsive hydrogels are an area of active discovery for approaches to deliver therapeutics in response to disease-specific indicators. Glucose-responsive delivery of insulin is of particular interest in better managing diabetes. Accordingly, hydrogels have been explored as platforms that enable both a rate and dose of insulin release aligning with the real-time physiological disease state; materials often include glucose sensing by dynamic-covalent cross-linking between phenylboronic acids (PBAs) and diols, with competition from ambient glucose reducing cross-link density of the material and accelerating release of encapsulated insulin. Yet, these materials historically have challenges with insulin leakage, offer limited glucose-responsive release of the insulin payload, and require unreasonably high injection pressures for syringe administration. Here, a thermogel platform prepared from temperature-induced micelles formed into a network by PBA-Diol cross-linking is optimized using a formulation-centered approach to maximize glucose-responsive insulin delivery. Importantly, the dual-responsive nature of this platform enables a low-viscosity sol at ambient temperature for facile injection, solidifying into a stable viscoelastic hydrogel network once in the body. The final optimized formulation affords acceleration in insulin release in response to glucose and enables single dose blood glucose control in diabetic rodents when subjected to multiple glucose challenges.

On The Analysis of Blood Glucose Levels of Diabetic Patients

Paired observation tests (Paired t-test, Wilcoxon signed ranked test and Sign test) were employed to determine if there is any significant difference between fasting blood sugar and oral glucose tolerance tests of 47 diabetic patients. First, Jarque-Bera (JB) test was done to check for normality and it showed that not all the mean differences were normally distributed. Two sample t-test was used to check whether the level of change in blood glucose for fasting patients and patients who had glucose intake are the same. The fasting blood sugar test and oral glucose tolerance test were done hourly on two different occasions. The results revealed no difference between blood glucose testing on arrival and blood glucose testing after resting for one hour. The level of change in blood glucose after two hours for fasting patients was not the same with the level of change two hours after glucose administration. It was concluded that a single fasting blood glucose test is sufficient to diagnose diabetes on a visit to the laboratory while oral glucose tolerance test conducted hourly is necessary to monitor the blood to know when the glucose level is going high or low.

Association between country preparedness indicators and quality clinical care for cardiovascular disease risk factors in 44 lower- and middle-income countries: A multicountry analysis of survey data.

