Diabetes Care in the Hospital: Standards of Medical Care in Diabetes-2019

Stress-induced hyperglycemia and expression of glucose cell transport genes in skeletal muscle of critically ill patients: a cross-sectional study

OBJECTIVE

To explore the association between diabetes and stress-induced hyperglycemia with skeletal muscle expression of key genes related to glucose transport.

METHODS

This is a cross-sectional study. Skeletal muscle biopsies were taken from the left vastus muscle of critically ill adult patients within 24 hours of intensive care unit admission, and the expression of the genes of interest, namely insulin receptor substrate 1 (IRS1), insulin receptor substrate 2 (IRS2), solute carrier family 2 member 1 (SLC2A1), and solute carrier family 2 member 4 (SLC2A4), was analyzed using quantitative polymerase chain reaction. The primary analysis was planned to compare the gene expression pattern between patients with and without diabetes mellitus. The secondary analyses compared the gene expression in subgroups of patients with different levels of glycemia, glycemic variability, and glycemic gap.

RESULTS

A total of 50 consecutive patients (15 with diabetes mellitus and 35 without diabetes mellitus) were included from April 2018 to September 2018. No differences in gene expression were found between patients with or without diabetes mellitus. Individuals with hyperglycemia > 200 mg/dL at intensive care unit admission exhibited a downregulation of IRS1 compared to those without (0.4 [0.1-0.8] versus 1.1 [0.3-2.2], p = 0.04). Similarly, patients with a glycemic gap ≥ 80 mg/dL exhibited a downregulation of IRS1 compared to those with a glycemic gap < 80 mg/dL (0.3 [0.1-0.7] versus 1 [0.4-2] p=0.04). There was no difference in gene expression between patients with glycemic variability higher or lower than 40 mg/dL.

CONCLUSION

No significant changes were found in skeletal muscle expression of IRS1, IRS2, SLC2A1, and SLC2A4 in critically ill patients with or without diabetes mellitus. However, IRS1 was downregulated in patients with stress-induced hyperglycemia.

Association between insulin-associated gene polymorphisms and new-onset diabetes mellitus in statin-treated patients

BACKGROUND

While statins are effective at managing lipid levels, there is growing evidence for new-onset diabetes mellitus (NODM). The insulin signalling pathway (ISP) inhibited by statins is one of the potential mechanisms; however, most studies have been limited to in vitro settings. Therefore, this study aimed to identify the genetic associations within the ISP-related genes and NODM.

METHODS

We performed a retrospective analysis of samples collected prospectively from February 2021 to May 2021. Among ISP-related genes, we selected 11 candidate genes (IGF1, IGF2, IGF1R, INSR, IRS1, IRS2, PIK3CA, PIK3CB, PIK3R1, AKT1 and AKT2). An additional analysis was conducted comparing patients with DM prior to statin therapy and controls to determine whether the single nucleotide polymorphisms (SNPs) are specific to statin.

RESULTS

A total of 602 patients were analysed, including 71 (11.8%) with statin-induced NODM. After adjustment, IGF1R rs2715439, INSR rs1799817, INSR rs2059807 and PIK3R1 rs3730089 were found to be independently associated with NODM. In an additional analysis, all SNPs that demonstrated an association with statin-induced NODM lost their significance in patients with DM prior to statin therapy.

CONCLUSION

This study revealed the ISP-related genetic effects, specifically involving genes such as INSR, IGF1R and PIK3R1, in the development of statin-induced NODM. Our findings suggest a potential mechanism of statin-induced NODM related to ISP-related genetic variants.

Sex-specific optimal cut-off points for metabolic health indicators to predict incident type 2 diabetes mellitus

BACKGROUND AND AIM

We aimed to determine the optimal cut-off points for metabolic health indicators, including insulin resistance (IR), glucose, insulin, BMI, and waist circumference, in middle-aged nondiabetic people to predict future type 2 diabetes mellitus (T2DM).

METHODS AND RESULTS

The data came from 12,543 Atherosclerosis Risk Communities Study participants, including 5758 men and 6785 women. They did not have diabetes at baseline and were followed for incident T2DM within 3, 6, and 9 years. IR was estimated using four IR metrics: HOMA-IR, METS-IR, TyG index, and TG/HDL-C. We used the Youden index to determine the optimal cut-off values. In females, the cut-off points for glucose to predict incident T2DM ranged from 96 to 102 mg/dL, with Area Under the Curve (AUC) values of 0.64-0.85. In males, the cut-off points ranged from 102 to 106 mg/dL, with AUC values of 0.60-0.83. For HOMA-IR, the cut-off points in females varied from 2.4 to 3.2, with AUC values of 0.69-0.78, while they ranged from 2.8 to 3.2 in males. The optimal cut-off values for METS-IR, TyG index, TG/HDL-C, insulin, BMI, and waist circumference were 40-43, 8.6-8.9, 2.0-3.2, 9-15 μU/mL, 28-29 kg/m2, and 91-97 cm in women, and 44-45, 8.8-8.9, 2.9-3.2, 11-12 μU/mL, 27-29 kg/m2, and 99-103 cm in men.

CONCLUSIONS

The optimal threshold for each predictor's prediction of incident T2DM varied by sex. The eight predictors' order of predictive performance were fasting glucose, HOMA-IR, METS-IR, insulin, BMI, waist circumference, TyG index, and TG/HDL-C.

Medications that Regulate Gastrointestinal Transit Influence Inpatient Blood Glucose

Objective

A multitude of factors affect a hospitalized individual's blood glucose (BG), making BG difficult to predict and manage. Beyond medications well established to alter BG, such as beta-blockers, there are likely many medications with undiscovered effects on BG variability. Identification of these medications and the strength and timing of these relationships has potential to improve glycemic management and patient safety.

Materials and Methods

EHR data from 103,871 inpatient encounters over 8 years within a large, urban health system was used to extract over 500 medications, laboratory measurements, and clinical predictors of BG. Feature selection was performed using an optimized Lasso model with repeated 5-fold cross-validation on the 80% training set, followed by a linear mixed regression model to evaluate statistical significance. Significant medication predictors were then evaluated for novelty against a comprehensive adverse drug event database.

Results

We found 29 statistically significant features associated with BG; 24 were medications including 10 medications not previously documented to alter BG. The remaining five factors were Black/African American race, history of type 2 diabetes mellitus, prior BG (mean and last) and creatinine.

Discussion

The unexpected medications, including several agents involved in gastrointestinal motility, found to affect BG were supported by available studies. This study may bring to light medications to use with caution in individuals with hyper- or hypoglycemia. Further investigation of these potential candidates is needed to enhance clinical utility of these findings.

Conclusion

This study uniquely identifies medications involved in gastrointestinal transit to be predictors of BG that may not well established and recognized in clinical practice.

Glycaemic outcomes in hospital with IDegAsp versus BIAsp30 premixed insulins

BACKGROUND AND AIMS

IDegAsp (Ryzodeg 70/30), a unique premixed formulation of long-acting insulin degludec and rapid-acting insulin aspart, is increasing in use. Management of IDegAsp during hospitalisation is challenging because of degludec's ultra-long duration of action. We investigated inpatient glycaemia in patients treated with IDegAsp compared to biphasic insulin aspart (BIAsp30; Novomix30).

METHODS

We performed a retrospective observational study at two hospitals assessing inpatients with type 2 diabetes treated with IDegAsp or BIAsp30 prior to and during hospital admission. Standard inpatient glycaemic outcomes were analysed based on capillary blood glucose (BG) measurements.

RESULTS

We assessed 88 individuals treated with IDegAsp and 88 HbA1c-matched individuals treated with BIAsp30. Patient characteristics, including insulin dose at admission, were well matched, but the IDegAsp group had less frequent twice-daily insulin dosing than the BIAsp30 group (49% vs 87%, P < 0.001). Patient-days with BG <4 mmol/L were not different (10.6% vs 9.9%, P = 0.7); however, the IDegAsp group had a higher patient-day mean BG (10.4 (SD 3.4) vs 10.0 (3.4) mmol/L, P < 0.001), and more patient-days with mean BG >10 mmol/L (48% vs 38%, P < 0.001) compared to the BIAsp30 group. Glucose was higher in the IDegAsp group in the evening (4 PM to midnight) (11.6 (SD 4.0) vs 10.9 (4.6) mmol/L, P = 0.004), but not different at other times during the day.

CONCLUSIONS

Inpatients treated with IDegAsp compared to BIAsp30 had similar hypoglycaemia incidence, but higher hyperglycaemia incidence, potentially related to less frequent twice-daily dosing. With the increasing use of IDegAsp in the community, development of hospital management guidelines for this insulin formulation is needed.

Impact of steroid use and glycemic control on postoperative complications in diabetic gynecologic oncology patients undergoing laparotomy

Objective

We aimed to assess the impact of preoperative steroid administration and perioperative glycemic control on postoperative complications in diabetic gynecologic oncology patients undergoing laparotomy.

