Is it possible to constantly and accurately monitor blood sugar levels, in people with Type 1 diabetes, with a discrete device (non-invasive or invasive)?

Real-time continuous glucose monitors using subcutaneous needle-type sensors continue to develop. The limitations of currently available systems, however, include time lag behind changes in blood glucose, the invasive nature of such systems, and in some cases, their accuracy. Non-invasive techniques have been developed, but, to date, no commercial device has been successful. A key research priority for people with Type 1 diabetes identified by the James Lind Alliance was to identify ways of monitoring blood glucose constantly and accurately using a discrete device, invasive or non-invasive. Integration of such a sensor is important in the development of a closed-loop system and the technology must be rapid, selective and acceptable for continuous use by individuals. The present review provides an update on existing continuous glucose-sensing technologies, and an overview of emergent techniques, including their accuracy and limitations.

P4171Population characteristics, interventions and outcomes in hospitalized orthotopic heart transplant patients with sudden cardiac arrest: a nationwide United States analysis from 2007 to 2015

Background

Sudden cardiac arrest (SCA) is a leading cause of death in the United States (US), claiming up to 450,000 lives annually and accounting for ∼25% of deaths following orthotopic heart transplantation (OHT),

Purpose

We sought to characterize OHT patients suffering SCA and their subsequent management, in comparison to the general, native heart (NH) population, using a large national inpatient database.

Methods

A cross-sectional analysis was performed among US OHT & NH patients hospitalized with incident SCA or ventricular fibrillation/flutter. We analyzed demographics, baseline characteristics, procedural utilization and outcomes. Groups were compared with standard statistical techniques. A P-value <0.05 was considered significant.

Results

From 2007–2015, 920 SCA admissions were identified among 121,083 (0.8%) OHT hospitalizations, compared to 1,731,658 (0.6%) in the general population (P<0.001). OHT patients were younger (P<0.001) and predominantly men (P<0.001). More OHT patients had diabetes (P=0.01), while the NH group had more coronary disease (P=0.01). Mechanical circulatory support use was similar in both groups overall, and OHT patients were more likely to undergo transplantation (P=0.015). Pacemaker/defibrillator implants were more common in NH than OHT patients (P<0.001). Acute kidney injury and in-hospital mortality were significantly greater in OHT patients.

Table 1. SCA in OHT & general populations Orthotopic Heart Transplant General Population P-value (N=121,083) (N=278,463,550) Sudden cardiac arrest (SCA) events, n (%) 920 (0.8%) 1,731,658 (0.6%) <0.001 Age, mean (SD) 57 (17) 66 (16) <0.001 Male sex, n (%) 644 (72%) 1,004,362 (58%) <0.001 Coronary artery disease, n (%) 275 (30%) 675,908 (39%) 0.012 Mechanical circulatory support, n (%) 64 (7%) 104,151 (6%) 0.230 Repeat heart transplantation, n (%) 5 (0.5%) 1199 (0.1%) 0.015 Pacemaker or defibrillator implant, n (%) 45 (5%) 136,314 (8%) <0.001 In-hospital mortality, n (%) 555 (60%) 932,812 (54%) 0.014 Cardiogenic shock, n (%) 78 (8%) 208,778 (12%) <0.001 Acute kidney injury, n (%) 418 (45%) 608,035 (35%) 0.003

Conclusions

SCA hospitalizations occur more often and with higher mortality in OHT patients compared to the general population. Earlier recognition of at-risk patients may result in improved utilization of potentially life-saving therapies.

Surgical options for glycaemic control in Type 1 diabetes

In recent years, bariatric surgery, also referred to as metabolic surgery, has become the most successful treatment option in those with Type 2 diabetes and obesity. There are some similarities in the pathological pathways in Type 1 and Type 2 diabetes, but the use of surgery in Type 1 diabetes remains unestablished and controversial. The treatment and management of Type 1 diabetes can be very challenging but recent advances in surgical interventions and technology has the potential to expand and optimize treatment options. This review discusses the current status of some surgical options available to people with Type 1 diabetes. These include implantable continuous glucose monitoring systems, continuous intraperitoneal insulin infusion pumps, closed-loop insulin delivery systems (also known as the artificial pancreas system) utilizing the latter two modalities of glucose monitoring and insulin delivery, and bariatric or metabolic surgery. Whole pancreas and islet transplantation are beyond the scope of this review but are briefly discussed.

