Diabetes Care in the Hospital: Standards of Medical Care in Diabetes-2021

Clinical presentation and outcomes of care in adults with diabetic ketoacidosis pre-COVID-19 and during-COVID-19 at a tertiary, referral hospital in Nairobi, Kenya

BACKGROUND

Prognosis of DKA has improved over time with the availability of evidence-based protocols and resources. However, in Kenya, there are limited resources for the appropriate diagnosis and management of DKA, mostly limited to tertiary-level referral facilities. This study aimed to review the clinical presentation, management, and outcomes of adult patients admitted with DKA and assess differences in these parameters before and during the COVID-19 pandemic.

METHODS

This was a retrospective study of DKA admissions from January 2017 to December 2021. Patient data were retrieved from the medical records department using ICD-10 codes, and individual details were abstracted on clinical presentation, management, and outcomes of DKA. Comparisons were made between pre-COVID-19 and during COVID-19 durations.

RESULTS

150 patients admitted with DKA were included (n = 48 pre- COVID-19, n = 102 during COVID-19 (n = 23 COVID-19 positive, n = 79 COVID-19 negative)). Median age was 47 years (IQR 33.0, 59.0), median HbA1C was 12.4% [IQR 10.8, 14.6]), and most patients had severe DKA (46%). Most common DKA precipitants were infections (40.7%), newly diagnosed diabetes (33.3%) and missed medication (25.3%). There was a significant difference in pulmonary infections as a DKA precipitant, between the pre- COVID and during COVID-19 pandemic (21.6% during COVID-19 versus 6.3% pre- COVID-19; p = 0.012). Median total insulin dose used was 110.0 units [IQR 76.0, 173.0], and a 100% of patients received basal insulin. Median length of hospital stay was 4.0 days [IQR 3.0, 6.0] and time to DKA resolution was 30.0 h [IQR 24.0, 48.0]. There were 2 deaths (1.3%), none directly attributable to DKA. Severity of DKA significantly differed between pre- COVID-19, COVID-19 positive and COVID-19 negative DKA (52.2% of COVID-19 positive had moderate DKA compared to 26.6% of COVID-19 negative and 22.9% of Pre-COVID-19 (p = 0.006)).

CONCLUSION

Even in developing regions, good outcomes can be achieved with the appropriate facilities for DKA management. Clinician and patient education is necessary to ensure early detection and prompt referral to avoid patients presenting with severe DKA. Exploratory studies are needed to assess reasons for prolonged time to DKA resolution found in this study.

Technology in the management of diabetes in hospitalised adults

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.

Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Payer Status and Medication Management-Part Six of the Movement Is Life Special ONJ Series

This article is the sixth in the Movement is Life series and focuses on insurance coverage and medication management in the perioperative period, 2 tangentially related variables that affect patient outcomes. Our aim is to use current practices and literature to develop recommendations for nurse navigators' execution of preoperative optimization protocols related to payer status and medication management. Discussions with nurse navigators and a literature search were used to gather information and develop recommendations specific to optimizing payer status and medication management. Nurse navigators connected patients to resources and provided education regarding financial concerns and medications, and findings from the literature discussed insurance status among TJA patients. Nurse navigators can contribute to payer status and medication management optimization by providing patient education and resource referrals. In addition, we recommend conducting repeated medication reconciliation and developing awareness of financial resources and perioperative medication management guidelines.

Risk factors for hypoglycaemia in non-critical hospitalised diabetic patients

OBJECTIVE

To determine the risk factors for hypoglycaemia in patients with diabetes on general hospital wards based on a systematic review of the literature since 2013 and meta-analysis.

METHODS

Systematic review of the literature focused on the conceptual and methodological aspects of the PRISMA Declaration. The search carried out in Pub Med, Web of Science, Medline, Scielo, Lilacs, OVID, grey literature and Google Academic focused on risk factors for hypoglycaemia in patients with diabetes on general hospital wards. The CASPe (Critical Appraisal Skills Programme Spanish) tool was applied for quality control.

RESULTS

From 805 references, 70 potentially eligible articles were identified for review of abstracts and full text. Finally, according to inclusion and exclusion criteria, seven studies with 554,601 patients of Asian, European and North American ethnicity were selected. A meta-analysis performed using the random effects model found an association between the presence of hypoglycaemia and: the use of insulin (OR 2.89 [95% CI: 1.8-4.5]); the use of long-acting insulin (OR 2.27 [95% CI: 1.8-2.8]) or fast-acting insulin (OR 1.4 [95% CI: 1.18-1.85]); nasogastric tube feeding (OR 1.75 [95% CI: 1.33-2.3]); chronic kidney disease (OR 1.65 [95% CI: 1.14-2.38]); congestive heart failure (OR 1.36 [95% CI: 1.10-1.68]); and elevated levels of glycosylated haemoglobin (OR 1.59 [95% CI: 1.32-1.91]).

CONCLUSION

The factors associated with the risk of hypoglycaemia in non-critically ill hospitalised patients with type 2 diabetes were: use of any insulin; nasogastric tube feeding; elevated glycosylated haemoglobin levels; history of congestive heart failure; and chronic kidney disease.

Queensland Inpatient Diabetes Survey (QuIDS): patient experience survey evaluation

BACKGROUND

Measurement of inpatient experience can allow for treatment tailored to patient preferences and needs. The patient experience of diabetes care has not been explored in Queensland hospitals.

AIMS

To investigate the experiences of patients with diabetes when hospitalised using the Queensland Inpatient Diabetes Survey (QuIDS).

METHODS

In 2019 and 2021, patient experience surveys were collected as part of the statewide QuIDS, a cross-sectional study assessing the quality of inpatient care received by people with diabetes in Queensland, Australia. Patient responses were categorised and frequencies reported as percentages. Free text comments were analysed using thematic analysis methods. Pooled descriptive data were presented.

RESULTS

Responses were collected from 27 hospitals in 2019 (n = 526, 52.4% of all patients with diabetes) and 35 hospitals in 2021 (n = 709, 55.5%). Overall, patients were satisfied with their inpatient diabetes care. Areas for improvement identified by surveyed patients include the choice and timing of meals, staff knowledge about diabetes and increased diabetes self-management. Access to a specialist diabetes team was also identified as being potentially underutilised. Patient comments fell into four major themes: communication, food choices, patient autonomy and education.