Methods

This retrospective cohort study included gynecologic oncology patients with Type I and Type II diabetes (DM) undergoing laparotomy for any gynecologic indication at a single academic center from 10/2017 to 09/2020. The primary outcome was the rate of postoperative complications. Preoperative steroid administration and 24-hour postoperative average serum blood glucose (BG) ≥ 180 mg/dL were the studied exposures. Data was analyzed with SPSS Statistics v.28.

Results

225 patients met inclusion criteria; 47.6 % had postoperative complications. Patient demographics were similar between patients with and without postoperative complications. Patients with complications had higher BMIs (36.8 vs. 34.0; p = 0.03), bowel surgery (33.0 % vs. 17.1 %; p = 0.008), operative time ≥ 240 min (14.2 % vs. 5.1 %; p = 0.02) and average BG ≥ 180 (63.6 % vs. 40.2 %; p < 0.01). On multivariate analysis, bowel surgery (OR 2.4 (1.2-4.8); p = 0.01) and average BG ≥ 180 (OR 2.8 (1.6-4.9); p < 0.01) remained significant predictors of postoperative complications. There were no differences in complication rates (42.3 % vs. 42.6 %; p = 1.0) between patients who received preoperative steroids and those who did not. When stratified by average postoperative BG < 180 mg/dL vs. BG ≥ 180 mg/dL, there was no difference in Clavien-Dindo classification, 30-day readmission rate (28.2 % vs. 22.1 %; p = 0.49) or 30-day mortality rate (2.9 % vs. 0.0 %; p = 0.53).

Conclusion

The administration of preoperative steroids did not increase complication rates. Perioperative hyperglycemia was associated with an increased risk of postoperative complications. Optimizing perioperative glycemic control is imperative to decrease postoperative complications.

Glucose metabolism in gestational diabetes and their relationship with fat mass / muscle mass index

Introduction

During pregnancy, women experience metabolic changes that may induce insulin resistance, which can be traced to the blood glucose levels A number of factors may intervene in the metabolism of glucose in pregnant women; one of them is body composition. This factor is useful for studying metabolic diseases, for which the identification of the fat mass/muscle mass index (FMMMI) considered an especially relevant factor. Owing to their nature, techniques such as bioimpedance have been sparsely used for analysis during pregnancy.

Aim

This study aimed to identify the relationship between fat mass / muscle mass index and glucose metabolism in pregnant women.

Methods

This descriptive cross-sectional study included 231 women between the ages of 18 and 35 years and 24-28 weeks of gestation, who attended a state hospital for regular check-ups and exhibited risk factors for the development of gestational diabetes (GD) according to the Current Practice Guidelines in Primary Care. The participants underwent a physical examination, anthropometric measurements bio impedance were obtained, and oral glucose tolerance curves were constructed. FMMMI was calculated.

Results

The prevalence of gestational diabetes was observed to be 13.4%. Women with a GD diagnosis had a significantly higher FMMMI than in those with no GD (0.746 ± 0.168 vs 0.567 ± 0.167;p < 0.005). The assessment of the FMMMI tertiles revealed that GD prevalence was higher in tertile 3 than in tertiles 1 and 2 (tertile 1: 2.6%; tertile 2: 9.1%; tertile 3: 24%).

Conclusion

FMMMI is associated with glucose tolerance test response in pregnant women and a higher prevalence of GD.

Using Expert Elicitation to Adjust Published Intervention Effects to Reflect the Local Context

Background. Local health services make limited use of economic evaluation to inform decisions to fund new health service interventions. One barrier is the relevance of published intervention effects to the local setting, given these effects can strongly reflect the original evaluation context. Expert elicitation methods provide a structured approach to explicitly and transparently adjust published effect estimates, which can then be used in local-level economic evaluations to increase their local relevance. Expert elicitation was used to adjust published effect estimates for 2 interventions targeting the prevention of inpatient hypoglycemia. Methods. Elicitation was undertaken with 6 clinical experts. They were systematically presented with information regarding potential differences in patient characteristics and quality of care between the published study and local contexts, and regarding the design and application of the published study. The experts then assessed the intervention effects and provided estimates of the most realistic, most pessimistic, and most optimistic intervention effect sizes in the local context. Results. The experts estimated both interventions would be less effective in the local setting compared with the published effect estimates. For one intervention, the experts expected the lower complexity of admitted patients in the local setting would reduce the intervention's effectiveness. For the other intervention, the reduced effect was largely driven by differences in the scope of implementation (hospital-wide in the local setting compared with targeted implementation in the evaluation). Conclusions. The pragmatic elicitation methods reported in this article provide a feasible and acceptable approach to assess and adjust published intervention effects to better reflect expected effects in the local context. Further development and application of these methods is proposed to facilitate the use of local-level economic evaluation.

Highlights

Local health services make limited use of economic evaluation to inform their decisions on the funding of new health service interventions. One barrier to use is the relevance of published intervention evaluations to the local setting.Expert elicitation methods provide a structured way to consider differences between the evaluation and local settings and to explicitly and transparently adjust published effect estimates for use in local economic evaluations.The pragmatic elicitation methods reported in this article offer a feasible and acceptable approach to adjusting published intervention effects to better reflect the effects expected in the local context. This increases the relevance of economic evaluations for local decision makers.

Insulin feedback is a targetable resistance mechanism of PI3K inhibition in glioblastoma

BACKGROUND

Insulin feedback is a critical mechanism responsible for the poor clinical efficacy of phosphatidylinositol 3-kinase (PI3K) inhibition in cancer, and hyperglycemia is an independent factor associated with poor prognosis in glioblastoma (GBM). We investigated combination anti-hyperglycemic therapy in a mouse model of GBM and evaluated the association of glycemic control in clinical trial data from patients with GBM.

METHODS

The effect of the anti-hyperglycemic regimens, metformin and the ketogenic diet, was evaluated in combination with PI3K inhibition in patient-derived GBM cells and in an orthotopic GBM mouse model. Insulin feedback and the immune microenvironment were retrospectively evaluated in blood and tumor tissue from a Phase 2 clinical trial of buparlisib in patients with recurrent GBM.

RESULTS

We found that PI3K inhibition induces hyperglycemia and hyperinsulinemia in mice and that combining metformin with PI3K inhibition improves the treatment efficacy in an orthotopic GBM xenograft model. Through examination of clinical trial data, we found that hyperglycemia was an independent factor associated with poor progression-free survival in patients with GBM. We also found that PI3K inhibition increased insulin receptor activation and T-cell and microglia abundance in tumor tissue from these patients.

CONCLUSION

Reducing insulin feedback improves the efficacy of PI3K inhibition in GBM in mice, and hyperglycemia worsens progression-free survival in patients with GBM treated with PI3K inhibition. These findings indicate that hyperglycemia is a critical resistance mechanism associated with PI3K inhibition in GBM and that anti-hyperglycemic therapy may enhance PI3K inhibitor efficacy in GBM patients.

Association between diabetes and stress-induced hyperglycemia with skeletal muscle gene expression of INSR in critically ill patients: A prospective cohort study

This study aimed to investigate the association between diabetes and stress-induced hyperglycemia with skeletal muscle gene expression of INSR of critically ill patients. Skeletal muscle biopsies were prospectively taken from the vastus muscle, and the expression level of INSR was analyzed using RT-qPCR. Fifty patients were included from April 2018 to September 2018. No significant differences in skeletal muscle gene expression were found between patients with or without diabetes. Similarly, there were no differences in gene expression between groups according to the presence of hypoglycemia 〈 70 mg/dl or hyperglycemia 〉 140 mg/dl. Patients with glycemic variability ≥ 40 mg/dl exhibited a downregulation of INSR compared to those with glycemic variability < 40 mg/dl (1.3 [0.01-5] vs. 2.1 [0.7 - 3.4] fold-changes, P = 0.045). The same pattern was observed when glycemic gap threshold of 80 mg/dl was used (1.4 [0.25-5] vs 1 [0.01 - 2.3] fold-changes in patients with glycemic gap < 80 mg/dl and glycemic gap ≥ 80 mg/dl respectively, P = 0.015). In conclusion, INSR was downregulated in the skeletal muscle of critically ill patients with stress-induced hyperglycemia.