Clinical and laboratory profile of anti-M

Anti-M is a frequently detected naturally occurring antibody that has been reported in various clinical settings and also in voluntary donors. We describe here the clinical and laboratory findings of 11 cases with anti-M detected at our center. This report is a retrospective study in which we reviewed our immunohematology laboratory records for cases involving anti-M. Both donor and patient data from a 28-month period (September 2014 to December 2016) were reviewed. During this period, 11 examples of anti-M were detected (8 patients, 1 voluntary whole blood donor, and 1 hematopoietic stem cell donor. Anti-M was also detected in one external quality assessment scheme sample received during this period. In conclusion, anti-M can be detected in various clinical settings. This antibody can be clinically significant; in the laboratory, it can present as a serologic problem such as an ABO group discrepancy or an incompatible crossmatch. After detection, management and course of action is determined by both the antibody characteristics and the clinical setting. Anti-M is a frequently detected naturally occurring antibody that has been reported in various clinical settings and also in voluntary donors. We describe here the clinical and laboratory findings of 11 cases with anti-M detected at our center. This report is a retrospective study in which we reviewed our immunohematology laboratory records for cases involving anti-M. Both donor and patient data from a 28-month period (September 2014 to December 2016) were reviewed. During this period, 11 examples of anti-M were detected (8 patients, 1 voluntary whole blood donor, and 1 hematopoietic stem cell donor. Anti-M was also detected in one external quality assessment scheme sample received during this period. In conclusion, anti-M can be detected in various clinical settings. This antibody can be clinically significant; in the laboratory, it can present as a serologic problem such as an ABO group discrepancy or an incompatible crossmatch. After detection, management and course of action is determined by both the antibody characteristics and the clinical setting.

Selective RET kinase inhibition for patients with RET-altered cancers

Background

Alterations involving the RET kinase are implicated in the pathogenesis of lung, thyroid and other cancers. However, the clinical activity of multikinase inhibitors (MKIs) with anti-RET activity in RET-altered patients appears limited, calling into question the therapeutic potential of targeting RET. LOXO-292 is a selective RET inhibitor designed to inhibit diverse RET fusions, activating mutations and acquired resistance mutations.

Patients and methods

Potent anti-RET activity, high selectivity, and central nervous system coverage were confirmed preclinically using a variety of in vitro and in vivo RET-dependent tumor models. Due to clinical urgency, two patients with RET-altered, MKI-resistant cancers were treated with LOXO-292, utilizing rapid dose-titration guided by real-time pharmacokinetic assessments to achieve meaningful clinical exposures safely and rapidly.

Results

LOXO-292 demonstrated potent and selective anti-RET activity preclinically against human cancer cell lines harboring endogenous RET gene alterations; cells engineered to express a KIF5B-RET fusion protein -/+ the RET V804M gatekeeper resistance mutation or the common RET activating mutation M918T; and RET-altered human cancer cell line and patient-derived xenografts, including a patient-derived RET fusion-positive xenograft injected orthotopically into the brain. A patient with RET M918T-mutant medullary thyroid cancer metastatic to the liver and an acquired RET V804M gatekeeper resistance mutation, previously treated with six MKI regimens, experienced rapid reductions in tumor calcitonin, CEA and cell-free DNA, resolution of painful hepatomegaly and tumor-related diarrhea and a confirmed tumor response. A second patient with KIF5B-RET fusion-positive lung cancer, acquired resistance to alectinib and symptomatic brain metastases experienced a dramatic response in the brain, and her symptoms resolved.

Conclusions

These results provide proof-of-concept of the clinical actionability of RET alterations, and identify selective RET inhibition by LOXO-292 as a promising treatment in heavily pretreated, multikinase inhibitor-experienced patients with diverse RET-altered tumors.