CONCLUSION

Many patients reported positive inpatient experiences; however, patients also expressed dissatisfaction with their inpatient diabetes care. Our data provide unique insight and an opportunity to improve standards of care and service provision for inpatients with diabetes.

The impact of the implementation of computerized insulin order sets for the control of hyperglycemia in hospitalized cardiac patients

Background

Glycemic control is crucial in managing hospitalized patients with type II diabetes (T2DM), and it presents as a clinical challenge in the cardiac population. Therefore, we aimed to evaluate the impact of computerized insulin order sets in T2DM hospitalized cardiac patients.

Methods

A quasi-experimental, pre- and post-study design. We included T2DM patients who were hospitalized for at least 3 days. Patients undergoing cardiac surgery were excluded. The primary endpoint was the mean difference in random blood glucose level (BGL) before and after the implementation of insulin order sets. While the secondary endpoints were to compare the median differences in fasting BGLs and the number of hyperglycemic and hypoglycemic episodes during the first 7 days. The study consisted of three phases: pre-implementation, intervention and post-phase. In the intervention phase, insulin order sets were integrated into the electronic prescribing system, and education was provided to the cardiology department. The post-phase included the patient's post-implementations.

Results

A total of 194 patients were enrolled during the study period. The mean random BGL was 11.17 mmol/L, 95% CI, 10.6-11.7 in the pre-phase and 9.5 mmol/L, 95% CI, 9-1 -9.9 mmol/L in the post-phase (P < 0.001). The median fasting BGL was 9.2 mmol/L (7.4-11.8, IQR) in the pre-phase and 8.5 mmol/L (6.6-10.3, IQR) in the post-phase (P = 0.027). The number of hypoglycemic episodes was 24 in pre-phase and 33 in post-phase (P = 0.13).

Conclusion

The use of computerized insulin order sets was associated with potential improvements in random and fasting glycemic control without increasing the risk of hyperglycemia or hypoglycemia.

Metabolic Disorders in Liver Transplant Recipients: The State of the Art

Liver transplantation represents a chief therapeutic approach for acute liver failure, end-stage liver disease and hepatocellular carcinoma. Despite witnessing advancements in short- and medium-term survival over recent decades, attributed to refinements in surgical techniques and immunosuppressive protocols, long-term mortality remains impervious to modification. Notably, cardiovascular disease emerges as a predominant cause of mortality among liver transplant recipients. This trend is accentuated by the increasing prominence of non-alcoholic steatohepatitis-related cirrhosis as an indication for liver transplantation. Moreover, the administration of immunosuppressive agents is intricately linked to the degradation of the metabolic profile in liver transplant recipients, thereby contributing to the initiation or exacerbation of cardiovascular risk factors, such as hypertension, diabetes, and dyslipidaemia. In addition, the post-liver transplantation period is marked by a decline in lifestyle quality and a failure to acknowledge the psychological distress experienced by patients throughout the transplant process. These factors can precipitate a deterioration in the patient's metabolic profile, exacerbated by suboptimal therapeutic compliance. This narrative review aims to comprehensively address the principal metabolic disorders intricately associated with liver transplantation.

Glycemic Management in Insulin-Naive Patients in the Inpatient Setting

Objective

The ideal inpatient insulin regimen efficiently attains the target blood glucose range, effectively treats hyperglycemia, and minimizes the risk of hypoglycemia. The objective of this study was to compare glycemic targets achieved by using correctional monotherapy (CM) and basal-bolus therapy (BBT) in insulin-naive patients in the inpatient setting to determine optimal blood glucose management for these patients.

Design

This was a retrospective observational cohort study of 792 patients with diabetes not on home insulin therapy who were admitted to an academic hospital over a 5.5-month period. The percentages of hyperglycemic and hypoglycemic values in each group were compared.

Results

Among the 3,112 measured blood glucose values obtained from 792 patients within the first 24 hours of insulin administration, 28.5% were hyperglycemic in the BBT group compared with 23.5% in the CM group. When adjusted for covariates, there was a 23% decrease in hyperglycemia in the BBT group (incidence rate ratio = 0.77, 95% CI 0.64-0.95, P = 0.006). Increases in A1C and admission blood glucose, as well as decreases in admission creatinine and inpatient steroid use, were independently associated with higher rates of hyperglycemia, adjusted for all other covariates. There was no significant difference between the groups in the rate of hypoglycemia in the first 24 hours, which was 1.9% in the BBT group and 1.4% in the CM group (P = 0.301).

Conclusion

Utilizing BBT in insulin-naive patients admitted to the hospital within the first 24 hours of insulin administration results in lower rates of hyperglycemia without higher rates of hypoglycemia when compared with CM.

Towards an integrated type 1 diabetes management in low-resource settings: barriers faced by patients and their caregivers in healthcare facilities in Ghana

BACKGROUND

In Low-Middle-Income Countries (LMICs), young people living with Type 1 Diabetes Mellitus (T1DM) face structural barriers which undermine adequate T1DM management and lead to poor health outcomes. However, research on the barriers faced by young people living with T1DM have mostly focused on patient factors, neglecting concerns regarding plausible barriers that may exist at the point of healthcare service delivery.

OBJECTIVE

This study sought to explore barriers faced by young people living with T1DM and their caregivers at the point of healthcare service delivery.

METHODS

Data were drawn from a qualitative research in southern Ghana. The research was underpinned by a phenomenological study design. Data were collected from 28 young people living with T1DM, 12 caregivers, and six healthcare providers using semi-structured interview guides. The data were collected at home, hospital, and support group centres via face-to-face interviews, telephone interviews, and videoconferencing. Thematic and framework analyses were done using CAQDAS (QSR NVivo 14).