The relationship between hyperglycaemia on admission and patient outcome is modified by hyperlactatemia and diabetic status: a retrospective analysis of the eICU collaborative research database

Both blood glucose and lactate are well-known predictors of organ dysfunction and mortality in critically ill patients. Previous research has shown that concurrent adjustment for glucose and lactate modifies the relationship between these variables and patient outcomes, including blunting of the association between blood glucose and patient outcome. We aim to investigate the relationship between ICU admission blood glucose and hospital mortality while accounting for lactate and diabetic status. Across 43,250 ICU admissions, weighted to account for missing data, we assessed the predictive ability of several logistic regression and generalised additive models that included blood glucose, blood lactate and diabetic status. We found that inclusion of blood glucose marginally improved predictive performance in all patients: AUC-ROC 0.665 versus 0.659 (p = 0.005), with a greater degree of improvement seen in non-diabetics: AUC-ROC 0.675 versus 0.663 (p < 0.001). Inspection of the estimated risk profiles revealed the standard U-shaped risk profile for blood glucose was only present in non-diabetic patients after controlling for blood lactate levels. Future research should aim to utilise observational data to estimate whether interventions such as insulin further modify this effect, with the goal of informing future RCTs of interventions targeting glycaemic control in the ICU.

Predictive value of glycemic gap and stress glycemia ratio among critically ill patients with acute kidney injury: a retrospective analysis of the MIMIC-III database

BACKGROUND AND AIMS

Acute hyperglycemia has been identified as a risk factor for acute kidney injury occurrence and mortality in various diseases. The aim of the current study was to investigate the relationship between stress-induced hyperglycemia and adverse outcomes in critically ill patients with AKI.

METHODS

We extracted clinical data from Multiparameter Intelligent Monitoring in Intensive Care III version 1.4. Blood glucose and glycosylated hemoglobin during the first 24 h of ICU admission were used to calculate glycemic gap and stress hyperglycemia ratio (SHR). The outcomes included ICU mortality and need for renal replacement therapy. The association of the glycemic gap and SHR with outcomes were determined via logistic regression model and receiver-operating curves. The subgroup analysis of patients with and without diabetes was performed separately.

RESULTS

Higher glycemic gap and SHR were observed in patients who had increased need of RRT, higher mortality rates and longer ICU stay. Multivariate analysis demonstrated that higher glycemic gap (OR 1.01, 95%CI 1.00-1.02, P = 0.015), as well as SHR (OR 1.32; 95%CI 1.07-1.64, P = 0.009), were independently associated with ICU mortality after adjusting for potential covariates. In subgroup analysis, the association of glycemic gap and SHR were only significant in the non-diabetic population as for the outcome of ICU mortality (OR 2.25, 95%CI 1.64-3.08, P < 0.001 and OR 1.99; 95%CI 1.46-2.72, P < 0.001, respectively).

CONCLUSIONS

The glycemic gap and SHR might serve as a potential prognostic indicator of ICU mortality in critically ill patients with AKI, especially in the non-diabetic population.

Diabetes associates with mortality in critically ill patients with SARS-CoV-2 pneumonia: No diabetes paradox in COVID-19

Background

Diabetes mellitus (DM) is not associated with increased mortality in critically ill patients, a phenomenon known as the "diabetes paradox". However, DM is a risk factor for increased mortality in patients with COVID-19. This study aims to investigate the association of DM and stress-induced hyperglycemia at intensive care unit (ICU) with mortality in this population.

Methods

This is a retrospective study. Electronic medical records from patients admitted from March 2020 to September 2020 were reviewed. Primary outcome was mortality. Secondary outcomes were ICU and hospital mortality and stay, and need for mechanical ventilation and renal replacement therapy.

Results

187 patients were included. Overall mortality was 43.2%, higher in patients with DM (55.7% vs. 34%; p = 0.007), even after adjustment for age, hypertension, and disease severity. When patients were separated into groups, named normoglycemia (without DM and glycemia ≤140 mg/dL), stress-induced hyperglycemia (without DM and glycemia >140 mg/dL), and DM (previous diagnosis or HbA1c ≥ 6.5%), the mortality rate was 25.8%, 37.3%, and 55.7%, respectively (p = 0.021). Mortality was higher in patients with higher glycemic variability. No statistical difference related to secondary outcomes was observed.

Conclusions

DM, hyperglycemia, and glycemic variability associated with increased mortality in critically ill patients with severe COVID-19, but did not increase the rates of other clinical outcomes. More than stress-induced hyperglycemia, DM was associated with mortality.

The EUPEMEN (EUropean PErioperative MEdical Networking) Protocol for Bowel Obstruction: Recommendations for Perioperative Care

Mechanical bowel obstruction is a common symptom for admission to emergency services, diagnosed annually in more than 300,000 patients in the States, from whom 51% will undergo emergency laparotomy. This condition is associated with serious morbidity and mortality, but it also causes a high financial burden due to long hospital stay. The EUPEMEN project aims to incorporate the expertise and clinical experience of national clinical specialists into development of perioperative rehabilitation protocols. Providing special recommendations for all aspects of patient perioperative care and the participation of diverse specialists, the EUPEMEN protocol for bowel obstruction, as presented in the current paper, aims to provide faster postoperative recovery and reduce length of hospital stay, postoperative morbidity and mortality rate.

Effects of Statin Dose, Class, and Use Intensity on All-Cause Mortality in Patients with Type 2 Diabetes Mellitus

PURPOSE

to examine the impact of statins on reducing all-cause mortality among individuals diagnosed with type 2 diabetes. This investigation explored the potential correlations between dosage, drug classification, and usage intensity with the observed outcomes.

METHODS

The research sample consisted of individuals aged 40 years or older diagnosed with type 2 diabetes. Statin usage was determined as a frequent usage over a minimum of one month subsequent to type 2 diabetes diagnosis, where the average statin dose was ≥28 cumulative defined daily doses per year (cDDD-year). The analysis employed an inverse probability of treatment-weighted Cox hazard model, utilizing statin usage status as a time-varying variable, to evaluate the impact of statin use on all-cause mortality.

RESULTS

The incidence of mortality was comparatively lower among the cohort of statin users (n = 50,804 (12.03%)), in contrast to nonusers (n = 118,765 (27.79%)). After adjustments, the hazard ratio (aHR; 95% confidence interval (CI)) for all-cause mortality was estimated to be 0.32 (0.31-0.33). Compared with nonusers, pitavastatin, rosuvastatin, pravastatin, simvastatin, atorvastatin, fluvastatin, and lovastatin users demonstrated significant reductions in all-cause mortality (aHRs (95% CIs) = 0.06 (0.04-0.09), 0.28 (0.27-0.29), 0.29 (0.28-0.31), 0.31 (0.30-0.32), 0.31 (0.30-0.32), 0.36 (0.35-0.38), and 0.48 (0.47-0.50), respectively). In Q1, Q2, Q3, and Q4 of cDDD-year, our multivariate analysis demonstrated significant reductions in all-cause mortality (aHRs (95% CIs) = 0.51 (0.5-0.52), 0.36 (0.35-0.37), 0.24 (0.23-0.25), and 0.13 (0.13-0.14), respectively; p for trend <0.0001). Because it had the lowest aHR (0.32), 0.86 DDD of statin was considered optimal.

CONCLUSIONS

In patients diagnosed with type 2 diabetes, consistent utilization of statins (≥28 cumulative defined daily doses per year) was shown to have a beneficial effect on all-cause mortality. Moreover, the risk of all-cause mortality decreased as the cumulative defined daily dose per year of statin increased.

Comparison of Weight Reduction, Change in Parameters and Safety of a Very Low Carbohydrate Diet in Comparison to a Low Carbohydrate Diet in Obese Japanese Subjects with Metabolic Disorders

Recently, low-carbohydrate diets (LCDs) have gained worldwide attention. LCDs are potentially effective for Japanese overweight and obese individuals with metabolic disorders. However, few randomized trials of LCDs have focused on the difference between LCDs and VLCDs. We conducted a randomized, prospective study of 42 Japanese, obese adults aged 28–65 years to evaluate the efficacy and safety of LCD and VLCD. To ensure the accuracy of the study, all test meals were provided, and compliance was checked using a smartphone app. Body composition measurements and blood tests were performed before and after the 2-month dietary intervention. The results showed that both methods significantly reduced body weight and fat, and also improved lipid abnormalities and liver function. In the current study, the reductions in weight and fat were comparable. The results of a questionnaire at the end of the study indicated that the LCD was easier to carry out than the VLCD, suggesting that the LCD was sustainable. The present study was unique in that it was a randomized, prospective study of Japanese subjects and that accurate data were obtained by providing meals.

Diabetes Ketoacidosis and Hyperosmolar Hyperglycemic Syndrome in Companion Animals

Diabetes mellitus is a common endocrinopathy in dogs and cats. Diabetes ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are life-threatening complications of diabetes resulting from an imbalance between insulin and the glucose counter-regulatory hormones. The first part of this review focuses on the pathophysiology of DKA and HHS, and rarer complications such as euglycemic DKA and hyperosmolar DKA. The second part of this review focuses on the diagnosis and treatment of these complications.