Cardiovascular diseases are leading causes of death, globally, and health systems that deliver quality clinical care are needed to manage an increasing number of people with risk factors for these diseases. Indicators of preparedness of countries to manage cardiovascular disease risk factors (CVDRFs) are regularly collected by ministries of health and global health agencies. We aimed to assess whether these indicators are associated with patient receipt of quality clinical care. We did a secondary analysis of cross-sectional, nationally representative, individual-patient data from 187,552 people with hypertension (mean age 48.1 years, 53.5% female) living in 43 low- and middle-income countries (LMICs) and 40,795 people with diabetes (mean age 52.2 years, 57.7% female) living in 28 LMICs on progress through cascades of care (condition diagnosed, treated, or controlled) for diabetes or hypertension, to indicate outcomes of provision of quality clinical care. Data were extracted from national-level World Health Organization (WHO) Stepwise Approach to Surveillance (STEPS), or other similar household surveys, conducted between July 2005 and November 2016. We used mixed-effects logistic regression to estimate associations between each quality clinical care outcome and indicators of country development (gross domestic product [GDP] per capita or Human Development Index [HDI]); national capacity for the prevention and control of noncommunicable diseases ('NCD readiness indicators' from surveys done by WHO); health system finance (domestic government expenditure on health [as percentage of GDP], private, and out-of-pocket expenditure on health [both as percentage of current]); and health service readiness (number of physicians, nurses, or hospital beds per 1,000 people) and performance (neonatal mortality rate). All models were adjusted for individual-level predictors including age, sex, and education. In an exploratory analysis, we tested whether national-level data on facility preparedness for diabetes were positively associated with outcomes. Associations were inconsistent between indicators and quality clinical care outcomes. For hypertension, GDP and HDI were both positively associated with each outcome. Of the 33 relationships tested between NCD readiness indicators and outcomes, only two showed a significant positive association: presence of guidelines with being diagnosed (odds ratio [OR], 1.86 [95% CI 1.08-3.21], p = 0.03) and availability of funding with being controlled (OR, 2.26 [95% CI 1.09-4.69], p = 0.03). Hospital beds (OR, 1.14 [95% CI 1.02-1.27], p = 0.02), nurses/midwives (OR, 1.24 [95% CI 1.06-1.44], p = 0.006), and physicians (OR, 1.21 [95% CI 1.11-1.32], p < 0.001) per 1,000 people were positively associated with being diagnosed and, similarly, with being treated; and the number of physicians was additionally associated with being controlled (OR, 1.12 [95% CI 1.01-1.23], p = 0.03). For diabetes, no positive associations were seen between NCD readiness indicators and outcomes. There was no association between country development, health service finance, or health service performance and readiness indicators and any outcome, apart from GDP (OR, 1.70 [95% CI 1.12-2.59], p = 0.01), HDI (OR, 1.21 [95% CI 1.01-1.44], p = 0.04), and number of physicians per 1,000 people (OR, 1.28 [95% CI 1.09-1.51], p = 0.003), which were associated with being diagnosed. Six countries had data on cascades of care and nationwide-level data on facility preparedness. Of the 27 associations tested between facility preparedness indicators and outcomes, the only association that was significant was having metformin available, which was positively associated with treatment (OR, 1.35 [95% CI 1.01-1.81], p = 0.04). The main limitation was use of blood pressure measurement on a single occasion to diagnose hypertension and a single blood glucose measurement to diagnose diabetes. In this study, we observed that indicators of country preparedness to deal with CVDRFs are poor proxies for quality clinical care received by patients for hypertension and diabetes. The major implication is that assessments of countries' preparedness to manage CVDRFs should not rely on proxies; rather, it should involve direct assessment of quality clinical care.

Increased Incidence of New-Onset Diabetes Mellitus Type II Following Haploidentical Bone Marrow Transplant with Post-Transplant Cyclophosphamide for Sickle Cell Disease

Introduction: Haploidentical bone marrow transplant (haplo-BMT) with post-transplant cyclophosphamide (PTCy) provides near universal donor availability and curative potential for individuals with severe sickle cell disease (SCD). However, a recently recognized late-effect following allogeneic hematopoietic cell transplant is new-onset post-transplant diabetes mellitus type II (PTDM), which occurs in up to 50% of patients and is associated with a three-fold increase in mortality (Griffith et al BBMT 2011, Engelhardt et al BBMT 2019). Known risk factors for PTDM include older age, total body irradiation, and non-Caucasian ethnicity. Studies have shown that pre-transplant insulin resistance and enhanced immune cell alloreactivity are other important contributing factors (Engelhardt et al Blood 2011). To our knowledge, the incidence of PTDM following haplo-BMT with PTCy for SCD has not been characterized, in a population which is predominantly African-American, with a crude prevalence of diabetes mellitus type II of 16.4 (14.7-18.2), and thus represents an unmet need. We hypothesized that the ethnicity and chronic inflammatory state that exists in individuals with SCD contributes to an increased risk of PTDM and may be associated with worse transplant-related outcomes. Methods: We analyzed a multi-center cohort of 33 patients with SCD who underwent haplo-BMT with PTCy. All patients received the reduced-intensity conditioning as shown in Figure 1. Ten patients (31%) had preconditioning with hydroxyurea, azathioprine and hyper-transfusion. Patients with existing diabetes mellitus or follow-up time less than one year were excluded. PTDM was defined as any random single blood glucose level of &amp;gt; 200 mg/dL between D0 and D+100 of transplant. Baseline patient and transplant-related variables were analyzed. Immune subsets were analyzed by flow cytometry at one, two, three, six, and twelve months post-haplo-BMT. Results: The median age at transplant was 11.5 years. Median at age last follow up was 16 years. Baseline and transplant-related data are summarized in Table 1. No patients experienced primary graft failure, while three patients had secondary graft failure at a median of 87 days (range 60-604 days) following haplo-BMT (Table 1). Donor chimerism at 6 months and 1 year was &amp;gt;95% for myeloid and lymphoid lineages for all patients. Fourteen patients (44%) developed PTDM at a median time of 18 days (range 3-40 days), though only three (21%) were treated with corticosteroids prior to the development of PTDM (Table 1). In the PTDM cohort, the median time to corticosteroid use was 22 days. Sixteen patients required corticosteroids for any indication (13 PTDM, 3 non-PTDM), with a median time of administration of 32 days. The starting dose in prednisone equivalents in both groups was 1 mg/kg. All four deaths occurred in the PTDM cohort. The cumulative incidence of grade II-IV acute GVHD was 6/33 (18%). One patient (3%) developed grade IV acute GvHD of the skin and gut, while moderate-severe chronic GvHD developed in six patients (18%). The median time to acute GvHD was 36 days for the entire cohort (36 days for PTDM group, 37.5 days for non-PTDM group). Quantitative reconstitution of CD8 T-cells was significantly lower at one and two months post-haplo-BMT for PTDM compared to non-PTDM patients. CD4 subsets tended to be lower in the PTDM cohort. No significant difference was seen for CD56 cellular subsets at any time period. Conclusion: PTDM is a frequent occurrence following haplo-BMT for SCD and developed prior to corticosteroid exposure. Early T-cell reconstitution may impact glucose homeostasis. Prospective studies with longer follow up are needed to determine the clinical implications in transplant survivors following allogeneic hematopoietic cell transplant for SCD. Disclosures Dholaria: bms: Research Funding; Poseida: Research Funding; Angiocrine: Research Funding; Takeda: Research Funding; J&amp;J: Research Funding.