RESULTS

Eight key barriers were identified. These were: shortage of insulin and management logistics; healthcare provider knowledge gaps; lack of T1DM care continuity; poor healthcare provider-caregiver interactions; lack of specialists' care; sharing of physical space with adult patients; long waiting time; and outdated treatment plans. The multiple barriers identified suggest the need for an integrated model of T1DM to improve its care delivery in low-resource settings. We adapted the Chronic Care Model (CCM) to develop an Integrated Healthcare for T1DM management in low-resource settings.

CONCLUSION

Young people living with T1DM, and their caregivers encountered multiple healthcare barriers in both in-patient and outpatient healthcare facilities. The results highlight important intervention areas which must be addressed/improved to optimise T1DM care, as well as call for the implementation of a proposed integrated approach to T1DM care in low-resource settings.

Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Diabetes and Cardiovascular Disease-Part 3 of the Movement Is Life Special ONJ Series

Diabetes and cardiovascular disease are some of the most common risk factors for complications after total joint arthroplasty (TJA). Preoperative optimization programs are dependent on nurse navigators for coordination of interventions that improve patients' health and surgical outcomes. This article uses information regarding the current practices for diabetes and cardiovascular disease management to provide recommendations for nurse navigators when managing these risk factors prior to TJA. We consulted nurse navigators and conducted a literature review to learn about strategies for addressing diabetes and cardiovascular disease in preoperative optimization programs. Nurse navigators can play a critical role in addressing these conditions by providing patient education and implementing preoperative optimization protocols that incorporate discussion regarding guidelines for diabetes and cardiovascular disease management prior to surgery. This article shares recommendations and resources for nurse navigators to help address diabetes and cardiovascular disease as part of preoperative optimization programs.

Staff knowledge, attitudes and practices regarding glycaemic management in adult intensive care units: A national survey

BACKGROUND

Hyperglycaemia is common in critically ill adult patients. Many studies have identified the content, methods, and effects of glycaemic control but have not explored the effects of knowledge, attitudes, and practices (KAP) on glycaemic control in critically ill adults. Various factors also influence the KAP of intensive care unit (ICU) staff.

AIMS

To assess KAP regarding glucose management for critically ill adults among nurses and medical professionals and identify the factors that influence their KAP in ICUs.

METHODS

A multicentre cross-sectional survey.

RESULTS

In total, 403/459 (response rate: 87.8%) participants from ICUs in nine tertiary hospitals in China participated in this study, 82.4% of whom were female and 93.4% of whom were nurses. The mean work experience was 8.88 years, and the mean critical care experience was 6.59 years. The scoring rate for the three dimensions of knowledge, attitudes, and practices were 82.35%, 87.69%, and 76%, respectively. We did not find any other factors affecting the KAP scores except for the level of knowledge awareness (p < 0.001), awareness of the importance (p < 0.001), and training for glucose control (p = 0.004).

CONCLUSION

ICU staff KAP regarding glycaemic control in critically ill adults among ICU professionals were acceptable in China. However, ICU professionals' current knowledge regarding nutrition, glucose variability, and skills related to glucose management could be improved.

RELEVANCE TO CLINICAL PRACTICE

ICU educators should provide more skills-related training for healthcare professionals in the glycaemic management of critically ill adults. Moreover, the process of managing blood glucose in adult ICU patients is a collaborative, multidisciplinary team effort, with monitoring and feedback required during implementation.

Timing of SGLT2i initiation after acute myocardial infarction

BACKGROUND

Pharmacological post-MI treatment is routinely initiated at intensive/cardiac care units. However, solid evidence for an early start of these therapies is only available for dual platelet therapy and statins, whereas data on beta blockers and RAAS inhibitors are heterogenous and mainly limited to STEMI and heart failure patients. Recently, the EMMY trial provided the first evidence on the beneficial effects of SGLT2 inhibitors (SGLT2i) when initiated early after PCI. In patients with type 2 diabetes mellitus, SGLT2i are considered "sick days drugs" and it, therefore, remains unclear if very early SGLT2i initiation following MI is as safe and effective as delayed initiation.

METHODS AND RESULTS

The EMMY trial evaluated the effect of empagliflozin on NT-proBNP and functional and structural measurements. Within the Empagliflozin group, 22 (9.5%) received early treatment (< 24 h after PCI), 98 (42.2%) within a 24 to < 48 h window (intermediate), and 111 (48.1%) between 48 and 72 h (late). NT-proBNP levels declined by 63.5% (95%CI: - 69.1; - 48.1) in the early group compared to 61.0% (- 76.0; - 41.4) in the intermediate and 61.9% (- 70.8; - 45.7) in the late group (n.s.) within the Empagliflozin group with no significant treatment groups-initiation time interaction (pint = 0.96). Secondary endpoints of left ventricular function (LV-EF, e/e`) as well as structure (LVESD and LVEDD) were also comparable between the groups. No significant difference in severe adverse event rate between the initiation time groups was detected.

CONCLUSION

Very early administration of SGLT2i after acute myocardial infarction does not show disadvantageous signals with respect to safety and appears to be as effective in reducing NT-proBNP as well as improving structural and functional LV markers as initiation after 2-3 days.

Association between time in range 70-180 mg/dl in early stage and severity with in patients acute pancreatitis

BACKGROUND

It is not well understood whether glucose control in the early stage of acute pancreatitis(AP) is related to outcome. This study aimed to investigate the association between blood glucose time in range (TIR) of 70-180 mg/dL in the first 72 h(h) on admission and the progression of AP.

METHODS

Individuals admitted with AP to the Gastroenterology Department of the Affiliated Changzhou No.2 People's Hospital of Nanjing Medical University between January 2017 and December 2021 were included and retrospectively evaluated. The percentage of TIR between 70 and 180 mg/dL in the first 72 h was calculated. According to the progress of AP at discharge, patients were divided into mild pancreatitis(MAP), and moderately severe acute pancreatitis (MSAP), or severe acute pancreatitis (SAP) groups. We examined the association between TIR or TIR ≥ 70% and AP severity using logistic regression models stratified by a glycosylated hemoglobin (HbA1c) level of 6.5%. Receiver operating characteristic (ROC) curves were generated to assess the ability of the TIR to predict MSAP or SAP.