A randomized controlled pilot study of continuous glucose monitoring and flash glucose monitoring in people with Type 1 diabetes and impaired awareness of hypoglycaemia

AIM

Hypoglycaemia in Type 1 diabetes is associated with mortality and morbidity, especially where awareness of hypoglycaemia is impaired. Clinical pathways for access to continuous glucose monitoring (CGM) and flash glucose monitoring technologies are unclear. We assessed the impact of CGM and flash glucose monitoring in a high-risk group of people with Type 1 diabetes.

METHODS

A randomized, non-masked parallel group study was undertaken. Adults with Type 1 diabetes using a multiple-dose insulin-injection regimen with a Gold score of ≥ 4 or recent severe hypoglycaemia were recruited. Following 2 weeks of blinded CGM, they were randomly assigned to CGM (Dexcom G5) or flash glucose monitoring (Abbott Freestyle Libre) for 8 weeks. The primary outcome was the difference in time spent in hypoglycaemia (below 3.3 mmol/l) from baseline to endpoint with CGM versus flash glucose monitoring.

RESULTS

Some 40 participants were randomized to CGM (n = 20) or flash glucose monitoring (n = 20). The participants (24 men, 16 women) had a median (IQR) age of 49.6 (37.5-63.5) years, duration of diabetes of 30.0 (21.0-36.5) years and HbA_1c of 56 (48-63) mmol/mol [7.3 (6.5-7.8)%]. The baseline median percentage time < 3.3 mmol/l was 4.5% in the CGM group and 6.7% in the flash glucose monitoring. At the end-point the percentage time < 3.3 mmol/l was 2.4%, and 6.8% respectively (median between group difference -4.3%, P = 0.006). Time spent in hypoglycaemia at all thresholds, and hypoglycaemia fear, were different between groups, favouring CGM.

CONCLUSION

CGM more effectively reduces time spent in hypoglycaemia in people with Type 1 diabetes and impaired awareness of hypoglycaemia compared with flash glucose monitoring. (Clinical Trial Registry No: NCT03028220).

Sociotechnical Requirements Analysis for Clinical Systems

Objective: We explore sociotechnical requirements by examining the use of a computerized patient record system in an intensive care unit of a U.S. hospital and present two sociotechnical requirements, awareness and coordination, embedded in the users’ work.

Method: The study is based on observation during seven months of the use of a computerized patient record system in a surgical intensive care unit. During that period semi-formal interviews, informal interviews were held.

Results and Conclusions: A key step in the design of clinical systems is the development and analysis of requirements. However, traditional requirements analysis is based on a set of assumptions that break down in the highly collaborative, exception-filled clinical domain. Sociotechnical requirement analysis enabled the designers to gather a much richer description of the environment surrounding the computer system, highlighting awareness and coordination, embedded in the users’ work.

Revisiting the use of condoms in Brazil

INTRODUCTION

It is known that a single prevention strategy is not enough to control multiple HIV epidemics around the world and in Brazil. However, it is not only necessary to recognize the importance of condoms as part of the policy of HIV/AIDS prevention but also discuss its limits. In this article, we aim to investigate the use of condoms in Brazil, draw critical reflections, and understand how they can once again be highlighted in Brazil's prevention strategy going forward.

METHODS

A narrative review of literature was conducted using keywords in PubMed. Reports from national surveys that guide the epidemiological and behavioral surveillance of the Brazilian Ministry of Health were also included.

RESULTS

A total of 40 articles and 3 reports were included in the review and 11 intervention studies to promote the condom use; the main findings were as follows: 1) Despite the increase in national studies on sexual behavior, little attention is given to the role of condom use; 2) There are few studies examining the factors associated with condom use among key populations such as men who have sex with men (MSM), female sex workers (FSW), drug users (DU), and transvestites and transexuals (TT), while substantial studies focus on adolescents and women; 3) Evidence suggests that a combination of interventions is more effective.

DISCUSSION

new prevention technologies must not lose sight of the critical importance of condoms, and efforts to reintroduce them should focus on the role of pleasure in addition to their potential to minimize the risk of HIV.

