Ultrarapid Insulin Use Can Reduce Postprandial Hyperglycemia and Late Hypoglycemia, Even in Delayed Insulin Injections: A Connected Insulin Cap-Based Real-World Study

Objectives: Reaching optimal postprandial glucose dynamics is a daily challenge for people with type 1 diabetes (T1D). This study aimed to analyze the postprandial hyperglycemic excursion (PHEs) and late postprandial hypoglycemia (LPH) risk according to prandial insulin time and type. Research Design and Methods: Real-world, retrospective study in T1D using multiple daily injections (MDI) analyzing 5 h of paired continuous glucose monitoring and insulin injections data collected from the connected cap Insulclock®. Meal events were identified using the rate of change detection methodology. Postprandial glucometrics and LPH (glucose <70 mg/dL 2-5 h after a meal) were evaluated according to insulin injection time and rapid (RI) or ultrarapid analog, Fiasp® (URI), use. Results: Meal glycemic excursions (n = 2488), RI: 1211, 48.7%; UR: 1277, 51.3%, in 82 people were analyzed according to injection time around the PHE: -45 to -15 min; -15 to 0 min; and 0 to +45 min. In 63% of the meals, insulin was injected after the PHE started. Lower PHE was observed with URI versus RI (glucose peak-baseline; mg/dL; mean ± standard deviation): 106.7 ± 35.2 versus 111.2 ± 40.3 (P = 0.003), particularly in 0/+45 injections: 111.6 ± 40.2 versus 118.1 ± 43.3; (P = 0.002). One third (29.1%) of participants added a second (correction) injection. The use of URI and avoiding a second injection were independently associated with less LPH risk, even in delayed injections (0/+45), (-36%, odds ratio [OR] 0.641; confidence interval [CI]: 0.462-0.909; P = 0.012) and -56% (OR 0.641; CI: 0.462-0.909 P = 0.038), respectively. Conclusions: URI analog use as prandial insulin reduces postprandial hyper- and hypoglycemia, even in delayed injections.

Evaluation of pharyngeal lidocaine anesthesia for esophagogastroduodenoscopy: Double-blind randomized control trial

OBJECTIVES

The aim of this study was to assess whether the use of topical pharyngeal anesthesia improves endoscopist- and patient-reported tolerance and satisfaction, the total dose of propofol used and the rate of adverse effects associated with this procedure.

METHODS

This double-blind randomized clinical trial was conducted in patients undergoing elective oesophagogastroduodenoscopy, who met the inclusion criteria. Patients were randomly assigned to receive five squirts of lidocaine 10% spray (50 mg, n = 268) or placebo (n = 271) 3 min before starting the procedure or sedation. The main outcome measures were patient- and endoscopist-reported tolerance, and additionally, satisfaction with the procedure, adverse events and supplementary propofol used.

RESULTS

In the lidocaine group, it was twice (odds ratio [OR] 2.136, 95% confidence interval [CI] 1.228-3.715) or three times (OR 3.311, 95% CI 1.623-6.757) more likely that the endoscopist rated the procedure as well tolerated and easy to intubate than as well tolerated but the patient difficult to intubate or as poorly tolerated, respectively. Further, in these patients, less propofol was used (80 vs. 100 mg, P = 0.001). Controls were more likely to cough during the intubation (OR 2.172, 95% CI 1.378-3.423) and the procedure (OR 1.989, 95% CI 1.325-2.984), as well as more likely to retch (OR 3.582, 95% CI 1.667-7.7).

CONCLUSIONS

Topical lidocaine may improve the procedure as rated by the endoscopist, as well as reduce the requirement for propofol and rate of adverse events such as retching and coughing. No adverse events associated with lidocaine administration were observed. ClinicalTrials registration no. NCT02733471.

Effect of Obesity and Roux-En-Y Gastric Surgery on Omeprazole Pharmacokinetics

INTRODUCTION

The prevalence of obesity is increasing globally. The principal aim was to evaluate whether gastric bypass surgery modifies the bioavailability and pharmacokinetic (PK) parameters of omeprazole.