RESULTS

A total of 298 individuals were included, of whom 35 developed MSAP or SAP. Logistic regression analyses indicated that TIR was independently associated with the incidence of more serious AP (odds ratio [OR] = 0.962, 95% CI = 0.941-0.983, p = 0.001). This association remained significant in individuals with HbA1c levels ≤ 6.5% (OR = 0.928, 95% CI = 0.888-0.969, p = 0.001). A TIR ≥ 70% was independently associated with reduced severity only in people with well-antecedent controls (OR = 0.238; 95% CI = 0.071-0.802; p = 0.020). TIR was not powerful enough to predict the severity of AP in both patients with poor antecedent glucose control (AUC = 0.641) or with HbA1c < 6.5% (AUC = 0.668).

CONCLUSIONS

TIR was independently associated with severity in patients with AP, particularly those with good antecedent glucose control.

Exploratory Multisite MR Spectroscopic Imaging Shows White Matter Neuroaxonal Loss Associated with Complications of Type 1 Diabetes in Children

BACKGROUND AND PURPOSE

Type 1 diabetes affects over 200,000 children in the United States and is associated with an increased risk of cognitive dysfunction. Prior single-site, single-voxel MRS case reports and studies have identified associations between reduced NAA/Cr, a marker of neuroaxonal loss, and type 1 diabetes. However, NAA/Cr differences among children with various disease complications or across different brain tissues remain unclear. To better understand this phenomenon and the role of MRS in characterizing it, we conducted a multisite pilot study.

MATERIALS AND METHODS

In 25 children, 6-14 years of age, with type 1 diabetes across 3 sites, we acquired T1WI and axial 2D MRSI along with phantom studies to calibrate scanner effects. We quantified tissue-weighted NAA/Cr in WM and deep GM and modeled them against study covariates.

RESULTS

We found that MRSI differentiated WM and deep GM by NAA/Cr on the individual level. On the population level, we found significant negative associations of WM NAA/Cr with chronic hyperglycemia quantified by hemoglobin A1c (P < .005) and a history of diabetic ketoacidosis at disease onset (P < .05). We found a statistical interaction (P < .05) between A1c and ketoacidosis, suggesting that neuroaxonal loss from ketoacidosis may outweigh that from poor glucose control. These associations were not present in deep GM.

CONCLUSIONS

Our pilot study suggests that MRSI differentiates GM and WM by NAA/Cr in this population, disease complications may lead to neuroaxonal loss in WM in children, and deeper investigation is warranted to further untangle how diabetic ketoacidosis and chronic hyperglycemia affect brain health and cognition in type 1 diabetes.

Postcardiac Surgery Euglycemic Diabetic Ketoacidosis in Patients on Sodium-Glucose Cotransporter 2 Inhibitors

OBJECTIVES

To evaluate sodium-glucose cotransporter 2 inhibitors (SGLT2i) use and complications (euglycemic diabetic ketoacidosis [eDKA] rate, mortality, infection, hospital, and cardiovascular intensive care unit [CVICU] length of stay [LOS]) in patients undergoing cardiac surgery.

DESIGN

A retrospective study.

SETTING

At an academic university hospital.

PARTICIPANTS

Adult patients undergoing cardiac surgery.

INTERVENTIONS

SGLT2i use versus no SGLT2i use.

MEASUREMENTS AND MAIN RESULTS

The authors evaluated patients undergoing cardiac surgery within 24 hours of hospital admission (between February 2, 2019 to May 26, 2022) for SGLT2i prevalence and eDKA frequency. The outcomes were compared using Wilcoxon rank sum and chi-square testing as appropriate. The cohort included 1,654 patients undergoing cardiac surgery, of whom 53 (3.2%) were prescribed an SGLT2i before surgery; 8 (15.1%) of 53 had eDKA. The authors found no differences between patients with and without SGLT2i use in hospital LOS (median [IQR]: 4.5 [3.5-6.3] v 4.4 [3.4-5.6] days, p = 0.46) or CVICU LOS (median [IQR]: 1.2 [1.0-2.2] v 1.1 [1.0-1.9] days, p = 0.22), 30-day mortality (1.9% v 0.7%, p = 0.31), or sternal infections (0.0% v 0.3%, p = 0.69). Among patients prescribed an SGLT2i, those with and without eDKA had similar hospital LOS (5.1 [4.0-5.8] v 4.4 [3.4-6.3], p = 0.76); however, CVICU LOS was longer in patients with eDKA (2.2 [1.5-2.9] v 1.2 [0.9-2.0], p = 0.042). Mortality (0.0% v 2.2%, p = 0.67) and wound infections (0.0% v 0.0%, p > 0.99) were similarly rare.

CONCLUSIONS

Postoperative eDKA occurred in 15% of patients on an SGLT2i prior to cardiac surgery, and was associated with longer CVICU LOS. Future studies into SGLT2i management perioperatively are important.

Expanding the use of patient-reported outcomes (PROs): Screening youth with type 1 diabetes from underrepresented populations

AIM

Youth from lower socioeconomic status (SES) have suboptimal type 1 diabetes (T1D) outcomes. Patient reported outcomes (PROs) measure psychosocial states and are associated with T1D outcomes, however are understudied in low SES youth. We aimed to evaluate associations between PROs and public insurance status, a proxy for low SES.

METHODS

We analyzed survey data from 129 youth with T1D (age 15.7 ± 2.3 years, 33 % publicly insured) screened with PROMIS Global Health (PGH, measuring global health) and Patient Health Questionnaire (PHQ-9, measuring depressive symptoms) during diabetes appointments. Correlation and regression analyses evaluated differences in PGH and PHQ-9 by insurance status.

RESULTS

For youth with public insurance, lower global health correlated with lower self-monitoring blood glucose (SMBG; r = 0.38,p = 0.033) and older age (r = -0.45,p = 0.005). In youth with private insurance, lower global health correlated with lower SMBG (r = 0.27,p = 0.018) and female sex (rho = 0.26,p = 0.015). For youth with private insurance, higher depressive symptoms correlated with higher body mass index (r = 0.22,p = 0.03) and fewer SMBG (r = -0.35,p = 0.04). In multivariate regression analyses, public insurance was inversely associated with global health (p = 0.027).

