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Thabit H, Schofield J. Technology in the management of diabetes in hospitalised adults. Diabetologia 2024:10.1007/s00125-024-06206-4. [PMID: 38953925 DOI: 10.1007/s00125-024-06206-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 05/14/2024] [Indexed: 07/04/2024]
Abstract
Suboptimal glycaemic management in hospitals has been associated with adverse clinical outcomes and increased financial costs to healthcare systems. Despite the availability of guidelines for inpatient glycaemic management, implementation remains challenging because of the increasing workload of clinical staff and rising prevalence of diabetes. The development of novel and innovative technologies that support the clinical workflow and address the unmet need for effective and safe inpatient diabetes care delivery is still needed. There is robust evidence that the use of diabetes technology such as continuous glucose monitoring and closed-loop insulin delivery can improve glycaemic management in outpatient settings; however, relatively little is known of its potential benefits and application in inpatient diabetes management. Emerging data from clinical studies show that diabetes technologies such as integrated clinical decision support systems can potentially mediate safer and more efficient inpatient diabetes care, while continuous glucose sensors and closed-loop systems show early promise in improving inpatient glycaemic management. This review aims to provide an overview of current evidence related to diabetes technology use in non-critical care adult inpatient settings. We highlight existing barriers that may hinder or delay implementation, as well as strategies and opportunities to facilitate the clinical readiness of inpatient diabetes technology in the future.
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Affiliation(s)
- Hood Thabit
- Diabetes, Endocrinology and Metabolism Centre, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK.
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.
| | - Jonathan Schofield
- Diabetes, Endocrinology and Metabolism Centre, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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Reznik Y, Carvalho M, Fendri S, Prevost G, Chaillous L, Riveline JP, Hanaire H, Dubois S, Houéto P, Pasche H, Mianowska B, Renard E. Should people with type 2 diabetes treated by multiple daily insulin injections with home health care support be switched to hybrid closed-loop? The CLOSE AP+ randomized controlled trial. Diabetes Obes Metab 2024; 26:622-630. [PMID: 37921083 DOI: 10.1111/dom.15351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 10/15/2023] [Accepted: 10/15/2023] [Indexed: 11/04/2023]
Abstract
AIM The study aim was to evaluate the feasibility, safety and efficacy of automated insulin delivery (AID) assisted by home health care (HHC) services in people with type 2 diabetes unable to manage multiple daily insulin injections (MDI) at home on their own. PATIENTS AND METHODS This was an open label, multicentre, randomized, parallel group trial. In total, 30 adults with type 2 diabetes using MDI and requiring nursing support were randomly allocated to AID or kept their usual therapy over a 12-week period. Both treatments were managed with the support of HHC services. The primary outcome was the percentage time in the target glucose range of 70-180 mg/dl (TIR). Secondary outcomes included other continuous glucose monitoring metrics, glycated haemoglobin (HbA1c) levels, daily insulin doses, body weight, and of quality of life scores, fear of hypoglycaemia and satisfaction questionnaires. RESULTS Age (69.7 vs. 69.3 years) and HbA1c (9.25 vs. 9.0) did not differ in MDI and AID at baseline. Compared with MDI, AID resulted in a significant increase in TIR by 27.4% [95% CI (15.0-39.8); p < .001], a decrease in time above range by 27.7% and an unchanged time below range of <1%. A between-group difference in HbA1c was 1.3% favouring AID. Neither severe hypoglycaemia nor ketoacidosis occurred in either group. Patient and caregiver satisfaction with AID was high. CONCLUSIONS AID combined with tailored HHC services significantly improved glycaemic control with no safety issues in people with type 2 diabetes previously under an MDI regimen with HHC. AID should be considered a safe option in these people when lacking acceptable glucose control.