Association of pre-allogeneic hematopoietic stem cell transplant 25-hydroxy-vitamin D level and development of acute skin graft-versus-host-disease: A retrospective analysis of 154 patients

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Background: The pathophysiology of acute skin graft versus host disease (asGVHD) is thought to be initiated when donor T cells encounter recipient dendritic cells (DC) and become activated. Studies have shown that vitamin D (VD) inhibits DC maturation, polarizes T cell populations toward Th2 cytokine phenotype, And biases toward tolerating T cell populations. We analyzed pre-SCT serum vitamin D levels and sought to determine an association with development of acute skin GVHD. Methods: 154 patients, with matched SCT at UTSW Medical Center from December 2007 to December 2014, and who had serum samples banked prior to conditioning were included in the analysis. Pertinent data were extracted from the UTSW BMT database and EMR. Serum samples collected 1-3 months prior to SCT were used to detect 25-hydroxyvitamin D (VD) concentrations. Cumulative incidence (CI) of asGVHD grade II-IV were assessed within 100 days post-SCT. A significantl difference (p-value = 0.026, Breslow-Day test) in the associations between Vit D and asGVHD for patients under RIC and ABLgroups was present, so we analyzed the primary endpoint, time to asGVHD since SCT, separately among two these 2 groups. CI functions were constructed with death and relapse as competing risks. Results: Out of 154 patients, 93 were male, mean age was 51, range 20-72 and median VD was 21 ng/ml (range 7.1-63.3). There were 112 patients with VD < 25 ng/mL (VD < 25) and 41 with VD ≥ 25 ng/mL (VD≥25). Age, conditioning regimen, donor type, cell source, ABO compatibility, GVHD prophylaxis were similar in both groups. Overall CI asGVHD was 24%. CI of asGVHD was 23.8% in VD≥25 and 24.1% in VD < 25. Patients were then analyzed separately with respect to type of conditioning regimen they received (Ablative (ABL) vs Reducing intensity (RIC)). Figure 1A shows that in the ABL group the CI of asGVHD appears increased in patient with VitD≥25 (40% vs 27.1%, p = 0.27). In contrast, Figure 1B shows that in RIC group the CI of asGVHD is higher for those with VD < 25 (4.8% vs 24.1% , p = 0.05). Conclusions: After accounting for competing factors, KM analysis in the RIC group showed that patients with VD level < 25 ng/mL were at a higher risk of developing asGVHD. Further studies to clarify the association between VD status and development of asGVHD are warranted.

Cerebral Air Embolism as Possible Cause of Stroke During Therapeutic Endobronchial Application of Argon Plasma Coagulation

A 68-year-old male was admitted for evaluation of an endobronchial mass obstructing the right middle lobe (RML) and right lower lobe (RLL) of the lung. Flexible bronchoscopy revealed a notable endobronchial lesion in the bronchus intermedius that completely obstructed the RML and the RLL. Argon plasma coagulation (APC) at 30 watts and gas flow at 0.8 liters/minute to 1 liter/minute were applied to the tumor. In the recovery room, the patient was discovered to have a left-sided facial droop and left-sided weakness. The initial computed tomography (CT) scan of the brain and an angiogram of the head and neck were normal, but a repeat CT scan of the head several hours later was remarkable for an area of hypoattenuation in the right frontoparietal lobe concerning for infarct. A magnetic resonance imaging (MRI) brain scan confirmed acute to sub-acute cortical infarcts. Given the direct temporal relation between the onset of neurologic symptoms and the usage of APC with bronchoscopy, a cerebral air embolism (CAE) was thought to be the cause of the patient's acute stroke.