Effectiveness of an online course for medicine residents on glycaemic management of hospitalized patients with diabetes

Background

Hyperglycaemia and hypoglycaemia in hospitalized patients are associated with poor clinical outcomes. We assessed whether administration of an online educational course for medicine residents improves the glycaemic management of hospitalized patients with diabetes.

Methods

We conducted this quasi-experimental, pre-post study from January 2019 to April 2019. The contents of the course were in compliance with the American Diabetes Association Guidelines 2018. After participating in the online course, the change in the knowledge of residents was assessed by pre- and post-test questionnaire and changes in the inpatient diabetes care were assessed by case record review of the hospitalized patients with diabetes managed by them before and after the participation in the course.

Results

Fifty-six residents participated and completed the online course. Their average post-test scores increased by 11.6%. One hundred and eighteen patients managed by the residents in the same wards before and after the participation in the course were studied. After attending the course, glycaemic targets were predetermined in 75.4% of patients compared to 32.2% before and adequacy of glucose monitoring improved. The total hypoglycaemic event rate reduced significantly by 45.8% and this was accompanied by a trend towards improved glycaemic control. At the time of discharge, the patient awareness on insulin injection technique, hypoglycaemic symptoms and its home remedies were significantly increased.

Conclusion

The administration of an online course increases the knowledge level of residents, improves patient safety and may improve glycaemic control in hospitalized patients with diabetes.

Strategies for intraoperative glucose management: a scoping review

PURPOSE

Perioperative hyperglycemia is associated with adverse outcomes for patients with and without diabetes. Guidelines and published protocols for intraoperative glycemic management have substantial variation in their recommendations. We sought to characterize the current evidence-guiding intraoperative glycemic management in a scoping review.

SOURCES

Our search strategy included MEDLINE (Ovid and EBSCO), PubMed, PubMed Central, EMBASE, CINAHL, Cochrane Library, SciVerse Scopus, and Web of Science and a gray literature search of Google, Google Scholar, hand searching of the reference lists of included articles, OAISter, institutional protocols, and ClinicalTrails.gov.

PRINCIPAL FINDINGS

We identified 41 articles that met our inclusion criteria, 24 of which were original research studies. Outcomes and exposures were defined heterogeneously across studies, which limited comparison and synthesis. Investigators often created arbitrary and differing categories of glucose values rather than analyzing glucose as a continuous variable, which limited our ability to combine results from different studies. In addition, the study populations and surgery types also varied considerably, with few studies performed during day surgeries and specific surgical disciplines. Study populations often included more than one type of surgery, indication, and urgency that were expected to have varying physiologic and inflammatory responses. Combining low- and high-risk patients in the same study population may obscure the harms or benefits of intraoperative glycemic management for high-risk procedures or patients.

CONCLUSION

Future studies examining intraoperative glycemic management should carefully consider the study population, surgical characteristics, and pre- and postoperative management of hyperglycemia.

[Hyperglycemia in critically ill]

In critical illness hyperglycemia is associated with increased mortality. Based on the currently available evidence, an intravenous insulin therapy should be initiated when blood glucose is above 180 mg/dl. After initiation of insulin therapy blood glucose should be maintained between 140 and 180 mg/dl.

The prevalence of chronic medication therapy problems and pharmacists' interventions among hospitalized perioperative patients: a retrospective observational study

BACKGROUND

Inadequate preoperative management of chronic medications can place perioperative patients at risk and cause unnecessary delays in surgical procedures. This study aims to investigate the prevalence of chronic medication therapy problems (CMTPs) in hospitalized perioperative patients and assess the relevance of pharmacists' interventions.

METHODS

We conducted a retrospective study of pharmacist-led preoperative management of chronic medications in hospitalized adult patients from November 2018 to April 2019. The recorded drug-related problems (DRPs) were retrospectively reviewed and categorized according to the Pharmaceutical Care Network Europe classification V9.1 and were analyzed with a multinomial regression model to identify risk factors.

RESULTS

A total of 254 DRPs were recorded, with an average of 0.52 DRPs per patient. Treatment safety (66.9%) was the most common DRP. The most frequent causes of perioperative DRPs and nonperioperative DRPs were drug selection (72.9%) and patient related (50.8%), respectively. Of the 292 documented interventions, 71.6% were fully accepted by the clinicians and patients. The majority (68.9%) of the recorded problems were completely resolved. The number of comorbidities (OR = 3.815) and the number of chronic medications taken (OR = 1.539) were risk factors for the occurrence of DRPs.

CONCLUSION

The findings of this study suggest that pharmacist-led chronic medication therapy management in surgical wards may be an effective method to help reduce medication-related surgical risks and optimize the medication therapies used for the long-term treatment of chronic diseases.

Use of Cross-sectional and Perspective Mapping to Spatially and Statistically Represent Inpatient Glucose Control

BACKGROUND

The use of inpatient location for the depiction of glycemic control is an alternative approach to the traditional analysis of hospital-derived glucometric data. Our aim was to develop a method of spatial representation and to test for corresponding statistical variation in inpatient glucose control data.

METHODS

Point-of-care blood glucose data from inpatients with diabetes mellitus were extracted. Calculations included patient-day weighted means (PDWMs) and percentage of patient hospital days with hypoglycemia. Results were overlaid onto hospital floor plans, and room numbers were used as geolocators to generate cross-sectional (2-dimensional) and perspective (3-dimensional) views of the data. Linear mixed and mixed-effects logistic regression models were used to compare the location effect and to assess statistical variation in the data after adjusting for age, sex, and severity of illness.

RESULTS

Visual inspection of cross-sectional and perspective maps demonstrated variation in glucometric outcomes across areas within the hospital. Statistical analysis confirmed significant variation between some hospital wings and floors.

CONCLUSIONS

Spatial depiction of glucometric data within the hospital could yield insights into hot spots of poor glycemic control. Future studies on how to operationalize this approach, and whether this method of analysis can drive changes in glycemic management practices, need to be conducted.

Impact of admission and early persistent stress hyperglycaemia on clinical outcomes in acute pancreatitis

BACKGROUND

To determine the impact of glucose levels at admission and during first week (early phase) on clinical outcomes in patients with acute pancreatitis (AP) and to investigate the relationship between stress hyperglycaemia (SHG) and hypertriglyceridaemia (HTG).

METHODS

Two independent and prospective databases were retrospectively analysed (n = 1792). Patients admitted with pain of less than 48 hours and confirmed AP were included. SHG was defined as admission blood glucose ≥ 10.00 mmol/L (non-diabetic) or ≥ 16.67 mmol/L (diabetic). Blood glucose records for the first week were inspected to determine whether SHG lasted ≥ 48 hours (persistent) or < 48 hours (transient). Clinical outcomes were compared between designated patient groups using multivariate and trend analyses. The correlation between SHG and HTG (serum triglyceride ≥ 5.65 mmol/L) was also analysed.

RESULTS

On admission, SHG was present in 27.8% (499/1792) patients; during the first 48 hours of admission, transient and persistent SHG was found in 31% (556/1792) and 8.0% (144/1792) patients, respectively. Admission SHG was associated with higher incidence of persistent organ failure, acute necrotic collection, major infection, and mortality as well as prolonged length of hospital stay (all P < 0.05). Duration of SHG was also associated with worsened clinical outcomes (all P < 0.05). In HTG-AP patients, more severe clinical outcomes were observed in those who concomitantly had SHG (P < 0.05).

CONCLUSIONS

Admission and persistent SHG during the first week of admission worsens clinical outcomes of AP patients. These effects are more pronounced when admission HTG co-existed.

Bias or biology? Importance of model interpretation in machine learning studies from electronic health records

Objective

The rate of diabetic complication progression varies across individuals and understanding factors that alter the rate of complication progression may uncover new clinical interventions for personalized diabetes management.

Materials and Methods

We explore how various machine learning (ML) models and types of electronic health records (EHRs) can predict fast versus slow onset of neuropathy, nephropathy, ocular disease, or cardiovascular disease using only patient data collected prior to diabetes diagnosis.

Results

We find that optimized random forest models performed best to accurately predict the diagnosis of a diabetic complication, with the most effective model distinguishing between fast versus slow nephropathy (AUROC = 0.75). Using all data sets combined allowed for the highest model predictive performance, and social history or laboratory alone were most predictive. SHapley Additive exPlanations (SHAP) model interpretation allowed for exploration of predictors of fast and slow complication diagnosis, including underlying biases present in the EHR. Patients in the fast group had more medical visits, incurring a potential informed decision bias.

Discussion

Our study is unique in the realm of ML studies as it leverages SHAP as a starting point to explore patient markers not routinely used in diabetes monitoring. A mix of both bias and biological processes is likely present in influencing a model's ability to distinguish between groups.

Conclusion

Overall, model interpretation is a critical step in evaluating validity of a user-intended endpoint for a model when using EHR data, and predictors affected by bias and those driven by biologic processes should be equally recognized.