METHODS

Controlled, open-label, bioavailability clinical trial in patients undergoing Roux-en-Y gastric bypass (RYGB). Healthy patients with obesity (body mass index >35) were included and assessed for omeprazole PKs before and after RYGB (1 and 6 months). PK sampling was done at baseline and several times up to 12 h after drug dosing. Pre- and post-surgery parameters were compared using paired ANOVA or Wilcoxon tests, and control versus cases using ANOVA or Mann-Whitney tests. Given the post-surgery change in body weight, parameters were corrected by dose/body weight.

RESULTS

Fourteen case and 24 control subjects were recruited; 92% were women (N = 35/38). In patients who underwent RYGB, maximum plasma concentration (Cmax) was significantly reduced at 1 and 6 months after surgery compared with presurgery values (p = 0.001). Regarding the AUC, the values are lower at 1 and 6 months after surgery than at baseline (p < 0.001). The drug clearance was also increased in the first month after surgery. No differences were found between patients 6 months after surgery and controls. Cmax and AUC corrected by dose/body weight were significantly different between the baseline surgery subjects and controls. Discusion/Conclusions: Omeprazole bioavailability is reduced in patients with obesity at 1 and 6 months after RYGB. However, omeprazole PK parameters 6 months after RYGB are similar to control subjects, and thus no dose correction is required after RYGB for a given indication.

Comparison of different scales for the evaluation of anxiety and compliance with anesthetic induction in children undergoing scheduled major outpatient surgery

INTRODUCTION

Anxiety in children triggered by a scheduled surgical intervention is a major issue due to its frequency and consequences. Preoperative anxiety is associated with increased patient fear and agitation on anesthetic induction. The aim of this study is to compare three preoperative anxiety scales for children undergoing elective outpatient surgery, and to correlate each of these tools with the degree of patient compliance on induction, as assessed by the Induction Compliance Checklist (ICC).

METHODS

An observational prospective study was performed on a cohort of children with ages between 2 and 16 years old, scheduled for outpatient surgery. Anxiety was assessed upon arrival to the hospital (M0), during transfer to the surgical unit (M1), and in the operating room during anesthetic induction (M2). Anxiety in the parents (measured with the State-Trait Anxiety Inventory, STAI) and in the children (measured with the Spence Anxiety Scale-Pediatric, SCAS-P, the State-Trait Anxiety Inventory Children, STAIC, and Modified Yale Preoperative Anxiety Scale, m-YPAS) was assessed. Compliance with anesthetic induction was assessed with ICC.

RESULTS

The study included 76 patients (72.4% male, median age 7.9 years). Anxiety scores (m-YPAS) increased as the moment of surgery approached, being greater at the entrance to the surgical unit (M0 = 26.1 ± 9.5; M1 = 31.8 ± 18.1; M2 = 33.5 ± 21.1). A strong correlation was found between ICC scale and m-YPAS at M1 (0.738) and M2 timepoints (0.794), but not with the rest of scales at M0.

CONCLUSIONS

Standard anxiety assessment scales do not predict the quality of anesthetic induction. m-YPAS scale can detect increasing anxiety in children as they approach the surgical procedure and this correlates strongly with a worse anesthetic induction, defined by higher score on ICC scale.

Thirty-day outcomes in frail older patients discharged home from the emergency department with acute heart failure: effects of high-risk criteria identified by the DEED FRAIL-AHF trial

OBJECTIVES

To study the effect of high-risk criteria on 30-day outcomes in frail older patients with acute heart failure (AHF) discharged from an emergency department (ED) or an ED's observation and short-stay areas.

MATERIAL AND METHODS

Secondary analysis of discharge records in the Older AHF Key Data registry. We selected frail patients (aged > 70 years) discharged with AHF from EDs. Risk factors were categorized as modifiable or nonmodifiable. The outcomes were a composite endpoint for a cardiovascular event (revisits for AHF, hospitalization for AHF, or cardiovascular death) and the number of days alive out-of-hospital (DAOH) within 30 days of discharge.