Fifteen-minute Frequency of Glucose Measurements and the Use of Threshold Alarms: Impact on Mitigating Dysglycemia in Critically Ill Patients.

The use of near-continuous blood glucose (BG) monitoring has the potential to improve glycemic control in critically ill patients. The MANAGE IDE trial evaluated the performance of the OptiScanner (OS) 5000 in a multicenter cohort of 200 critically ill patients. An Independent Group reviewed the BG run charts of all 200 patients and voted whether unblinded use of the OS, with alarms set at 90 and 130 to 150 mg/dL to alert the clinical team to impending hypoglycemia and hyperglycemia, respectively, would have eliminated episodes of dysglycemia: hypoglycemia, defined as a single BG <70 mg/dL; hyperglycemia, defined as >4 hours of BG >150 mg/dL; severe hyperglycemia, defined as >4 hours of BG >200 mg/dL and increased glucose variability (GV), defined as coefficient of variation (CV) >20%. At least one episode of dysglycemia occurred in 103 (51.5%) of the patients, including 6 (3.0%) with hypoglycemia, 83 (41.5%) with hyperglycemia, 18 (9.0%) with severe hyperglycemia, and 40 (20.0%) with increased GV. Unblinded use of the OS with appropriate alarms would likely have averted 97.1% of the episodes of dysglycemia: hypoglycemia (100.0%), hyperglycemia (96.4%), severe hyperglycemia (100.0%), and increased GV (97.5%). Point accuracy of the OS was very similar to that of the point of care BG monitoring devices used in the trial. Unblinded use of the OS would have eliminated nearly every episode of dysglycemia in this cohort of critically ill patients, thereby markedly improving the quality and safety of glucose control.

Association between exposure to arsenic, nickel, cadmium, selenium, and zinc and fasting blood glucose levels