Factors Associated With Discordant A1C-Estimated and Measured Average Glucose Among Hospitalized Patients With Diabetes

In this retrospective analysis, we explored the correlation between measured average glucose (mAG) and A1C-estimated average glucose (eAG) in hospitalized patients with diabetes and identified factors associated with discordant mAG and eAG at the transition from home to hospital. Having mAG lower than eAG was associated with Black race, other race, increasing length of stay, community hospital setting, surgery, fever, metformin use, certain inpatient diets, home antihyperglycemic treatment, and coded type 1 or type 2 diabetes. Having mAG higher than eAG was associated with certain discharge services (e.g., intensive care unit), higher BMI, hypertension, tachycardia, higher albumin, higher potassium, anemia, inpatient glucocorticoid use, and treatment with home insulin, secretagogues, and glucocorticoids. These factors should be considered when using patients' A1C as an indicator of outpatient glycemic control to determine the inpatient antihyperglycemic regimens.

Is it time to personalise glucose targets during critical illness?

PURPOSE OF REVIEW

Dysglycaemia complicates most critical care admissions and is associated with harm, yet glucose targets, particularly in those with preexisting diabetes, remain controversial. This review will summarise advances in the literature regarding personalised glucose targets in the critically ill.

RECENT FINDINGS

Observational data suggest that the degree of chronic hyperglycaemia in critically ill patients with diabetes attenuates the relationship between mortality and several metrics of dysglycaemia, including blood glucose on admission, and mean blood glucose, glycaemic variability and hypoglycaemia in the intensive care unit. The interaction between acute and chronic hyperglycaemia has recently been quantified with novel metrics of relative glycaemia including the glycaemic gap and stress hyperglycaemia ratio. Small pilot studies provided preliminary data that higher blood glucose thresholds in critically ill patients with chronic hyperglycaemia may reduce complications of intravenous insulin therapy as assessed with biomakers. Although personalising glycaemic targets based on preexisting metabolic state is an appealing concept, the recently published CONTROLLING trial did not identify a mortality benefit with individualised glucose targets, and the effect of personalised glucose targets on patient-centred outcomes remains unknown.

SUMMARY

There is inadequate data to support adoption of personalised glucose targets into care of critically ill patients. However, there is a strong rationale empowering future trials utilising such an approach for patients with chronic hyperglycaemia.

Constructing an Adapted Cascade of Diabetes Care Using Inpatient Admissions Data: Cross-sectional Study

BACKGROUND

The diabetes mellitus cascade of care has been constructed to evaluate diabetes care at a population level by determining the percentage of individuals diagnosed and linked to care as well as their reported glycemic control.

OBJECTIVE

We sought to adapt the cascade of care to an inpatient-only setting using the electronic health record (EHR) data of 81,633 patients with type 2 diabetes.

METHODS

In this adaptation, linkage to care was defined as prescription of diabetes medications within 3 months of discharge, and control was defined as hemoglobin A1c (HbA1c) below individual target levels, as these are the most reliably captured items in the inpatient setting. We applied the cascade model to assess differences in demographics and percent loss at each stage of the cascade; we then conducted two-sample chi-square equality of proportions tests for each demographic. Based on findings in the previous literature, we hypothesized that women, Black patients, younger patients (<45 years old), uninsured patients, and patients living in an economically deprived area called the Promise Zone would be disproportionately unlinked and uncontrolled. We also predicted that patients who received inpatient glycemic care would be more likely to reach glycemic control.

RESULTS

We found that out of 81,633 patients, 28,716 (35.2%) were linked to care via medication prescription. Women and younger patients were slightly less likely to be linked to care than their male and older counterparts, while Black patients (n=19,141, 23.4% of diagnosed population vs n=6741, 23.5% of the linked population) were as proportionately part of the linked population as White patients (n=58,291, 71.4% of diagnosed population vs n=20,402, 71.0% of the linked population). Those living in underserved communities (ie, the Promise Zone) and uninsured patients were slightly overrepresented (n=6789, 8.3% of diagnosed population vs n=2773, 9.7% of the linked population) in the linked population as compared to patients living in wealthier zip codes and those who were insured. Similar patterns were observed among those more likely to reach glycemic control via HbA1c. However, conclusions are limited by the relatively large amount of missing glycemic data.

CONCLUSIONS

We conclude that inpatient EHR data do not adequately capture the care cascade as defined in the outpatient setting. In particular, missing data in this setting may preclude assessment of glycemic control. Future work should integrate inpatient and outpatient data sources to complete the picture of diabetes care.

Tert-Butylhydroquinone alleviates insulin resistance and liver steatosis in diabetes

OBJECTIVES:

This work aimed to determine tert-Butylhydroquinone (TBHQ)'s effects on insulin resistance (IR) and liver steatosis in diabetic animals and to explore the underpinning mechanisms.

MATERIALS AND METHODS:

Male ApoE^-/-mice underwent streptozocin (STZ) administration while receiving a sucrose/fat-rich diet for type 2 diabetes mellitus (T2DM) establishment. This was followed by a 6-week TBHQ administration. Body weight, fasting (FBG) and postprandial (PBG) blood glucose amounts, and insulin concentrations were measured, and the oral glucose tolerance test (OGTT) was carried out. Hematoxylin and eosin (H and E) staining and immunoblot were carried out for assessing histology and protein amounts in the liver tissue samples. In addition, cultured HepG2 cells were administered HClO and insulin for IR induction, and immunoblot was carried out for protein evaluation. Finally, the cells were stained with the Hoechst dye for apoptosis evaluation.

RESULTS:

The model animals showed T2DM signs, and TBHQ decreased FBG, ameliorated glucose tolerance and reduced liver steatosis in these animals. In addition, TBHQ markedly upregulated AMPKα2, GLUT4 and GSK3 β, as well as phosphorylated PI3K and AKT in the liver of mice with T2DM. In agreement, TBHQ decreased HClO-and insulin-related IR in cells and suppressed apoptosis through AMPKα2/PI3K/AKT signaling.

CONCLUSIONS:

TBHQ alleviates IR and liver steatosis in a mouse model of T2DM likely through AMPKα2/PI3K/AKT signaling.

Pragmatic review of interventions to prevent inpatient hypoglycaemia

AIMS

This pragmatic review aimed to map and summarize the literature on model of care interventions to prevent inpatient hypoglycaemia. Model of care interventions were broadly defined as interventions that either directly target the workforce or where implementation had a strong workforce effect. The review intended to provide information for decision-makers in local health care settings regarding potential interventions to prevent inpatient hypoglycaemia in their local context.

METHODS

PubMed, Embase, CINAHL Plus and Scopus were systematically searched from 2009 to 2019 using key search terms for hypoglycaemia and hospital and evaluation. Included articles had to report an inpatient hypoglycaemia-related outcome. Interventions were categorized by intervention type and setting. Dysglycaemia outcomes were extracted (severe-hypoglycaemia, hypoglycaemia, hyperglycaemia and severe-hyperglycaemia).

RESULTS

Forty-nine articles were included in the review. Interventions were categorized as: services (n = 8), role expansion (n = 6), education (n = 9), audit and feedback (n = 1), alerts and reminders (n = 3), protocol implementation methods (n = 1), order sets (n = 6), insulin charts (n = 1) and electronic glycaemic management systems (n = 14). Twenty-one articles reported on ICU-specific interventions, and 28 on interventions in non-ICU-specific settings. Study designs were predominantly non-randomized (n = 40).

CONCLUSIONS

The review found positive evidence for a diverse range of evaluated interventions to prevent inpatient hypoglycaemia. Local decision-makers can use this review to identify interventions relevant to their local context. We suggest they evaluate those interventions using a decision analytic framework that combines the published evidence on effectiveness with local prevalence data to estimate the expected cost-effectiveness of the intervention options when implemented in their local context.

Dietary pattern of patients with type 2 diabetes mellitus including date consumption

Aim

Assess the relationship between date palm fruit consumption and diabetic control among Saudi patients with type 2 diabetes mellitus.

Subjects and methods

Saudi patients with type 2 diabetes (n = 404, aged 55.3 ± 9.7 years) were included in this study. Height, weight and blood pressure were initially measured. Blood glucose levels (fasting and random), glycated hemoglobin HbA1c, total cholesterol, high-density lipoprotein, low-density lipoprotein and triglycerides were retrieved from the patient’s medical records. The amount and frequency of habitual consumption of date fruits were obtained from patients using a validated dietary questionnaire.

Results

The results revealed that high consumption of date fruits was statistically significantly correlated with lower HbA1c and fasting blood glucose (p < 0.01).