RESULTS

We included 380 patients with a mean (SD) age of 86 (5.5) years (61.2% women). Modifiable risk factors were identified in 65.1%, nonmodifiable ones in 47.8%, and both types in 81.6%. The 30-day cardiovascular composite endpoint occurred in 83 patients (21.8%). The mean 30-day DAOH observed was 27.6 (6.1) days. Highrisk factors were present more often in patients who developed the cardiovascular event composite endpoint: the rates for patients with modifiable, nonmodifiable, or both types of risk were, respectively, as follows in comparison with patients not at high risk: 25.0% vs 17.2%, P = .092; 27.6% vs 16.7%, P = .010; and 24.7% vs 15.2%, P = .098). The 30-day DAOH outcome was also lower for at-risk patients, according to type of risk factor present: modifiable, 26.9 (7.0) vs 28.4 (4.4) days, P = .011; nonmodifiable, 27.1 (7.0) vs 28.0 (5.0) days, P = .127; and both, 27.1 (6.7) vs 28.8 (3.4) days, P = .005). After multivariate analysis, modifiable risk remained independently associated with fewer days alive (adjusted absolute difference in 30-day DAOH, -1.3 days (95% CI, -2.7 to -0.1 days). Nonmodifiable factors were associated with increased risk for the 30-day cardiovascular composite endpoint (adjusted absolute difference, 10.4%; 95% CI, -2.1% to 18.7%).

CONCLUSION

Risk factors are common in frail elderly patients with AHF discharged home from hospital ED areas. Their presence is associated with a worse 30-day prognosis.

Short-course antibiotic regimen compared to conventional antibiotic treatment for gram-positive cocci infective endocarditis: randomized clinical trial (SATIE)

Background

Most serious complications of infective endocarditis (IE) appear in the so-called “critical phase” of the disease, which represents the first days after diagnosis. The majority of patients overcoming the acute phase has a favorable outcome, yet they remain hospitalized for a long period of time mainly to complete antibiotic therapy. The major hypothesis of this trial is that in patients with clinically stable IE and adequate response to antibiotic treatment, without signs of persistent infection, periannular complications or metastatic foci, a shorter antibiotic time period would be as efficient and safe as the classic 4 to 6 weeks antibiotic regimen.

Methods

Multicenter, prospective, randomized, controlled open-label, phase IV clinical trial with a non-inferiority design to evaluate the efficacy of a short course (2 weeks) of parenteral antibiotic therapy compared with conventional antibiotic therapy (4–6 weeks).

Sample: patients with IE caused by gram-positive cocci, having received at least 10 days of conventional antibiotic treatment, and at least 7 days after surgery when indicated, without clinical, analytical, microbiological or echocardiographic signs of persistent infection. Estimated sample size: 298 patients. Intervention: Control group: standard duration antibiotic therapy, (4 to 6 weeks) according to ESC guidelines recommendations. Experimental group: short-course antibiotic therapy for 2 weeks. The incidence of the primary composite endpoint of all-cause mortality, unplanned cardiac surgery, symptomatic embolisms and relapses within 6 months after the inclusion in the study will be prospectively registered and compared.

Conclusions

SATIE will investigate whether a two weeks short-course of intravenous antibiotics in patients with IE caused by gram-positive cocci, without signs of persistent infection, is not inferior in safety and efficacy to conventional antibiotic treatment (4–6 weeks).

Trial registration

ClinicalTrials.gov Identifier: NCT04222257 (January 7, 2020).

EudraCT 2019–003358-10.

Planning to reduce 30-day adverse events after discharge of frail elderly patients with acute heart failure: design and rationale for the DEED FRAIL-AHF trial

OBJECTIVES

To demonstrate the efficacy of a system for comprehensive care transfer (Multilevel Guided Discharge Plan [MGDP]) for frail older patients diagnosed with acute heart failure (AHF) and to validate the results of MGDP implementation under real clinical conditions. The MGDP seeks to reduce the number of adverse outcomes within 30 days of emergency department (ED) discharge.

MATERIAL AND METHODS

We will enroll frail patients over the age of 70 years discharged home from the ED with a main diagnosis of AHF. The MGDP includes the following components: 1) a checklist of clinical recommendations and resource activations, 2) scheduling of an early follow-up visit, 3) transfer of information to the primary care doctor, and 4) written instructions for the patient. Phase 1 of the study will be a matched-pair cluster-randomized controlled trial. Ten EDs will be randomly assigned to the intervention group and 10 to the control group. Each group will enroll 480 patients, and the outcomes will be compared between groups. Phase 2 will be a quasi-experimental study of the intervention in 300 new patients enrolled by the same 20 EDs. The outcomes will be compared to those for each Phase-1 group. The main endpoint at 30 days will be a composite of 2 outcomes: revisits to an ED and/for hospitalization for AHF or cardiovascular death.