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Affiliation(s)
- Yves Reznik
- Endocrinology and Diabetes Department, CHU Côte de Nacre, Caen Cedex, France and Unicaen, Caen Cedex, France
| | - Martin Carvalho
- Diabetology Department, Vert Coteau Clinic, Marseille, France
| | - Salha Fendri
- Diabetology Department, Amiens University Hospital, Amiens, France
| | - Gaetan Prevost
- Normandie Univ, UNIROUEN, Inserm U1239, CHU Rouen, Department of Endocrinology, Diabetes and metabolic diseases and Inserm CIC-CRB 140, Rouen, France
| | - Lucy Chaillous
- Diabetology Department, Nantes University Hospital, Nantes, France
| | - Jean Pierre Riveline
- Centre Universitaire du diabète et de ses complications, APHP, Hôpital Lariboisière, Paris, Île-de-France, France and Institut Necker Enfants Malades, INSERM U1151, CNRS UMR 8253, IMMEDIAB Laboratory, Paris, France
| | - Hélène Hanaire
- Diabetology Department, Rangueil, Toulouse University Hospital, Toulouse, France
| | - Séverine Dubois
- Diabetology Department, Angers University Hospital, Angers, France
| | | | | | - Beata Mianowska
- Department of Pediatrics, Diabetology, Endocrinology and Nephrology, Medical University of Lodz, Lodz, Poland
| | - Eric Renard
- Department of Endocrinology and Diabetes, Montpellier University Hospital, Montpellier, France and Institute of Functional Genomics, University of Montpellier, CNRS, INSERM, Montpellier, France
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Hesse M, Thylstrup B, Karsberg SH, Pedersen MM, Pedersen MU. ILC-OPI: impulsive lifestyle counselling versus cognitive behavioral therapy to improve retention of patients with opioid use disorders and externalizing behavior: study protocol for a multicenter, randomized, controlled, superiority trial. BMC Psychiatry 2021; 21:183. [PMID: 33827495 PMCID: PMC8028234 DOI: 10.1186/s12888-021-03182-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 03/24/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Substance use disorders show a high comorbidity with externalizing behavior difficulties, creating treatment challenges, including difficulties with compliance, a high risk of conflict, and a high rate of offending post-treatment. Compared with people with other substance use disorders those with opioid use disorders have the highest risk of criminal activity, but studies on the evidence base for psychosocial treatment in opioid agonist treatment (OAT) are scarce. The Impulsive Lifestyle Counselling (ILC) program may be associated with better retention and outcomes among difficult-to-treat patients with this comorbidity. METHODS The study is a multicenter, randomized, controlled, superiority clinical trial. Participants will be a total of 137 hard-to-treat individuals enrolled in opioid agonist treatment (OAT). Participants will be randomized to either a standard treatment (14 sessions of individual manual-based cognitive behavioral therapy and motivational interviewing (MOVE-I)) or six sessions of ILC followed by nine sessions of MOVE-I. All participants will receive personalized text reminders prior to each session and vouchers for attendance, as well as medication as needed. The primary outcome is retention in treatment. Secondary measures include severity of drug use and days of criminal offending for profit three and nine months post-randomization. A secondary aim is, through a case-control study, to investigate whether participants in the trial differ from patients receiving treatment as usual in municipalities where ILC and MOVE-I have not been implemented in OAT. This will be done by comparing number of offences leading to conviction 12 months post-randomization recorded in the national criminal justice register and number of emergency room contacts 12 months post-randomization recorded in the national hospital register. DISCUSSION This is the first randomized, controlled clinical trial in OAT to test the effectiveness of ILC against a standardized comparison with structural elements to increase the likelihood of exposure to the elements of treatment. Results obtained from this study may have important clinical, social, and economic implications for publicly funded treatment of opioid use disorder. TRIAL REGISTRATION ISRCTN, ISRCTN19554367 , registered on 04/09/2020.
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Affiliation(s)
- Morten Hesse
- Centre for Alcohol and Drug Research, Bartholins Allé 10, 8000, Aarhus C, Denmark.
| | - Birgitte Thylstrup
- Centre for Alcohol and Drug Research, Bartholins Allé 10, 8000 Aarhus C, Denmark
| | | | | | - Mads Uffe Pedersen
- Centre for Alcohol and Drug Research, Bartholins Allé 10, 8000 Aarhus C, Denmark
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Karsberg SH, Pedersen MU, Hesse M, Thylstrup B, Pedersen MM. Group versus individual treatment for substance use disorders: a study protocol for the COMDAT trial. BMC Public Health 2021; 21:413. [PMID: 33637061 PMCID: PMC7913269 DOI: 10.1186/s12889-021-10271-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 01/19/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Alcohol and other drug use disorders contribute substantially to the global burden of illness. The majority of people with substance use disorders do not receive any treatment for their problems, and developing treatments that are attractive and effective to patients should be a priority. However, whether treatment is best delivered in a group format or an individual format has only been studied to a very limited degree. The COMDAT (Combined Drug and Alcohol Treatment) trial evaluates the feasibility, acceptability, and cost effectiveness of MOVE group (MOVE-G) treatment versus MOVE individual (MOVE-I) treatment in four community-based outpatient treatment centres in Denmark. METHODS A two-arm non-inferiority trial comparing MOVE-I (Pedersen et al., Drug Alcohol Depend 218:108363, 2020) with MOVE-G a combined group treatment for both alcohol use disorder and drug use disorder. The primary objective is to examine whether MOVE-G is non-inferior to MOVE-I in relation to abstinence from drug and/or alcohol, number of sessions received, and completion of treatment as planned. All participants will receive treatment based on cognitive behavioral therapy and motivational interviewing, vouchers for attendance and text reminders, as well as medication as needed (MOVE). Participants (n = 300) will be recruited over a one-year period at four public treatment centers in four Danish municipalities. A short screening will determine eligibility and randomization status. Hereafter, participants will be randomized to the two treatment arms. A thorough baseline assessment will be conducted approximately 1 week after randomization. Follow-up assessments will be conducted at 9 months post-randomization. In addition, patients' use of drugs and alcohol, and patients' wellbeing will be measured in all sessions. The main outcome measures are drug and alcohol intake at 9 months follow-up, number of sessions attended, and dropout from treatment. DISCUSSION The present study will examine the potential and efficacy of combined groups (patients with alcohol and drug disorders in the same group) versus individually based treatment both based on the treatment method MOVE (Pedersen et al., Drug Alcohol Depend 218:108363, 2020). TRIAL REGISTRATION ISRCTN88025085 , registration date 30/06/2020.