CONCLUSION

PGH is a particularly salient PRO in youth with public insurance. Global health may be an important psychosocial factor to assess in youth with T1D from low SES backgrounds.

What, why and how to monitor blood glucose in critically ill patients

Critically ill patients are prone to high glycemic variations irrespective of their diabetes status. This mandates frequent blood glucose (BG) monitoring and regulation of insulin therapy. Even though the most commonly employed capillary BG monitoring is convenient and rapid, it is inaccurate and prone to high bias, overestimating BG levels in critically ill patients. The targets for BG levels have also varied in the past few years ranging from tight glucose control to a more liberal approach. Each of these has its own fallacies, while tight control increases risk of hypoglycemia, liberal BG targets make the patients prone to hyperglycemia. Moreover, the recent evidence suggests that BG indices, such as glycemic variability and time in target range, may also affect patient outcomes. In this review, we highlight the nuances associated with BG monitoring, including the various indices required to be monitored, BG targets and recent advances in BG monitoring in critically ill patients.

Perioperative glycemic management in adults presenting for elective cardiac and non-cardiac surgery

Perioperative dysglycemia is associated with adverse outcomes in both cardiac and non-cardiac surgical patients. Hyperglycemia in the perioperative period is associated with an increased risk of postoperative infections, length of stay, and mortality. Hypoglycemia can induce neuronal damage, leading to significant cognitive deficits, as well as death. This review endeavors to summarize existing literature on perioperative dysglycemia and provides updates on pharmacotherapy and management of perioperative hyperglycemia and hypoglycemia in surgical patients.

Reliability of Inpatient CGM: Comparison to Standard of Care

BACKGROUND

Optimal inpatient glycemic management targets a blood glucose (BG) of 140-180 mg/dL and is an important safety measure for hospitalized patients with hyperglycemia. Traditional barriers to appropriate insulin administration include incorrect timing of prandial insulin administration, failure to administer basal insulin to persons with insulin deficiency/type 1 diabetes mellitus (DM), and inaccurate insulin dosing or timing resulting in hypoglycemia. Given the ongoing rapid assimilation of technology to manage our patients with DM, we investigated the use of continuous glucose monitoring (CGM) in the inpatient setting as a potential solution to traditional barriers to optimal hyperglycemia management for inpatient care. In this study, we evaluated the efficacy of use of inpatient CGM for insulin dosing in comparison with current standard of care and whether CGM could aid in minimizing hypoglycemic events.

METHODS

This study evaluated the use of Abbott professional (blinded) Freestyle Libre CGMs in participants treated with basal bolus insulin administered with subcutaneous insulin (basal bolus therapy [BBT]: n = 20) or on intravenous insulin (IVI) infusions (n =16) compared with standard point of care (POC) BG measurements. All participants on IVI were admitted with a diagnosis of diabetic ketoacidosis (DKA). The CGM data was not available in real time. Sensors were removed at the time of discharge and data uploaded to Libre View. Continuous BG data were aggregated for each subject and matched to POC BG or lab chemistry values within five minutes. The POC BG results were assessed for comparability (CGM vs standard BG testing). Data were further analyzed for clinical decision-making for correction insulin.

RESULTS

The overall mean absolute relative difference including both IVI and BBT groups was 22.3% (SD, 9.0), with a median of 20.0%. By group, the IVI arm mean was 19.6% (SD, 9.4), with a median of 16.0%; for BBT, the arm mean was 24.6% (SD, 8.1), with a median 23.4%. Using the Wilcoxon two-sample test, the means were not different (P = .10), whereas the medians were (P = .015). The CGM consistently reported lower glucose values than POC BG in the majority of paired values (BBT arm mean difference = 44.8 mg/dL, IVI mean difference = 19.7 mg/dL). Glucose results were in agreement for the group 83% of the time with Bland-Altman Plot of Difference versus the mean of all glucometric data. Analysis of correction dose insulin using either CGM or POC BG values resulted in a negligible difference in calculated insulin dose recommended in those receiving subcutaneous insulin. Corrective doses were based on weight and insulin sensitivity (type 1 vs type 2 DM). Participants initially on IVI were included in a data set of BBT once IVI therapy ceased and basal bolus insulin regimen was started. The data of all basal bolus therapy participants with 1142 paired values of CGM versus POC glucose were used. The dosing difference was less for CGM than POC BG in the majority of paired values, and there was an absolute difference in dose of insulin of only 1.34 units. In the IVI group with 300 paired values of CGM versus POC glucose, there was an absolute difference in dose of insulin of only 0.74 units. About a third of the patients studied in the BBT arm experienced a hypoglycemic event with POC BG <70 mg/dL. If used in real time, CGM would have identified a hypoglycemic event for our patients on average 3 hours and 34 minutes before it was detected by standard POC BG. Two participants incurred severe nocturnal hypoglycemia during the study with POC BG <54 mg/dL with hypoglycemia detected on CGM up to 3 hours and 42 minutes before POC testing.

CONCLUSIONS

These results suggest that the use of inpatient CGM arrives at similar correction insulin dosing. The routine use of CGM for inpatients would consistently underestimate the BG compared with POC BG and could aid in minimizing and predicting hypoglycemia in the hospital setting. Our data support that the model of adoption of real-time inpatient CGM technology is anticipated to have significant impact in the clinical setting in efforts to maintain adequate glycemic control targeting BG 140-180 mg/dL while minimizing the frequency of hypoglycemic events.

SGLT-2 inhibitors and in-stent restenosis-related events after acute myocardial infarction: an observational study in patients with type 2 diabetes

BACKGROUND

No study evaluated the incidence of intra-stent restenosis (ISR)-related events in patients with type 2 diabetes (T2DM) and acute myocardial infarction (AMI) treated or not with sodium/glucose cotransporter 2 inhibitors (SGLT2i).

METHODS

We recruited 377 patients with T2DM and AMI undergoing percutaneous coronary intervention (PCI). Among them, 177 T2DM were treated with SGLT2 inhibitors before PCI. The primary outcome was major adverse cardiovascular events (MACE) defined as cardiac death, re-infarction, and heart failure related to ISR. In patients without ISR, minimal lumen area and minimal lumen diameter were assessed by coronary CT-angiography at 1-year follow-up.