Associations between single metal and fasting blood glucose (FBG) levels have been reported in previous studies. However, the association between multi-metals exposure and FBG level are little known. To assess the joints of arsenic (As), nickel (Ni), cadmium (Cd), selenium (Se), and zinc (Zn) co-exposure on FBG levels, Bayesian kernel machine regression (BKMR) statistical method was used to estimate the potential joint associations between As, Ni, Cd, Se, and Zn co-exposure and FBG levels among 1478 community-based Chinese adults from two counties, Shimen (n = 696) and Huayuan (n = 782), with different exposure profiles in Hunan province of China. The metals levels were measured in spot urine (As, Ni, and Cd) and plasma (Se and Zn) using inductively coupled plasma-mass spectrometry, respectively. The exposure levels of all the five metals were significantly higher in Shimen area (median: As = 57.76 μg/L, Cd = 2.75 μg/L, Ni = 2.73 μg/L, Se = 112.67 μg/L, Zn = 905.68 μg/L) than those in Huayuan area (As = 41.14 μg/L, Cd = 2.22 μg/L, Ni = 1.88 μg/L, Se = 65.59 μg/L, Zn = 819.18 μg/L). The BKMR analyses showed a significantly positive over-all effect of the five metals on FBG levels when metals concentrations were all above the 50th percentile while a statistically negative over-all effect when metals concentrations were all under the 50th percentile in Shimen area. However, a totally opposite over-all effect of the mixture of the five metals on FBG levels was found in Huayuan area. BKMR also revealed a non-linear exposure-effect of Zn on FBG levels in Huayuan area. In addition, interaction effects of As and Se on FBG level were observed. The relationship between single or combined metals exposure and FBG was different against different exposure profiles. Potential interaction effects of As and Se on FBG levels may exist.

Pilot study evaluating the monitoring of canine diabetes mellitus in primary care practice

ObjectivesThis study aimed to describe how canine diabetes mellitus (CDM) is monitored in primary care practice (PCP) and to report outcomes.DesignRetrospective case review.SettingPCP.Participants40 dogs of 22 different pedigrees and five...

Continuous Blood Glucose Monitoring Reveals Enormous Circadian Variations in Pregnant Diabetic Rats.

Diabetes in pregnancy is a major burden with acute and long-term consequences. Its treatment requires adequate diagnosis and monitoring of therapy. Many experimental research on diabetes during pregnancy has been performed in rats. Recently, continuous blood glucose monitoring of non-pregnant diabetic rats revealed an increased circadian variability of blood glucose that made a single blood glucose measurement per day inappropriate to reflect glycemic status. Continuous blood glucose measurement has never been performed in pregnant rats. We wanted to perform continuous blood glucose monitoring in pregnant rats to decipher the influence of pregnancy on blood glucose in diabetic and normoglycemic status. We used the transgenic Tet29 diabetes rat model with an inducible knock down of the insulin receptor via RNA interference upon application of doxycycline (DOX) leading to insulin resistant type II diabetes. All Tet29 rats received a HD-XG telemetry implant (Data Sciences International, USA) that measured blood glucose and activity continuously. Rats were divided into four groups and blood glucose was monitored until end of pregnancy or the corresponding period: Tet29 + DOX (diabetic) non-pregnant, Tet29 + DOX (diabetic) pregnant, Tet29 (normoglycemic) non-pregnant, Tet29 (normoglycemic) pregnant. All analyzed rats displayed a circadian variation in blood glucose concentration. Circadian variability was much more pronounced in pregnant diabetic rats than in normoglycemic pregnant rats. Pregnancy ameliorated variation in blood glucose in diabetic situation. Pregnancy continuously decreased blood glucose during normoglycemic pregnancy. Diabetic rats were less active than normoglycemic rats. We performed a calculation showing that application of continuous blood glucose measurement reduces animal numbers needed to detect a given effect in experimental setting by decreasing variability and SD. Continuous blood glucose monitoring via a telemetry device in pregnant rats provides a more informative picture of the glycemic situation in comparison to single measurements. This could improve diagnosis and therapy of diabetes, decrease animal numbers within experimental settings, and add another physiological parameter (activity) to the analysis that could be helpful in testing therapeutic concepts targeting blood glucose levels and peripheral muscle function. We propose continuous glucose monitoring as a new tool for the evaluation of pregnant diabetic rats.

The Effect of Elevated A1C on Immediate Postoperative Complications: A Prospective Observational Study.

IN BRIEF This study examined whether elevated A1C in patients with diabetes is associated with a higher incidence of postoperative infections and other complications. Researchers followed 50 noncardiac surgical patients for 7 postoperative days. Half of the patients had an A1C <7% and the other half had an A1C ≥7%. The two groups were otherwise comparable except that the higher-A1C group had significantly higher pre-induction and postoperative blood glucose levels, with wider variability in the first 24 hours after surgery. During the first postoperative week, 11 patients developed complications, of whom 10 were in the higher-A1C group. Elevated A1C, unlike a single preoperative blood glucose value, may predict difficult postoperative glucose control and postsurgical complications.