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Affiliation(s)
| | - Mads Uffe Pedersen
- Centre for Alcohol and Drug Research, Bartholins Allé 10, 8000 Aarhus C, Denmark
| | - Morten Hesse
- Centre for Alcohol and Drug Research, Bartholins Allé 10, 8000 Aarhus C, Denmark
| | - Birgitte Thylstrup
- Centre for Alcohol and Drug Research, Bartholins Allé 10, 8000 Aarhus C, Denmark
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Lal A, Haque N, Lee J, Katta SR, Maranda L, George S, Trivedi N. Optimal Blood Glucose Monitoring Interval for Insulin Infusion in Critically Ill Non-Cardiothoracic Patients: A Pilot Study. ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021036. [PMID: 33682835 PMCID: PMC7975947 DOI: 10.23750/abm.v92i1.9083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 01/05/2020] [Indexed: 11/29/2022]
Abstract
Objective: The American Diabetes Association and the Society of Critical Care Medicine recommend monitoring blood glucose (BG) every 1-2 hours in patients receiving insulin infusion to guide titration of insulin infusion to maintain serum glucose in the target range; however, this is based on weak evidence. We evaluated the compliance of hourly BG monitoring and relation of less frequent BG monitoring to glycemic status. Materials and Methods: Retrospective chart review performed on 56 consecutive adult patients who received intravenous insulin infusion for persistent hyperglycemia in the ICU at Saint Vincent Hospital, a tertiary care community hospital an urban setting in Northeast region of USA. The frequency of fingerstick blood glucose (FSBG) readings was reviewed for compliance with hourly FSBG monitoring per protocol and the impact of FSBG testing at different time intervals on the glycemic status. Depending on time interval of FSBG monitoring, the data was divided into three groups: Group A (<90 min), Group B (91-179 min) and Group C (≥180 min). Results: The mean age was 69 years (48% were males), 77% patients had preexisting type 2 diabetes mellitus (T2DM). The mean MPM II score was 41. Of the 1411 readings for BG monitoring on insulin infusion, 467 (33%) were in group A, 806 (57%) in group B and 138 (10%) in group C; hourly BG monitoring compliance was 12.6%. The overall glycemic status was similar among all groups. There were 14 (0.99%) hypoglycemic episodes observed. The rate of hypoglycemic episodes was similar in all three groups (p=0.55). Conclusion: In patients requiring insulin infusion for sustained hyperglycemia in ICU, the risk of hypoglycemic episodes was not significantly different with less frequent BG monitoring. The compliance to hourly blood glucose monitoring and ICU was variable, and hypoglycemic episodes were similar across the groups despite the variation in monitoring. Significance of the Study: The importance of glycemic control in ICU has been well established and it is a resource intensive venture. However, there are no major studies highlighting the most optimal time interval for blood glucose checks in critically ill patients on insulin infusion. With this study we hypothesize that time duration between blood glucose checks can be increased safely without any untoward effects. Our study provides evidence for effective resource management with reducing the time spent with every glucose check and directly translating into high value care.
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Affiliation(s)
| | - Nurul Haque
- Department of Medicine Merit Health River Region Hospital 2100 US-61, Vicksburg, MS 39183.
| | - Jennifer Lee
- Clinical Pharmacy Coordinator, Critical Care Department of Pharmacy 123 Summer Street Saint Vincent Hospital, Worcester, Massachusetts. USA 01608.
| | - Sai Ramya Katta
- Clinical Pharmacy Coordinator, Critical Care Department of Pharmacy 123 Summer Street Saint Vincent Hospital, Worcester, Massachusetts. USA 01608.
| | - Louise Maranda
- Department of Biostatistics University of Massachusetts Medical School.
| | - Susan George
- Clinical Associate Professor of Medicine University of Massachusetts Medical School Program Director, Internal Medicine Residency Chair, Department of Medicine Performance Improvement Committee 123 Summer Street Saint Vincent Hospital, Worcester, Massachusetts..
| | - Nitin Trivedi
- Director, Division of Endocrinology Associate Program Director, Internal Medicine Residency Department of Medicine, Saint Vincent Hospital Associate Professor of Medicine University of Massachusetts Medical School 123 Summer Street Saint Vincent Hospital, Worcester, Massachusetts.