RESULTS

Glycemic control was similar in SGLT2i-treated patients and never SGLT2i-users. The incidence of ISR-related MACE was higher in never SGLT2i-users compared with SGLT2i-treated patients, an effect independent of glycemic status (HR = 0.418, 95% CI = 0.241-0.725, P = 0.002) and observed also in the subgroup of patients with HbA1c < 7% (HR = 0.393, 95% CI = 0.157-0.984, P = 0.027). In patients without the event, the stent patency was greater in SGLT2i-treated patients compared with never SGLT2i-users at 1-year follow-up.

CONCLUSIONS

SGLT2i treatment in T2DM is associated with a reduced incidence of ISR-related events, independently of glycemic control.

The Impact of a Diabetes Transitions of Care Clinic on Hospital Utilization and Patient Care

BACKGROUND

There is currently limited guidance from the American Diabetes Association regarding transitions of care for patients with diabetes.

OBJECTIVE

This study's aim was to determine the impact of a diabetes-specific transitions of care clinic (TOCC) on hospital utilization and patient outcomes in recently discharged patients with diabetes.

METHODS

This retrospective study evaluated patients seen by TOCC as compared with similar patients discharged from the study institution the year prior. The primary outcome was a composite of the number of unique patients with readmissions/emergency department (ED) visits within 30 days of discharge. Secondary outcomes included a subcomponent analysis of readmissions/ED visits, index hospital length of stay (LOS), and to describe clinical interventions made in clinic. This study was approved by the institutional review board of the Office of Responsible Research Practice at the Ohio State University Wexner Medical Center.

RESULTS

There were 165 patients in the TOCC group and 157 in the control group based on the matching criteria. There was a statistically significant decrease in the primary outcome in the TOCC group versus the control group (18% vs 36%, P < 0.001). In evaluation of its subcomponents, there was a statically significant decrease in patients with readmissions (11% vs 26%, P < 0.001) but not ED visits (10% vs 17%, P = 0.096). The LOS for the TOCC group was shorter at 4 days versus 5 days in the control group (P = 0.055).

CONCLUSIONS AND RELEVANCE

The implementation of a diabetes-specific TOCC can decrease both readmissions and ED visits and may impact hospital LOS. In addition, a TOCC can be used to identify gaps in preventive care. The results from this study may help support the creation of similar TOCC at other institutions.

POCT urine dipstick versus central laboratory analyses: Diagnostic performance and logistics in the medical emergency department

OBJECTIVES

The aim of this study was to evaluate the logistics and diagnostic performances of dipstick analyses compared to their counterpart central laboratory analyses for detection of bacteriuria, proteinuria, hyperglycemia, ketosis and hematuria.

DESIGN AND METHODS

Urine dipstick results, urine culture results, flow cytometric cell counts, U-albumin-to-creatinine ratio, P-glucose and P-beta-hydroxybutyrate were retrospectively reviewed in a cohort of consecutive patients admitted to the medical emergency departments of two Danish hospitals. Sensitivity, specificity and predictive values of traditional dipstick analysis were estimated and dipstick was compared to flow cytometry for detection of significant bacteriuria using logistic regression. Turn-around-time for central laboratory analyses were assessed.

RESULTS

For each comparison, 1,997 patients or more were included. Traditional dipstick analyses for proteinuria, bacteriuria and ketosis reached sensitivities of up to 90%, while sensitivity for hyperglycemia was 59%. Flow cytometry outperformed traditional dipstick analysis for detection of bacteriuria with a difference in the area under the ROC-curve of 0.07. Turn-around-times for 95% delivery of central laboratory analysis results ranged from approximately 1½ to 2 h.

CONCLUSIONS

For the detection of bacteriuria and albuminuria, central laboratory analyses reach better performance than dipstick analysis while achieving acceptable turn-around-times and are thus viable alternatives to dipstick analysis. For detection of ketosis and hyperglycemia, dipstick analysis does not perform adequately, but as very short turn-around-time is often required, these conditions may be best diagnosed by point-of-care blood test rather than dipstick or central laboratory analyses. Dipstick hemoglobin analysis, flow cytometry and microscopic evaluation may serve each their distinct purposes, and thus are relevant in the emergency department.

Efficacy and safety of degludec U100 versus glargine U300 for the early postoperative management of patients with type 2 diabetes mellitus undergoing coronary artery bypass graft surgery: A non-inferiority randomized trial

AIMS

To compare the efficacy and safety of degludec U100 versus glargine U300 for the early postoperative management of patients with type 2 diabetes mellitus (T2D) undergoing coronary artery bypass graft (CABG) surgery.

METHODS

A total of 239 patients were randomly assigned (1:1) to receive a basal-bolus regimen in the early postoperative period using degludec U100 (n = 122) or glargine U300 (n = 117) as basal and glulisine before meals. The primary outcome was mean differences between groups in their daily BG concentrations. The major safety outcome was the occurrence of hypoglycemia.

RESULTS

There were no differences in mean daily BG concentrations (157 vs. 162 mg/dl), mean percentage of readings within target BG of 70-180 mg/dl (74% vs. 73%), daily basal insulin dose (19 vs. 21 units/day), length of stay (median [IQR]: 9 vs. 9 days), or hospital complications (21.3% vs. 21.4%) between treatment groups. There were no differences in the proportion of patients with BG <70 mg/dl (15.6% vs. 23.1%) or <54 mg/dl (1.6% vs. 4.3%) between degludec-100 and glargine-300 groups.

CONCLUSIONS

Treatment with degludec U100 is as effective and safe as glargine U300 for the early postoperative hospital management of patients with T2D undergoing CABG.

Association between uric acid level and contrast-induced acute kidney injury in patients with type 2 diabetes mellitus after coronary angiography: a retrospective cohort study

BACKGROUND

This study assessed the predictive value of uric acid (UA) for contrast-induced acute kidney injury (CI-AKI) in patients with type 2 diabetes mellitus (T2DM) who underwent coronary angiography (CAG). A nomogram to aid in the prediction of CI-AKI was also developed and validated, and the construction of a prognostic nomogram combined with clinical features was attempted.