Abstract WP17: Association of Blood Glucose and Clinical Outcome After Mechanical Thrombectomy for Acute Ischemic Stroke

Background: Elevated blood glucose (BG) levels at admission following acute ischemic stroke (AIS) have been associated with adverse clinical outcomes in thrombolytic and non-thrombolytic treated patients. This association has been inconsistent and has not been studied after mechanical thrombectomy (MT). The current study looks at multiple BG parameters and their association with outcome following MT in AIS. Methods: AIS patients undergoing MT with a retrievable stent between 2012 and 2016 at two stroke centers were studied. Favorable clinical outcome was defined as having a modified Rankin Scale score (mRS) of 0-2 at three months. Admission BG, maximum BG during the hospital stay, and serial measurements every 4-6 hours in the first 24 hours were recorded. The following demographic and clinical data was also collected: age, sex, baseline NIHSS score, onset-to-reperfusion times, HgA1c, and stroke mechanism. Results: Seventy-nine patients were identified (mean age 69, 49% male, SEM= 1.56); thirty-three patients had a favorable clinical outcome at three months and 46 had unfavorable outcomes. In univariate analysis, BG variability (standard deviation of BG, SD) in the first 24 hours following admission and maximum BG during hospital stay was associated with unfavorable outcomes (Table 1). The association between admission BG and favorable outcome was not statistically significant. In multivariate logistic regression analysis the SD of BG (OR= 1.08, 95% CI= 1.02-1.13, P= .005) had the highest predictive value for favorable outcome. Conclusions: Greater BG variability is associated with worse clinical outcome in patients with AIS undergoing MT. Using SD and/or serial measurements of BG appear better than single BG measurements at predicting clinical outcome in this population.

English

This study aimed to assess HbA1c performance against single fasting blood glucose (FBG) for diagnosis of undiagnosed type 2 diabetes (T2D) and impaired fasting glycaemia (IFG) among general medical outpatients in Botswana. Participants aged, &ge;20 years were cross-sectionally surveyed from August to October, 2014. All the participants underwent testing for HbA1c and FBG. The HbA1c sensitivity, specificity and predictive values in the diagnosis of T2D and IFG were computed and their Pearson&rsquo;s correlation and scatter diagrams determined. A total of 291 participants (74.2% women) with a mean age of 50.1&plusmn;11.0 years provided data for the current analysis. HbA1c at cut-off of &ge; 6.5% (48 mmol/mol) had a sensitivity and specificity for T2D of 100 (15.81 to 100.00) and 86.3% (86.16 to 89.92), respectively. Similarly, for IFG, the sensitivity and specificity was 100 (2.5 to 100) and 36.3% (30.3 to 42.6), respectively. The positive predictive value (PPV) was 4.8 (0.58 to 16.16) and 0.6% (0.02 to 3.45) for T2D and IFG screening, respectively. The negative predictive value (NPV) was 100% in both cases of T2D and IFG screening. HbA1c had a modest, positive correlation (r) with FBG for the overall population (r = 0.536, p &lt; 0.001); for women, (r = 0 .578, p &lt; 0.001) and men (r =0 .336, p =0.003). HbA1c had high sensitivity but widely varying specificity, high proportion of discordant results and poor prediction of T2D and IFG in this setting. Although, HbA1c correlation with fasting glucose was modest, both tests are required to improve diagnostic reliability in asymptomatic T2D screening program. Key words: Diabetes screening, HbA1c test, Botswana.