Conclusion

This cross-sectional study found an association between high date fruit consumption by patients with type 2 diabetes mellitus and lower HbA1c and fasting blood glucose levels. Further studies are required to verify this interesting finding

Imaging evaluation of the pancreas in diabetic patients

Diabetes mellitus (DM) is becoming a global epidemic and its diagnosis and monitoring are based on laboratory testing which sometimes have limitations. The pancreas plays a key role in metabolism and is involved in the pathogenesis of DM. It has long been known through cadaver biopsies that pancreas volume is decreased in patients with DM. With the development of different imaging modalities over the last two decades, many studies have attempted to determine whether there other changes occurred in the pancreas of diabetic patients. This review summarizes current knowledge about the use of different imaging approaches (such as CT, MR, and US) and radiomics for exploring pancreatic changes in diabetic patients. Imaging studies are expected to produce reliable information regarding DM, and radiomics could provide increasingly valuable information to identify some undetectable features and help diagnose and predict the occurrence of diabetes through pancreas imaging.

Glucose control after glucocorticoid administration in hospitalized patients - a retrospective analysis

BACKGROUND

Glucocorticoid (GC)-induced hyperglycemia is a frequent adverse effect in hospitalized patients. Guidelines recommend insulin treatment to a target range of 6-10 mmol/L (108-180 mg/dl), but efficacies of particular regimes have not been well-studied.

METHODS

In this retrospective cohort study, hospitalized patients receiving GCs at the medical ward were analyzed by treatment (basal-bolus vs. bolus-only vs. pre-mixed insulin) and compared to a non-insulin-therapy reference group. Coefficients of glucose variation (CV), percentage of glucose readings in range (4-10 mmol/L (72-180 mg/dl)) and hypoglycemia (< 4 mmol/L (< 72 mg/dl)) were evaluated.

RESULTS

Of 2424 hospitalized patients receiving systemic GCs, 875 (36%) developed GC-induced hyperglycemia. 427 patients (17%) had a previous diagnosis of diabetes. Adjusted relative risk ratios (RRR) for the top tertile of CV (> 29%) were 1.47 (95% Cl 1.01-2.15) for bolus-only insulin, 4.77 (95% CI 2.67-8.51) for basal-bolus insulin, and 4.98 (95% CI 2.02-12.31) for premixed insulin, respectively. Adjusted RRR for percentages of glucose readings in range were 0.98 (95% Cl 0.97-0.99) for basal-bolus insulin, 0.99 (95% Cl 0.98-1.00) for premixed insulin, and 1.01 (95% Cl 1.00-1.01) for bolus-only insulin, respectively. Adjusted RRR for hypoglycemia was 13.17 (95% Cl 4.35-39.90) for basal-bolus insulin, 8.92 (95% Cl 2.60-30.63) for premixed insulin, and 2.99 (95% Cl 1.01-8.87) for bolus-only insulin, respectively.

CONCLUSIONS

Current guidelines recommend a basal-bolus regimen for treatment of GC-induced hyperglycemia, but we found similar outcomes with pre-mixed and bolus-only insulin regimens. As GC-induced hyperglycemia is a frequent issue in hospitalized patients, it might be reasonable to prospectively study the ideal regimen.

Stress Hyperglycemia Is Independently Associated with Persistent Organ Failure in Acute Pancreatitis

BACKGROUND/AIMS

Stress hyperglycemia is common in critical illness but it has not been clearly studied in patients with acute pancreatitis (AP). This study aimed to investigate the specific blood glucose (BG) level that defines stress hyperglycemia and to determine the impact of stress hyperglycemia on clinical outcomes in AP patients.

METHODS

AP patients admitted ≤ 48 h after abdominal pain onset were retrospectively analyzed. Patients were stratified by pre-existing diabetes and stress hyperglycemia was defined using stratified BG levels for non-diabetes and diabetes with clinical outcomes compared.

RESULTS

There were 967 non-diabetic and 114 diabetic (10.5%) patients met the inclusion criteria and the clinical outcomes between these two groups were not significantly different. In non-diabetes, the cut-off BG level of ≥ 180 mg/dl was selected to define stress hyperglycemia with an 8.8-fold higher odds ratio for persistent organ failure (POF) (95% CI 5.4-14.3; P < 0.001). For diabetes, ≥ 300 mg/dl was selected with a 7.5-fold higher odds ratio for POF (95% CI 1.7-34.3; P = 0.009). In multivariable logistic regression, stress hyperglycemia was independently associated with POF, acute necrotic collection, major infection and mortality. The combination of BG and systemic inflammatory response syndrome (SIRS) score in predicting POF was better than SIRS or Glasgow score alone.

CONCLUSIONS

This study identifies a cut-off BG level of ≥ 180 mg/dl and ≥ 300 mg/dl was optimal to define stress hyperglycemia for non-diabetic and diabetic AP patients, respectively. There was a significant relationship between stress hyperglycemia and adverse clinical outcomes.

A comparison of the stress hyperglycemia ratio, glycemic gap, and glucose to assess the impact of stress-induced hyperglycemia on ischemic stroke outcome

BACKGROUND

The aim of this study is to compare metrics specific for stress-induced hyperglycemia (SIH) with glucose for predicting ischemic stroke outcome.

METHODS

This observational retrospective study (n = 300) included patients acutely hospitalized for ischemic stroke over a 3.8-year period. We assessed the association between acute ischemic stroke outcome with the stress hyperglycemia ratio (SHR, relative increase in glycemia) and glycemic gap (GG, absolute increase in glycemia) using admission values and 5-day maximum values, along with incidence of poor outcome above recognized clinical thresholds of glucose 10 mmol/L, SHR 1.14, and GG 2.5 mmol/L.

RESULTS

At admission, only SHR was associated with outcome after adjustment for clinical covariates (odds ratio [OR] = 2.88; 95% CI: 1.05-7.91; P = .041), while glucose or GG were not. Admission SHR ≥ 1.14 was also an indicator of poor outcome (39.1% vs 23.4%, P = .016), but not glucose ≥10 mmol/L or GG ≥ 2.5 mmol/L. All 5-day maximum glucose metrics were associated with outcome, as was any SHR ≥ 1.14 (40.9% vs 20.1%, P < .001) or GG ≥ 2.5 mmol/L (42.9% vs 23.4%, P = .011), but not glucose ≥10 mmol/L. Increased comorbidity was strongly associated with worse outcome (P < .001) in all models.

CONCLUSIONS

SHR provided the best prognostic insight at admission to assess the relationship between SIH and ischemic stroke outcome. Absolute glucose levels failed to account for natural interpatient variation in background glycemia and provided little prognostic insight. To assess the impact of SIH, future interventional studies need to be designed using designated markers of SIH such as SHR in preference to absolute glucose.

Factors related to glycemic control in children and adolescents with type 1 diabetes mellitus in Isfahan, Iran

PURPOSE

Glycemic control is traditionally evaluated by monitoring of hemoglobin A1c (HbA1c). This study aims to explore factors related to glycemic control among pediatrics with type 1 diabetes mellitus (T1DM).

METHODS

This cross-sectional study was conducted among 454 students aged 6-18 years with T1DM in 2018. Demographic and disease related information were collected by a validated questionnaire. Generalized Linear Models (GLM) were used to investigate the association of explanatory variables with HbA1c concentration.

RESULTS

The mean (SD) age of the participants was 11.7(± 3.3) years. The overall prevalence of suboptimal glycemic control was 85.5% (HbA1c ≥ 7%). Results showed that post pubertal children experienced a significant decrease in HbA1c levels compared to prepubertal children (β =-0.83, p = 0.003). Underweight children had an increase of 1.32% in HBA1c concentration compared with normal weight children (β = 1.32, P = 0.007). We also found that participants with passive smoking had higher HBA1c levels than those without (β = 0.536, P = 0.022).

CONCLUSIONS

The results indicated that age, BMI and passive smoking and were significantly associated with HbA1c levels. It is suggested that glycemic control is related to multiple factors and the interaction of these factors with each other may have positive or negative effects on it which should be investigated in future studies. Improved understanding in this area could lead to prevention of deterioration in glycemic control.

Dyslipidemia, Diabetes and Atherosclerosis: Role of Inflammation and ROS-Redox-Sensitive Factors

The prevalence of diabetes is growing at an alarming rate with increased disability, morbidity, and often premature mortality because of the various complications of this disorder. Chronic hyperglycemia, dyslipidemia, and other metabolic alterations lead to the development and progression of macro- and microvascular complications of diabetes including cardiovascular, retinal and kidney disease. Despite advances in glucose and lipid lowering treatments, a large number of diabetic individuals develop one or more types of these complications, ultimately leading to end-organ damage over the time. Atherosclerosis is the major macro-vascular complications of diabetes and the primary underlying cause of cardiovascular disease (CVD) posing heavy burden on the health care system. In this review, we discuss the involvement of dyslipidemia in the progression of atherosclerosis by activating the pro-inflammatory cytokines and oxidative stress-related factors. In addition, we also provide information on various pharmacological agents that provides protection against diabetic atherosclerosis by reducing inflammation and oxidative stress.