CONCLUSION

The study will assess the efficacy and feasibility of comprehensive MGDP transfer of care for frail older AHF patients discharged home.

Efficacy and side-effects profile of the ethinylestradiol and etonogestrel contraceptive vaginal ring: a systematic review and meta-analysis

OBJECTIVE

To assess the efficacy and tolerability (side-effects profile), and compliance of the combined contraceptive vaginal ring (CCVR) compared with combined oral hormonal contraceptives (COC).

DATA SOURCES

The PubMed, Embase, POPLINE, Cochrane Central Register of Controlled Trials (CENTRAL), LILACS, ClinicalTrials.gov, Clinical Trials Registry Platform (ICTRP) and CINAHL databases were searched.

METHODS OF STUDY SELECTION

Electronic databases were searched for randomised clinical trials comparing the CCVR with COC with a duration of at least 3 months between 01 December and 15 December 2015. The primary outcome was efficacy. The secondary outcomes were compliance, absence of withdrawal bleeding, breakthrough bleeding, nausea and headache. Heterogeneity was assessed using I² statistic and Cochran's Q statistic. Results were expressed as odds ratios (OR) with 95% confidence intervals (CIs) using random-effects models or fixed-effects models depending on the heterogeneity.

RESULTS

4368 records were identified, 2844 of which were removed after duplicates and 1524 records were screened. Of these, 1503 were excluded and 21 full text articles were assessed for eligibility. After removing another 7 articles, 14 records were finally included in the qualitative and quantitative analysis. The results show a trend to higher efficacy for the CCVR in preventing pregnancy (Peto OR: 0.52 [95% CI: 0.26-1.04]) and a significantly lower presence of nausea (Peto OR: 0.66 [95% CI: 0.46-0.93]). More cycles were compliant in the CCVR group (Peto OR: 1.22 [95% CI: 1.12-1.32]) and fewer women reported breakthrough bleeding (Peto OR: 0.68 [95% CI: 0.51-0.91]).

CONCLUSIONS

Our findings demonstrate that the CCVR is as effective and tolerable as the COC but with a better bleeding profile.

Assessment of the introduction of a blood management program in orthopaedic surgery

OBJECTIVE

To assess the impact of implementing a Patient Blood management program (PBM) on transfusion rates, hospital stay, and complications for total hip arthroplasty (THA) and total knee arthroplasty (TKA).

MATERIAL AND METHODS

A retrospective, observational study was conducted in Araba University Hospital from 2006 to 2011. All THA and TKA were included. The percentage of patients transfused with allogeneic blood was the primary endpoint. The mean of transfused blood bags, overall transfusion, complications (both overall and specific), patient age and sex, pre-operative and discharge hemoglobin, and hospital stay were recorded.

RESULTS

A total of 825 THA and 875 TKA were included. Both THA (47.6% in 2006 and 30.6% in 2011; P=.013) and TKA (33.6% in 2006 and 16.2% in 2011; P<.001) showed a significant decrease of allogeneic transfusion. The overall transfusion rate was also reduced in THA (65.7% in 2006 and 39.5% in 2011; P<.001) and TKA (38.3% in 2006 and 17.2% in 2011; P<.001). Hospital stay was reduced in both types of surgeries (P<.038 in THA and P<.0001 in TKA). In 2006 it was 9.2±2.9 days for THA and 11.1±4.7 days for TKA, whereas in 2011 it was 8.7±4.2 and 9.5±3.4 days for THA and TKA, respectively.

CONCLUSIONS

Our patient blood management has decreased the percentage of patients that need both allogeneic and autologous transfusion in a statistically significant way. Although the mean hospital stay decreased, the impact of the PBM cannot be established.

Variability in the detection and monitoring of chronic patients in primary care according to what is registered in the electronic health record

BACKGROUND

The electronic health record (EHR) allows a detailed study of the primary care consultations and assessment of variability among physicians regarding the implementation of practices for prevention, detection and monitoring of chronic diseases.