Complications During Ketogenic Diet Initiation: Prevalence, Treatment, and Influence on Seizure Outcomes

BackgroundMany centers still admit children for several days to start the ketogenic diet. The exact incidence of adverse effects during the admission and their potential later impact on seizure reduction has not been widely studied. MethodsWe performed a retrospective study of children with intractable epilepsy electively admitted for ketogenic diet initiation at our institution from 2011 to 2016. Charts were reviewed for adverse effects during the admission period and then examined for seizure reduction and compliance at three months. A rating scale (1 to 4) was created for severity of any adverse events. ResultsA total of 158 children were included, with the mean age 4.6 years. Potentially attributable adverse effects occurred in 126 (80%) children, most commonly emesis, food refusal, and hypoglycemia. Seventy-three (46%) children received some form of intervention by the medical team, most commonly the administration of juice (24%). Younger age was correlated with an increased likelihood of moderate to severe adverse effects during admission, often repeated hypoglycemia (3.6 versus 4.9 years, P = 0.04). Fasting was more likely to result in lethargy and a single blood glucose in the 30 to 40 mg/dL range, but it was not correlated with emesis, repeated hypoglycemia, or higher adverse effect scores. There was no statistically significant correlation between the severity of adverse effects and the three-month seizure reduction. ConclusionsMild easily treated adverse effects occurred in most children admitted for the ketogenic diet. Younger children were at greater risk for significant difficulties and should be monitored closely. Because fasting led to more lethargy and hypoglycemia, it may be prudent to avoid this in younger children.

Single, community-based blood glucose readings may be a viable alternative for community surveillance of HbA1c and poor glycaemic control in people with known diabetes in resource-poor settings

BackgroundThe term HbA1c (glycated haemoglobin) is commonly used in relation to diabetes mellitus. The measure gives an indication of the average blood sugar levels over a period of weeks or months prior to testing. For most low- and middle-income countries HbA1c measurement in community surveillance is prohibitively expensive. A question arises about the possibility of using a single blood glucose measure for estimating HbA1c and therefore identifying poor glycaemic control in resource-poor settings.DesignUsing data from the 2011–2012 US National Health and Nutrition Examination Surveys, we examined the relationship between HbA1c and a single fasting measure of blood glucose in a non-clinical population of people with known diabetes (n=333). A linear equation for estimating HbA1c from blood glucose was developed. Appropriate blood glucose cut-off values were set for poor glycaemic control (HbA1c≥69.4 mmol/mol).ResultsThe HbA1c and blood glucose measures were well correlated (r=0.7). Three blood glucose cut-off values were considered for classifying poor glycaemic control: 8.0, 8.9, and 11.4 mmol/L. A blood glucose of 11.4 had a specificity of 1, but poor sensitivity (0.37); 8.9 had high specificity (0.94) and moderate sensitivity (0.7); 8.0 was associated with good specificity (0.81) and sensitivity (0.75).ConclusionsWhere HbA1c measurement is too expensive for community surveillance, a single blood glucose measure may be a reasonable alternative. Generalising the specific results from these US data to low resource settings may not be appropriate, but the general approach is worthy of further investigation.

Minimization of Hypoglycemia as an Adverse Event During Insulin Infusion: Further Refinement of the Yale Protocol

Background: The management of hyperglycemia in the intensive care unit has been a controversial topic for more than a decade, with target ranges varying from 80–110 mg/dL to <200 mg/dL. Multiple insulin infusion protocols exist, including several computerized protocols, which have attempted to achieve these targets. Importantly, compliance with these protocols has not been a focus of clinical studies.Methods: GlucoCare™, a Food and Drug Administration (FDA)-cleared insulin-dosing calculator, was originally designed based on the Yale Insulin Infusion Protocol to target 100–140 mg/dL and has undergone several modifications to reduce hypoglycemia. The original Yale protocol was modified from 100–140 mg/dL to a range of 120–140 mg/dL (GlucoCare 120–140) and then to 140 mg/dL (GlucoCare 140, not a range but a single blood glucose [BG] level target) in an iterative and evidence-based manner to eliminate hypoglycemia <70 mg/dL. The final modification [GlucoCare 140(B)] includes the addition of bolus insulin “midprotocol” during an insulin infusion to reduce peak insulin rates for insulin-resistant patients. This study examined the results of these protocol modifications and evaluated the role of compliance with the protocol in the incidence of hypoglycemia <70 mg/dL.Results: Protocol modifications resulted in mean BG levels of 133.4, 136.4, 143.8, and 146.4 mg/dL and hypoglycemic BG readings <70 mg/dL of 0.998%, 0.367%, 0.256%, and 0.04% for the 100–140, 120–140, 140, and 140(B) protocols, respectively (P < 0.001). Adherence to the glucose check interval significantly reduced the incidence of hypoglycemia (P < 0.001). Protocol modifications led to a reduction in peak insulin infusion rates (P < 0.001) and the need for dextrose-containing boluses (P < 0.001).Conclusion: This study demonstrates that refinements in protocol design can improve glucose control in critically ill patients and that the use of GlucoCare 140(B) can eliminate all significant hypoglycemia while achieving mean glucose levels between 140 and 150 mg/dL. In addition, attention to the timely performance of glucose levels can also reduce hypoglycemic events.