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Abstract
Hypoglycemia in inpatients with diabetes remains the most common complication of diabetes therapies. Hypoglycemia is independently associated with increased morbidity and mortality, increased length of stay, increased readmission rate, and increased cost. This review describes the importance of reporting and addressing inpatient hypoglycemia; it further summarizes eight strategies that aid clinicians in the prevention of inpatient hypoglycemia: auditing the electronic medical record, formulary restrictions and dose-limiting strategies, hyperkalemia order sets, electronic glucose management systems, prediction tools, diabetes self-management, remote surveillance, and noninsulin medications.
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Affiliation(s)
- Paulina Cruz
- Division of Endocrinology, Metabolism and Lipid Research, Washington University in St. Louis, MO, USA
- Paulina Cruz, MD, Division of Endocrinology, Metabolism and Lipid Research, Washington University in St. Louis, Campus Box 8127, 660 S. Euclid Avenue, Saint Louis, MO 63110, USA.
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Upadhyay J, Trivedi N, Lal A. Risk of Future Type 2 Diabetes Mellitus in Patients Developing Steroid-Induced Hyperglycemia During Hospitalization for Chronic Obstructive Pulmonary Disease Exacerbation. Lung 2020; 198:525-533. [PMID: 32346783 DOI: 10.1007/s00408-020-00356-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 04/20/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE We evaluated the future risk of developing impaired glucose tolerance and type 2 diabetes mellitus (T2DM) in patient without T2DM who develop hyperglycemia with short-term systemic glucocorticoid therapy during hospitalization. METHODS Retrospective analysis was performed on charts of non-diabetic patients admitted with COPD exacerbation and treated with a course of high dose systemic corticosteroid during hospitalization. Patients with BMI over 40 kg/m2, endocrinopathy and on medications that could impair glucose tolerance were excluded. Patient data were collected for 1 year after initial hospitalization. Diagnosis of T2DM or IGT was based on the ADA criteria. 311 charts were reviewed, of which 64 patients met our inclusion criteria. Depending on the blood glucose readings during hospitalization, the patients were categorized into two groups: hyperglycemic (> 140 mg/dL; n = 42) and normoglycemic (≤ 140 mg/dL; n = 22). RESULTS In the hyperglycemic group, 17/42 (40%) patients developed prediabetes and 5/42 (12%) developed T2DM on follow-up. Interestingly, none of the patients developed IGT or T2DM in the normoglycemic group. Both the groups were well matched in terms of family history of DM, history of hypertension, hyperlipidemia, BMI > 25 kg/m2, weight change, tobacco and alcohol use, corticosteroid therapy duration, and cumulative steroid dose. After adjusting for all these risk factors, on logistic regression analysis, hyperglycemic patients had 37 times higher chance of developing IGT, compared to normoglycemic patients (p = 0.003). CONCLUSIONS Our study suggests that patients without T2DM with acute exacerbation of COPD who develop steroid-induced hyperglycemia in response to systemic corticosteroid treatment have an increased risk for developing future IGT or T2DM. Bigger studies are needed to support our findings since results drawn from our study have the limitations of smaller sample size (wider confidence interval) in a single center.
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Affiliation(s)
- Jagriti Upadhyay
- Division of Endocrinology, Dimock Community Health Center, Beth Israel Deaconess Medical Center, 55 Dimock Street, Roxbury, Boston, MA, USA
| | - Nitin Trivedi
- Division of Endocrinology and Metabolic Medicine, Saint Vincent Hospital, Worcester, MA, USA
- Internal Medicine Residency, Department of Medicine, Saint Vincent Hospital, Worcester, MA, USA
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Amos Lal
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55902, USA.
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[What is the current state of the artificial pancreas in diabetes care?]. Internist (Berl) 2019; 61:102-109. [PMID: 31863132 DOI: 10.1007/s00108-019-00713-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The artificial pancreas (also referred to as closed-loop system) brings us one step closer to the decade-long dream of automated insulin delivery. The closed-loop system directs subcutaneous insulin delivery corresponding to the glucose concentration using a control algorithm. Evidence shows that closed-loop systems substantially improve glucose control and quality of life; however, fully automated closed-loop systems have not yet been accomplished. Active input from patients is required for mealtime insulin dosing and corrections. This article provides an overview on the current state of development of the artificial pancreas in the treatment of diabetes.
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