OBJECTIVES

To describe the variability in the detection and surveillance of chronic conditions in primary care.

METHODS

Review of the medical records maintained by 1685 primary care physicians in the Basque Health Service. Estimation of age and sex standardized rates of compliance with evidence-based recommendations and the systematic component of variation (SCV).

RESULTS

Compliance with screening recommendations varied from 14.2% for chronic obstructive pulmonary disease (COPD) to 37.2% for hypercholesterolaemia of the at-risk populations. Variability between Primary Care Units (PCUs) was low (SCV(5) (-95) < 0.10) for high blood pressure, hypercholesterolaemia and diabetes and high (SCV(5) (-95) ≥ 0.20) for COPD. Based on the EHR registries, recommendations were followed to in at least 50% of relevant patients according to only 10 of the 44 good care practice (GCP) criteria. For 16 of the GCP criteria, the EHR data indicated compliance to the recommendations in <25% of patients diagnosed.

CONCLUSIONS

EHR data indicate that some of the preventative care practices recommended to detect chronic problems in primary care are unevenly implemented across PCUs. Notably, there is less variation in the case of conditions for which evidence-based clinical practice guidelines have been published. The level of monitoring is inadequate for all the conditions studied; particularly in those in which it is less evident that primary care is the right level of the health service to provide this care.

Knowledge, attitudes and perceptions of health professionals in relation to A/H1N1 influenza and its vaccine

OBJECTIVE

To determine the intention of health professionals, doctors and nurses, concerning whether or not to be vaccinated against A/H1N1 influenza virus, and their perception of the severity of this pandemic compared with seasonal flu.

MATERIAL AND METHODS

A cross-sectional study was carried out based on an questionnaire e-mailed to health professionals in public healthcare centres in Vitoria between 6 and 16 November 2009; the percentage of respondents who wanted to be vaccinated and who perceived the pandemic flu to carry a high risk of death were calculated.

RESULTS

A total of 115 people completed the questionnaire of whom 61.7% (n=71) were doctors and 38.3% (n=44) were nurses. Of these, 33.3% (n=23) of doctors and 13.6% (n=6) of nurses intended to be vaccinated (p=0.019). Even among those who considered themselves to be at a high risk, 70.6% (n=48) of doctors and 31.7% (n=13) of nurses participating in the study (p=0.001) planned to have the vaccination.

CONCLUSIONS

Most health professionals, and in particular nurses, had no intention to be vaccinated against A/H1N1 influenza virus at the beginning of the vaccination campaign.

[Population-based cross sectional study about vaccine acceptability and perception of the severity of A/H1N1 influenza: opinion of the general population and health professionals]

OBJECTIVES

To determine the intention of general population and health professionals to vaccinate against the H1N1 influenza A virus. To determine the perception of severity of the H1N1 influenza A in both groups compared to that of seasonal influenza.

METHODS

Cross-sectional telephone survey performed to a sample of population (obtained randomly from the Vitoria-Gasteiz telephone directory) and cross-sectional electronically-administered survey to a sample of health professionals from public health centres in Vitoria-Gasteiz, conducted between 6th and 16th November 2009. The relative and absolute frecuency of persons willing to be vaccinated and the proportion of those considering the H1N1 influenza A as a life-threatening risk were calculated in both groups.

RESULTS

219 (33%) persons out of 637 contacted telephone numbers answered the questionnaire, as well as 109 health professionals. 63.0% (n=138) of general population and 73.4% (n=80) of the professional group would not undergo vaccination, even if it was for free (p=0.595). If belonging to a high-risk group, the corresponding proportions of unwillingness were 14.6% (n=32) for general population and 40.4 (n=44) for professionals (p<0.001). The proportion of undecided persons is 25.6% (n=56) in general population, against 6.4% (n=7) among the professionals.

CONCLUSIONS

At the beginning of the vaccination campaign, the majority of population is unwilling to undergo immunization against the H1N1 influenza A virus. The proportion in general population is similar to that among the health professionals. However, when belonging to a high-risk group, there is a high proportion of undecided persons in general population.