Investigating the effects of treatment based on single high blood glucose in gestational diabetes screening on maternal and neonatal complications.

To create a positive step toward achieving an efficient method for gestational diabetes treatment, the present study was carried out to compare the treatment outcomes based on single impaired blood glucose versus regular method in health care centers in Iran. This randomized clinical trial was carried out in Tehran/Iran between March 2012 and August 2013. Study sample consisted of mothers whose fasting blood sugar was disturbed or a disturbed blood sugar was seen in OGTT with 75 g glucose load, according to ADA standards. For each outcome, multiple logistic regressions were used to control for the effects of potential confounders. When a confounder was measured on a continuous scale (e.g., age), LOWESS (locally weighted scatter plot smoothing) algorithm was used to determine whether the effect of that variable was linear. We also used the fractional polynomial regression to determine the optimal transformation of continuous covariates. The information of 189 pregnant women was used in this study; 87 in the interventional group (46 %) and 102 in the control group (54 %). Treatment based on the new protocol has very high protective effect (OR 0.25, 95 % CI 0.68-0.88) in terms of neonatal hyperbilirubinemia. This difference was not seen in other outcomes including stillbirth, macrosomic newborn delivery, hypoglycemia, and hypocalcemia. The risk of neonatal hypoglycemia reduced after the 25th week of gestation (OR 0.39, 95 % CI 0.15-0.98). Although the treatment of mild gestational diabetes could not significantly decrease severe neonatal outcomes, it did significantly reduce the risk of hyperbilirubinemia and its subsequent complications.

Prevalence of dysglycemia and association with outcomes in pediatric extracorporeal membrane oxygenation.

To evaluate the relationship between glucose derangement, insulin administration, and mortality among children on extracorporeal membrane oxygenation. Retrospective cohort. Tertiary PICU. Two hundred nine children receiving extracorporeal membrane oxygenation, including 97 neonates. None. Hyperglycemia and severe hyperglycemia were defined as a single blood glucose level greater than 15 mmol/L (270 mg/dL) and greater than 20 mmol/L (360 mg/dL), respectively. Hypoglycemia and severe hypoglycemia were defined as any single glucose level less than 3.3 mmol/L (60 mg/dL) and less than 2.2 mmol/L (40 mg/dL), respectively. A total of 15,912 glucose values were recorded. The median number of glucose values was 59 per patient, corresponding to a mean 0.53 ± 0.12 tests per hour. Sixty-nine patients (33.0%) without dysglycemia and who received no insulin were defined as the control group. Eighty-nine (42.6%) and 26 (12.4%) patients developed hyperglycemia and severe hyperglycemia, respectively. Sixty-three (30.1%) and 17 (8.1%) patients developed hypoglycemia and severe hypoglycemia, respectively. Sixty-one patients (29.2%) received IV insulin during extracorporeal membrane oxygenation. Both hyperglycemia and hypoglycemia were associated with increased mortality on extracorporeal membrane oxygenation (46% and 48%, respectively, vs 29% of controls; p = 0.03). However, after adjusting for severity of illness and extracorporeal membrane oxygenation complications, abnormal glucose levels were not independently related to mortality. Dysglycemia in children on extracorporeal membrane oxygenation was common but not independently associated with increased mortality. The optimal glucose range for this high-risk population requires further investigation.