METHODS

This study retrospectively enrolled T2DM patients who underwent CAG between December 2019 and December 2020 at the Affiliated Zhongda Hospital of Southeast University. Multivariable logistic regression analysis was used for the analysis of clinical outcomes. Receiver operating characteristic (ROC) analyses were performed to determine the area under the ROC curve (AUC) and the cut-off points for continuous clinical data. The prediction accuracies of models for CI-AKI were estimated through Harrell's concordance indices (C-index). Nomograms of the prognostic models were plotted for individualized evaluations of CI-AKI in T2DM patients after CAG.

RESULTS

A total of 542 patients with T2DM who underwent CAG were included in this study. We found that a high UA level (≥ 425.5 µmol/L; OR = 6.303), BUN level (≥ 5.98 mmol/L; OR = 3.633), Scr level (≥ 88.5 µmol/L; OR = 2.926) and HbA1C level (≥ 7.05%; OR = 5.509) were independent factors for CI-AKI in T2DM patients after CAG. The nomogram model based on UA, BUN, Scr and HbA1C levels presented outstanding performance for CI-AKI prediction (C-index: 0.878). Decision curve analysis (DCA) showed good clinical applicability in predicting the incidence of CI-AKI in T2DM patients who underwent CAG.

CONCLUSION

High UA levels are associated with an increased incidence of CI-AKI in T2DM patients after CAG. The developed nomogram model has potential predictive value for CI-AKI and might serve as an economic and efficient prognostic tool in clinical practice.

External validation of a machine learning model to predict hemodynamic instability in intensive care unit

Background

Early prediction model of hemodynamic instability has the potential to improve the critical care, whereas limited external validation on the generalizability. We aimed to independently validate the Hemodynamic Stability Index (HSI), a multi-parameter machine learning model, in predicting hemodynamic instability in Asian patients.

Method

Hemodynamic instability was marked by using inotropic, vasopressor, significant fluid therapy, and/or blood transfusions. This retrospective study included among 15,967 ICU patients who aged 20 years or older (not included 20 years) and stayed in ICU for more than 6 h admitted to Taipei Veteran General Hospital (TPEVGH) between January 1, 2010, and March 31, 2020, of whom hemodynamic instability occurred in 3053 patients (prevalence = 19%). These patients in unstable group received at least one intervention during their ICU stays, and the HSI score of both stable and unstable group was calculated in every hour before intervention. The model performance was assessed using the area under the receiver operating characteristic curve (AUROC) and was compared to single indicators like systolic blood pressure (SBP) and shock index. The hemodynamic instability alarm was set by selecting optimal threshold with high sensitivity, acceptable specificity, and lead time before intervention was calculated to indicate when patients were firstly identified as high risk of hemodynamic instability.

Results

The AUROC of HSI was 0.76 (95% CI, 0.75–0.77), which performed significantly better than shock Index (0.7; 95% CI, 0.69–0.71) and SBP (0.69; 95% CI, 0.68–0.70). By selecting 0.7 as a threshold, HSI predicted 72% of all 3053 patients who received hemodynamic interventions with 67% in specificity. Time-varying results also showed that HSI score significantly outperformed single indicators even up to 24 h before intervention. And 95% unstable patients can be identified more than 5 h in advance.

Conclusions

The HSI has acceptable discrimination but underestimates the risk of stable patients in predicting the onset of hemodynamic instability in an external cohort.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-04088-9.

Accuracy of the intermittently scanned continuous glucose monitoring system in critically ill patients: a prospective, multicenter, observational study

OBJECTIVE

Continuous glucose monitoring (CGM) has the potential to improve glucose control in the intensive care unit (ICU) setting. We sought to evaluate the accuracy of the intermittently scanned CGM (isCGM) system in critically ill patients.

RESEARCH DESIGN AND METHODS

Adult patients were consecutively enrolled from three ICUs from August 2020 to January 2021. The performance of FreeStyle Libre Pro was evaluated against the venous blood glucose samples as a reference. Numerical accuracy was examined by the mean absolute relative difference (MARD), the Bland-Altman analysis, and the International Organization for Standardization criteria. Clinical accuracy was assessed by performing the Clarke and consensus error grid analysis.

RESULTS

A total of 122 patients were included and 3416 matched glucose pairs were analyzed. The overall MARD was 18.0%, and the highest MARD (33.1%) was observed in the hypoglycemic range (&lt;70 mg/dL). The Bland-Altman analysis revealed a mean bias of -11.7 mg/dL, with the 95% limits of agreement of -73.0 to 49.5 mg/dL. The percentages of isCGM glucose values within ±15%/15, ±20%/20, and ±30%/30 mg/dL were 49.8%, 64.7%, and 84.5%, respectively. The Clarke and consensus error grid analysis showed acceptable clinical accuracy with 98.5% and 98.8% of glucose values falling into zones A and B.

CONCLUSIONS

Our study demonstrated suboptimal overall accuracy of isCGM for critically ill patients. Whether the adjunctive use of isCGM could improve glucose management and health outcomes in the critically ill needs further investigation.

CLINICAL TRIAL REGISTRATION

ChiCTR2100042036, Chinese Clinical Trial Registry.