Individualised versus conventional glucose control in critically-ill patients: the CONTROLING study-a randomized clinical trial

Purpose

Hyperglycaemia is an adaptive response to stress commonly observed in critical illness. Its management remains debated in the intensive care unit (ICU). Individualising hyperglycaemia management, by targeting the patient’s pre-admission usual glycaemia, could improve outcome.

Methods

In a multicentre, randomized, double-blind, parallel-group study, critically-ill adults were considered for inclusion. Patients underwent until ICU discharge either individualised glucose control by targeting the pre-admission usual glycaemia using the glycated haemoglobin A1c level at ICU admission (IC group), or conventional glucose control by maintaining glycaemia below 180 mg/dL (CC group). A non-commercial web application of a dynamic sliding-scale insulin protocol gave to nurses all instructions for glucose control in both groups. The primary outcome was death within 90 days.

Results

Owing to a low likelihood of benefit and evidence of the possibility of harm related to hypoglycaemia, the study was stopped early. 2075 patients were randomized; 1917 received the intervention, 942 in the IC group and 975 in the CC group. Although both groups showed significant differences in terms of glycaemic control, survival probability at 90-day was not significantly different (IC group: 67.2%, 95% CI [64.2%; 70.3%]; CC group: 69.6%, 95% CI [66.7%; 72.5%]). Severe hypoglycaemia (below 40 mg/dL) occurred in 3.9% of patients in the IC group and in 2.5% of patients in the CC group (p = 0.09). A post hoc analysis showed for non-diabetic patients a higher risk of 90-day mortality in the IC group compared to the CC group (HR 1.3, 95% CI [1.05; 1.59], p = 0.018).

Conclusion

Targeting an ICU patient’s pre-admission usual glycaemia using a dynamic sliding-scale insulin protocol did not demonstrate a survival benefit compared to maintaining glycaemia below 180 mg/dL.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00134-021-06526-8.

Glycemic variability of acute stroke patients and clinical outcomes: a continuous glucose monitoring study

Introduction:

Glycemic variability (GV) has been associated with worse prognosis in critically ill patients. We sought to evaluate the potential association between GV indices and clinical outcomes in acute stroke patients.

Methods:

Consecutive diabetic and nondiabetic, acute ischemic or hemorrhagic stroke patients underwent regular, standard-of-care finger-prick measurements and continuous glucose monitoring (CGM) for up to 96 h. Thirteen GV indices were obtained from CGM data. Clinical outcomes during hospitalization and follow-up period (90 days) were recorded. Hypoglycemic episodes disclosed by CGM but missed by finger-prick measurements were also documented.

Results:

A total of 62 acute stroke patients [48 ischemic and 14 hemorrhagic, median NIHSS score: 9 (IQR: 3–16) points, mean age: 65 ± 10 years, women: 47%, nondiabetic: 79%] were enrolled. GV expressed by higher mean absolute glucose (MAG) values was associated with a lower likelihood of neurological improvement during hospitalization before and after adjusting for potential confounders (OR: 0.135, 95% CI: 0.024–0.751, p = 0.022). There was no association of GV indices with 3-month clinical outcomes. During CGM recording, 32 hypoglycemic episodes were detected in 17 nondiabetic patients. None of these episodes were identified by the periodic blood glucose measurements and therefore they were not treated.

Conclusions:

Greater GV of acute stroke patients may be related to lower odds of neurological improvement during hospitalization. No association was disclosed between GV indices and 3-month clinical outcomes.

Intensification of Diabetes Medications at Hospital Discharge and Clinical Outcomes in Older Adults in the Veterans Administration Health System

IMPORTANCE

Transient elevations of blood glucose levels are common in hospitalized older adults with diabetes and may lead clinicians to discharge patients with more intensive diabetes medications than they were using before hospitalization.

OBJECTIVE

To investigate outcomes associated with intensification of outpatient diabetes medications at discharge.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study assessed patients 65 years and older with diabetes not taking insulin who were hospitalized in the Veterans Health Administration Health System between January 1, 2011, and September 28, 2016, for common medical conditions. Data analysis was performed from January 1, 2020, to March 31, 2021.

EXPOSURE

Discharge with intensified diabetes medications, defined as filling a prescription at hospital discharge for a new or higher-dose medication than was being used before hospitalization. Propensity scores were used to construct a matched cohort of patients who did and did not receive diabetes medication intensifications.

MAIN OUTCOMES AND MEASURES

Coprimary outcomes of severe hypoglycemia and severe hyperglycemia were assessed at 30 and 365 days using competing risk regressions. Secondary outcomes included all-cause readmissions, mortality, change in hemoglobin A1c (HbA1c) level, and persistent use of intensified medications at 1 year after discharge.

RESULTS

The propensity-matched cohort included 5296 older adults with diabetes (mean [SD] age, 73.7 [7.7] years; 5212 [98.4%] male; and 867 [16.4%] Black, 47 [0.9%] Hispanic, 4138 [78.1%] White), equally split between those who did and did not receive diabetes medication intensifications at hospital discharge. Within 30 days, patients who received medication intensifications had a higher risk of severe hypoglycemia (hazard ratio [HR], 2.17; 95% CI, 1.10-4.28), no difference in risk of severe hyperglycemia (HR, 1.00; 95% CI, 0.33-3.08), and a lower risk of death (HR, 0.55; 95% CI, 0.33-0.92). At 1 year, no differences were found in the risk of severe hypoglycemia events, severe hyperglycemia events, or death and no difference in change in HbA1c level was found among those who did vs did not receive intensifications (mean postdischarge HbA1c, 7.72% vs 7.70%; difference-in-differences, 0.02%; 95% CI, -0.12% to 0.16%). At 1 year, 48.0% (591 of 1231) of new oral diabetes medications and 38.5% (548 of 1423) of new insulin prescriptions filled at discharge were no longer being filled.

CONCLUSIONS AND RELEVANCE

In this national cohort study, among older adults hospitalized for common medical conditions, discharge with intensified diabetes medications was associated with an increased short-term risk of severe hypoglycemia events but was not associated with reduced severe hyperglycemia events or improve HbA1c control. These findings indicate that short-term hospitalization may not be an effective time to intervene in long-term diabetes management.

Prevalence of periodontitis in people clinically diagnosed with diabetes mellitus: a meta-analysis of epidemiologic studies

AIMS

The relationship between diabetes mellitus and periodontitis has long been discussed, but the conclusion of this relationship was controversial. We conducted this meta-analysis to explore the association between diabetes mellitus and the prevalence of periodontitis.

METHODS

PubMed, Embase, Web of Science, and the Cochrane Library were searched for studies reporting associations of periodontitis with diabetes. Gray literature was integrated from the Open-Gray database. Prevalence estimates and odds ratios were extracted by two independent reviewers and synthesized through meta-analyses.

RESULTS

Twenty-seven papers met the inclusion criteria involving 3092 diabetic patients and 23,494 controls. Overall prevalence of periodontitis was 67.8% in diabetics (combined types) and 35.5% in patients without diabetes (OR, 1.85; 95%CI, 1.61-2.11). Probing depth (MD 0.23; 95% CI, 0.17-0.29; I² = 25%) and plaque index (MD, 0.20; 95% CI, 0.18-0.23; P = 0.59; I² = 0%) severity scores were significantly greater among the diabetic group.

CONCLUSIONS

The prevalence and severity of periodontitis are greater in patients with diabetes than in non-diabetic populations.

Nursing Interns' Attitudes Toward, Preferences for, and Use of Diabetes Virtual Simulation Teaching Applications in China: National Web-Based Survey

BACKGROUND

Diabetes has placed heavy social and economic burdens on society and families worldwide. Insufficient knowledge and training of frontline medical staff, such as nurses, interns, and residents, may lead to an increase in acute and chronic complications among patients with diabetes. However, interns have insufficient knowledge about diabetes management. The factors that affect interns' current level of diabetes-related knowledge are still unclear. Therefore, understanding the behavioral intentions of interns is essential to supporting the development and promotion of the use of virtual simulation teaching applications.

OBJECTIVE

This study aimed to identify the determinants of nursing interns' intentions to use simulation-based education applications.

METHODS

From December 1, 2020, to February 28, 2021, the web-based survey tool Sojump (Changsha Xingxin Information Technology Co) was used to survey nursing interns in hospitals across China. Two survey links were sent to 37 partner schools in 23 major cities in China, and they were disseminated through participants' WeChat networks. Multiple regression analysis was used to determine the association between demographic information and basic disease information and the use of the application for treating adult patients.