Anti-Diabetic Assessment of the Hydro-Alcoholic Leaf Extracts of the Plant Tetrastigma angustifolia (Roxb.)a traditionally used North-Eastern Indian vegetable

Diabetes mellitus (DM) is a metabolic disorder characterized by chronic hyperglycaemia generally associated with oxidative stress. The present study aims to evaluate the hypoglycaemic activity of hydro-ethanolic (3:7) leaf extracts of Tetrastigma angustifolia (Roxb.) (Family: Vitaceae) to streptozotocin induced diabetic wistar albino rats. The blood glucose level was measured using single touch blood glucose test strips and glucometer on weekly intervals until the end of 21st day. Other blood parameters like total lipid and liver profiles were investigated after oral administration of extracts to diabetic rats after the treatment of three weeks. The Histopathological changes of the diabetic and vehicle control rats were also investigated in this study. Daily oral administration of hydro-alcoholic leaf extracts (HSE 250 mg/kg & 500 mg/kg body weight) and metformin hydrochloride (5 mg/kg body weight) showed improvement effect on blood glucose level as well as hyperlipidaemia and liver functions due to streptozotocin induced diabetes (Type II). The extract has beneficial effects to maintain the animal body weight and has the regenerating power to pancreatic cells. The hydro-alcoholic leaf extracts dose fractions of Tetrastigma angustifolia (Roxb.) exhibited significant anti-hyperglycemic activities. The extract showed improvement in parameters like body weight and lipid profiles as well as regeneration of â-cells of pancreas and so might be of value for the treatment of diabetes (Type- II).

Admission blood glucose helps predict 1 year, but not 2 years, mortality in an unselected cohort of acute general medical admissions.

We previously showed that hyperglycaemia in newly hospitalised medical inpatients is associated with longer length of hospital stay, higher 28-day readmission rates and increased 28-day mortality. We aimed to assess whether a single blood glucose measurement taken at the time of admission could help to predict 1 and 2 years mortality. We retrospectively reviewed data from all 1502 patients admitted to our Acute Medical Unit during February 2010. By using a blood glucose range of 6.5-7.0 mmol/l as the comparator, an admission blood glucose between 9.1 and 20 mmol/l was associated with an increased risk of death at 1 year (p < 0.05). In addition, those people with admission glucose readings of < 6.5 mmol/l showed a strong trend towards a higher mortality (p = 0.053) at 1 year. Thus admission blood glucose can be used to help predict the risk of 1 year mortality in an unselected cohort of general medical admissions.

Various blood glucose parameters that indicate hyperglycemia after intravenous thrombolysis in acute ischemic stroke could predict worse outcome.

BackgroundHyperglycemia is common after stroke, and it is well known to worsen its outcome. However, it is important to consider that blood glucose (BG) levels can undergo dynamic changes during the acute stage of ischemic stroke. We sought to investigate the clinical significance of various glucose parameters within first 24 hours in acute ischemic stroke (AIS). The study focused on hyperacute stage patients who underwent IVT and investigated which parameters of glucose demonstrated to be helpful for predicting outcome.MethodsThis was a retrospective study of consecutive patients with AIS at a single stroke center. Patients were consecutively enrolled if they were treated with IV-tPA within 3 hours of symptom onset. BG was measured immediately upon arrival in ER, after IVT and every 6–8 hours during the first 24 hours after IVT. The various parameters of BG were the following: BG before IVT, BG after IVT, mean BG (mBG), maximal BG (max BG), standard deviation of BG (sdBG), and standard deviation of mean BG (sdmBG).Results207 patients (127 men and 80 women) were included in this study. Seventy seven of 207 patients had favorable outcomes at 3 months. High BG after IVT, mBG and max BG were independently associated with mRS>2 at 3 months (adjusted by age, NIHSS, and atrial fibrillation). Several parameters of BG were also independently associated with early mortality within 3 months (BG after IVT, mBG, and max BG). BG after IVT and mBG over 180 mg/dL were independently associated with early mortality within 3 months.ConclusionSerial measurements of BG might be a better predictor of clinical outcome in patients with AIS treated with IVT than single BG measurements before IVT. Therefore, these results suggest that variable parameters of BG could be important for the prediction of clinical outcome in AIS treated with IVT.