Ischemic stroke in a patient with moderate to severe inherited factor VII deficiency

Thrombosis is known to occur in patients with rare inherited bleeding disorders, usually in the presence of a thrombotic risk factor such as surgery and/or factor replacement therapy, but sometimes spontaneously. We present the case of a 72-year-old African American male diagnosed with congenital factor VII (FVII) deficiency after presenting with ischemic stroke, presumably embolic, in the setting of atherosclerotic carotid artery stenosis. The patient had an international normalized ratio (INR) of 2.0 at presentation, with FVII activity of 6% and normal Extem clotting time in rotational thromboelastometry. He was treated with aspirin (325 mg daily) and clopidogrel (75 mg daily) with no additional bleeding or thrombotic complications throughout his admission. This case provides further evidence that moderate to severe FVII deficiency does not protect against thrombosis.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Late presentation to HIV/AIDS care in Brazil among men who self-identify as heterosexual

OBJECTIVE

To analyze the factors associated with late presentation to HIV/AIDS services among heterosexual men.

METHODS

Men infected by HIV who self-identified as heterosexual (n = 543) were included in the study. Descriptive, biivariate and logistic regression analyses were performed to evaluate the factors associated with late presentation (defined as individuals whose first CD4 count was <350 cells/mm³) in the study population.

RESULTS

The prevalence of late presentation was 69.8%. The multivariate logistic analysis showed testing initiated by the provider (OR_adjusted 3.75; 95%CI 2.45–5.63) increased the odds of late presentation. History of drug use (OR_adjusted 0.59; 95%CI 0.38–0.91), history of having sexually transmitted infections (OR_adjusted 0.64; 95%CI 0.42–0.97), and having less education (OR_adjusted 0.63; 95%CI 0.41–0.97) were associated with a decreased odds of LP.

CONCLUSIONS

Provider initiated testing was the only variable to increase the odds of late presentation. Since the patients in this sample all self-identified as heterosexual, it appears that providers are not requesting they be tested for HIV until the patients are already presenting symptoms of AIDS. The high prevalence of late presentation provides additional evidence to shift towards routine testing and linkage to care, rather than risk-based strategies that may not effectively or efficiently engage individuals infected with HIV.

A Physiologically Based Pharmacokinetic Model for Ganciclovir and Its Prodrug Valganciclovir in Adults and Children

A physiologically based pharmacokinetic (PBPK) model has been developed for ganciclovir and its prodrug valganciclovir. Initial bottom-up modeling based on physicochemical drug properties and measured in vitro inputs was verified in preclinical animal species, and then, a clinical model was verified in a stepwise fashion with pharmacokinetic data in adult, children, and neonatal patients. The final model incorporated conversion of valganciclovir to ganciclovir through esterases and permeability-limited tissue distribution of both drugs with active transport processes added in gut, liver, and kidney. A PBPK model which accounted for known age-related tissue volumes, composition and blood flows, and renal filtration clearance was able to simulate well the measured plasma exposures in adults and pediatric patients. Overall, this work illustrates the stepwise development of PBPK models which could be used to predict pharmacokinetics in infants and neonates, thereby assisting drug development in a vulnerable patient population where clinical data are challenging to obtain.

Tuberculosis diagnostics in Fiji: how reliable is culture?

SETTINGS

Acid-fast bacilli (AFB) smear microscopy and Mycobacterium tuberculosis culture are the first-line diagnostic tests for tuberculosis (TB). The contamination of TB cultures significantly reduces the reliability of TB diagnosis.

OBJECTIVE

To investigate factors associated with TB culture contamination in Fiji, and the relative diagnostic performance of culture compared to microscopy.

DESIGN

All tests performed at the Daulakao Mycobacterium Reference Laboratory (DMRL) in Fiji from 2010 to 2012 were reviewed. Study variables included AFB smear and TB culture results, age and type of specimen, referring TB testing centre and patient age.

RESULTS

Of 5708 specimens reviewed, 70% had both AFB smear and culture results recorded; 421 specimens were contaminated; 2.7% of specimens were either degraded or had no result recorded. There was moderate agreement (κ = 0.577) between the two tests. Culture was more likely to be positive at higher AFB smear scores. Culture contamination was associated with distance from the DMRL, sample age and operator-associated factors.

CONCLUSION

Increases in the speed of referral from TB testing centres or the addition of preservatives to sputum specimens may results in less culture contamination. The planned introduction of liquid culture techniques in combination with culture on Ogawa media is likely to increase the sensitivity of TB diagnosis in Fiji.