RESULTS

Overall, 883 nursing interns from 23 provinces in China responded to the survey. Among them, the virtual simulation utilization rate was 35.6% (314/883) and the awareness rate was 10.2% (90/883). In addition, among the interns, only 10.2% (90/883) correctly understood the concept of virtual simulation, and most of them (793/883, 89.8%) believed that scenario-simulation training or the use of models for teaching are all the same. Multiple regression analysis showed that the educational level, independent learning ability, and professional identity of the interns were related to use of the application (P<.05). Skills and knowledge that the interns most wanted to acquire included the treatment of hypoglycemia (626/883, 70.9%), functional test simulation (610/883, 69.1%), and blood glucose monitoring technology (485/883, 54.9%). A total of 60.5% (534/883) of the interns wanted to acquire clinical thinking skills, while 16.0% (141/883) wanted to acquire operational skills. Nursing trainees believed that the greatest obstacles to virtual simulation included limited time (280/883, 31.7%), the degree of simulation (129/883, 14.6%), the demand for satisfaction (108/883, 12.2%), and test scores (66/883, 7.5%).

CONCLUSIONS

The understanding and usage rate of diabetes virtual simulation teaching applications by Chinese nursing interns is very low. However, they have high requirements regarding this teaching method. Conducting high-quality randomized controlled trials and designing applications that are suitable for the needs of different nurse trainees will increase students' interest in learning and help improve diabetes knowledge among nursing interns.

Associations of galectin-3 expression and LGALS-3 (rs4652) gene variant with coronary artery disease risk in diabetics

Background

Galectin-3 protein encoded by lectin galactoside-binding soluble-3 (LGALS-3) gene is an important genetic factor in type 2 diabetes mellitus (T2DM) and its cardiovascular obstacles in various populations. We aimed to elicit the pro-inflammatory effect of galectin-3 as determined by interleukin-6 (IL-6) serum levels and to explore the relationship between galectin-3 (LGALS-3 rs4652) gene variant and its expression levels with coronary artery disease (CAD) risk among T2DM Egyptian patients.

Methods

112 lean subjects were compared to 100 T2DM without CAD and 84 T2DM with CAD. A tetra-primer amplification refractory mutation system polymerase chain reaction was used to test LGALS-3 (rs4652), and galectin3 expression was tested with a quantitative real-time polymerase chain reaction. Serum IL-6 was measured using an enzyme-linked immunosorbent assay.

Results

We found that the prevalence of LGALS-3 (rs4652) AC genotype and galectin-3 gene expression levels in T2DM with CAD were significantly higher than the additional 2 groups and were correlated positively to IL-6 circulating levels. Also, the C allele carriers (AC+CC) had significantly higher relative Galectin-3 expression levels compared to the A allele carriers (AA).

Conclusions

We concluded that galectin-3 expression levels and LGALS-3 (rs4652) AC genotype were coronary artery disease risk factors in people with type two diabetes among an Egyptian sample.

Evaluating Perioperative Glycemic Control of Non-cardiac Surgical Patients with Diabetes

INTRODUCTION

Hyperglycemia during the perioperative period has generally been accepted as a contributor of poor outcomes in patients with diabetes mellitus undergoing surgery. Although an optimal glycemic range has not been clearly established in the literature, a consensus among national medical organizations generally recommends serum glucose levels to be maintained less than 180 mg/dL during the perioperative period.

MATERIALS AND METHODS

The primary purpose of this evidence-based project was to identify the range of blood glucose values obtained from adult patients with diabetes mellitus undergoing non-cardiac surgery at a large military medical facility. The secondary purpose of this project was to assess the need for change in future practice. A retrospective review of the electronic medical record was conducted to identify adult surgical patients with diabetes scheduled for non-cardiac surgery. Preoperative and postoperative blood glucose values were obtained from the electronic medical record. The frequency of blood glucose values maintained within the recommended range of 140-180 mg/dL was recorded. Additional demographic data were collected to include age, height, weight, body mass index, length of surgery, and insulin/oral glycemic medications.

RESULTS

Of the 9,449 surgeries performed between January 1, 2013, and December 31, 2013, there were 762 (8%) adult non-cardiac surgical patients identified with either a diagnosis of diabetes or a blood glucose value reported during the perioperative period. The recommended blood glucose range of 140-180 mg/dL was achieved in 31.3% (179 of 572) of patients before surgery and 28.6% (71 of 248) after surgery. A blood glucose value was not recorded before or after surgery in 24.9% (190 of 762) of patients identified as having pre-diabetes or diabetes.

CONCLUSION

Diabetes is a frequent finding in surgical patients. Monitoring blood glucose values during the perioperative period may allow for early treatment and prevent complications related to poor glycemic control. The results of this project revealed 2 potential areas of improvement in the care of non-cardiac surgical patients with diabetes: (1) improving compliance with obtaining blood glucose values before and after surgery and (2) reducing the incidence of postoperative hyperglycemia (>180 mg/dL) which potentially could prevent avoidable complications related to poor glycemic control.

Stress Hyperglycemia and Osteocalcin in COVID-19 Critically Ill Patients on Artificial Nutrition

We aimed to study the possible association of stress hyperglycemia in COVID-19 critically ill patients with prognosis, artificial nutrition, circulating osteocalcin, and other serum markers of inflammation and compare them with non-COVID-19 patients. Fifty-two critical patients at the intensive care unit (ICU), 26 with COVID-19 and 26 non-COVID-19, were included. Glycemic control, delivery of artificial nutrition, serum osteocalcin, total and ICU stays, and mortality were recorded. Patients with COVID-19 had higher ICU stays, were on artificial nutrition for longer (p = 0.004), and needed more frequently insulin infusion therapy (p = 0.022) to control stress hyperglycemia. The need for insulin infusion therapy was associated with higher energy (p = 0.001) and glucose delivered through artificial nutrition (p = 0.040). Those patients with stress hyperglycemia showed higher ICU stays (23 ± 17 vs. 11 ± 13 days, p = 0.007). Serum osteocalcin was a good marker for hyperglycemia, as it inversely correlated with glycemia at admission in the ICU (r = -0.476, p = 0.001) and at days 2 (r = -0.409, p = 0.007) and 3 (r = -0.351, p = 0.049). In conclusion, hyperglycemia in critically ill COVID-19 patients was associated with longer ICU stays. Low circulating osteocalcin was a good marker for stress hyperglycemia.

Inpatient Glycemic Control With Sliding Scale Insulin in Noncritical Patients With Type 2 Diabetes: Who Can Slide?

OBJECTIVE

Despite clinical guideline recommendations, sliding scale insulin (SSI) is widely used for the hospital management of patients with type 2 diabetes (T2D). We aimed to determine which patients with T2D can be appropriately managed with SSI in non-critical care settings.

METHODS

We used electronic health records to assess inpatient glycemic control in medicine and surgical patients treated with SSI according to admission blood glucose (BG) concentration between June 2010 and June 2018. Primary outcome was the percentage of patients with T2D achieving target glycemic control, defined as mean hospital BG 70 to 180 mg/dL without hypoglycemia <70 mg/dL during SSI therapy.

RESULTS

Among 25,813 adult patients with T2D, 8,095 patients (31.4%) were treated with SSI. Among patients with admission BG <140 mg/dL and BG 140 to 180 mg/dL, 86% and 83%, respectively, achieved target control without hypoglycemia, as compared with only 18% of those with admission BG ≥250 mg/dL (P < .001). After adjusting for age, gender, body mass index (BMI), race, Charlson Comorbidity Index score, and setting, the odds of poor glycemic control increased with higher admission BG (BG 140-180 mg/dL: odds ratio [OR], 1.8; 95% CI, 1.5-2.2; BG 181-250 mg/dL: OR, 3.7; 95% CI, 3.1-4.4; BG >250 mg/dL: OR, 7.2; 95% CI, 5.8-9.0), as compared with patients with BG <140 mg/dL. A total of 1,192 patients (15%) treated with SSI required additional basal insulin during hospitalization.

CONCLUSION

Most non-intensive care unit patients with admission BG <180 mg/dL treated with SSI alone achieve target glycemic control during hospitalization, suggesting that cautious use of SSI may be a viable option for certain patients with mild hyperglycemia.

Advances in safe insulin infusions

Hyperglycaemia is recognized as a marker of adverse clinical outcomes for hospitalized patients with and without diabetes, including mortality, morbidity, increased length of stay, infections and overall complications. In some cases, intravenous (IV) insulin infusions are the optimal intervention and, to date, these have been compounded in hospital pharmacy departments or, alternatively, at the point of care, when timeliness is a concern or the pharmacy is closed. However, in-house compounding of high-risk medications such as IV insulin poses risks both for patients and institutions. The critical nature of certain high-risk therapies has led to the development of ready-to-administer products to improve the safety, timeliness, efficacy and efficiency of critical infusions. Recently, IV insulin, a high-alert therapy, has been added to the ready-to-use armamentarium. This narrative review explores the expanding indications, risks and opportunities associated with insulin infusions and potential options for improved safety.