Does the Hyperglycemia Impact on COVID-19 Outcomes Depend upon the Presence of Diabetes?-An Observational Study

Diabetes mellitus (DM) has emerged as a major risk factor for COVID-19 severity and SARS-CoV-2 infection can worsen glycemic control and may precipitate new-onset diabetes. At-admission hyperglycemia (AH) is a known predictor for worse outcomes in many diseases and seems to have a similar effect in COVID-19 patients. In this study, we aimed to assess the impact of AH regardless of pre-existing diabetes mellitus and new-onset diabetes diagnosis in the clinical severity of COVID-19 inpatients in the first months of the pandemic. A retrospective monocentric study on 374 COVID-19 inpatients (209 males) was developed to assess associations between AH (blood glucose levels in the Emergency Department or the first 24 h of hospitalization greater than 140 mg/dL) and severity outcomes (disease severity, respiratory support, admission to Intensive Care Unit (ICU) and mortality) in patients with and without diabetes. Considering diabetic patients with AH (N = 68;18.1%) there was a correlation with COVID-19 severity (p = 0.03), invasive mechanical ventilation (p = 0.008), and ICU admission (p = 0.026). No correlation was present with any severity outcomes in diabetic patients without AH (N = 33; 8.8%). All of the New-onset Diabetes patients (N = 15; 4%) had AH, and 12 had severe COVID-19; additionally, five patients were admitted to the ICU and three patients died. However, severity outcomes did not reach statistical correlation significance in this group. In nondiabetic patients with AH (N = 51; 13.6%), there was a statistically significant association with the need for oxygen therapy (p = 0.001), invasive mechanical ventilation (p = 0.01), and ICU admission (p = 0.03). Our results support data regarding the impact of AH on severity outcomes. It also suggests an effect of AH on the prognosis of COVID-19 inpatients, regardless of the presence of pre-existing diabetes or new-onset diabetes. We reinforce the importance to assess at admission glycemia in all patients admitted with COVID-19.

Movement Is Life-Optimizing Patient Access to Total Joint Arthroplasty: Diabetes Mellitus Disparities

This is one of a series of articles that focuses on maximizing access to total joint arthroplasty by providing preoperative optimization pathways to all patients to promote the best results and minimize postoperative complications. Because of inequities in health care, an optimization process that is not equipped to support the underserved can potentially worsen disparities in the utilization of arthroplasty. A staggering 10.5% of the American population lives with diabetes mellitus. Diabetes prevalence is 17% higher in rural communities compared with urban communities. Rates of diabetes are higher in African American, Hispanic, and American Indian populations. Barriers to health care are higher in rural areas and for vulnerable communities, positioning the management of diabetes at the intersection of risk. Poor glycemic control is a predictor of periprosthetic joint infection. Optimization tools include assessing for food security, knowledge of a social safety net and community resources, patient diabetic literacy, and relationships with primary care providers to ensure continuous check-ins as well as partnering with specialty endocrine diabetic clinics. Several strategic recommendations, such as healthcare navigators and promotores (Latinx population), are made to enable and empower, such as continuous glucose monitoring, the preoperative patient to reach a safe preoperative optimization goal for their TJA surgery.

Re-examining the widespread policy of stopping sodium-glucose cotransporter-2 inhibitors during acute illness: A perspective based on the updated evidence

Sodium-glucose cotransporter-2 (SGLT2) inhibitors are now seen as an integral part of therapy in type 2 diabetes to control not only blood glucose but to improve cardiovascular and kidney outcomes. Diabetic ketoacidosis (DKA) is an uncommon but serious complication of type 2 diabetes, which has a high case fatality rate. The absolute risk of DKA in large, prospective randomized clinical trials in people with type 2 diabetes using SGLT2 inhibitors has been low, although the relative risk is higher in those assigned to SGLT2 inhibitors compared with placebo. In those without diabetes but prescribed SGLT2 inhibitors for heart failure or chronic kidney disease, the risk of DKA is similar to placebo. Over the course of the COVID-19 pandemic, cases of DKA have also been reported in cases of COVID-19 hospitalizations. Consensus guidelines have recommended that SGLT2 inhibitors should be avoided in cases of serious illness and suggest they are not recommended for routine in-hospital use. However, recent data suggest potential beneficial effects of SGLT2 inhibitors in the setting of acute illness with COVID-19 with no increase in adverse events and low rates of DKA, which were non-severe. Given the low rates of DKA in cardiovascular outcome trials and in hospitalized patients with type 2 diabetes, the potential for SGLT2 inhibitors not being re-initiated following discharge and their cardiovascular and kidney benefits, we believe the practice of routine 'sick day' guidance should be re-examined based on current evidence with a call for further research in this area. Furthermore, high-quality trials of initiation of SGLT2 inhibitors in people admitted to hospital with cardiovascular disease or kidney disease, and trials of continuation of SGLT2 inhibitors in people, with careful monitoring of DKA should be conducted. These should be further supplemented with large observational studies.

Clinical Decision Support for Glycemic Management Reduces Hospital Length of Stay

OBJECTIVE

Dysglycemia influences hospital outcomes and resource utilization. Clinical decision support (CDS) holds promise for optimizing care by overcoming management barriers. This study assessed the impact on hospital length of stay (LOS) of an alert-based CDS tool in the electronic medical record that detected dysglycemia or inappropriate insulin use, coined as gaps in care (GIC).

RESEARCH DESIGN AND METHODS

Using a 12-month interrupted time series among hospitalized persons aged ≥18 years, our CDS tool identified GIC and, when active, provided recommendations. We compared LOS during 6-month-long active and inactive periods using linear models for repeated measures, multiple comparison adjustment, and mediation analysis.

RESULTS

Among 4,788 admissions with GIC, average LOS was shorter during the tool's active periods. LOS reductions occurred for all admissions with GIC (-5.7 h, P = 0.057), diabetes and hyperglycemia (-6.4 h, P = 0.054), stress hyperglycemia (-31.0 h, P = 0.054), patients admitted to medical services (-8.4 h, P = 0.039), and recurrent hypoglycemia (-29.1 h, P = 0.074). Subgroup analysis showed significantly shorter LOS in recurrent hypoglycemia with three events (-82.3 h, P = 0.006) and nonsignificant in two (-5.2 h, P = 0.655) and four or more (-14.8 h, P = 0.746). Among 22,395 admissions with GIC (4,788, 21%) and without GIC (17,607, 79%), LOS reduction during the active period was 1.8 h (P = 0.053). When recommendations were provided, the active tool indirectly and significantly contributed to shortening LOS through its influence on GIC events during admissions with at least one GIC (P = 0.027), diabetes and hyperglycemia (P = 0.028), and medical services (P = 0.019).

CONCLUSIONS

Use of the alert-based CDS tool to address inpatient management of dysglycemia contributed to reducing LOS, which may reduce costs and improve patient well-being.

Glucose variability is a marker for COVID-19 severity and mortality

Objective

We aimed to investigate the association between glucose coefficient of variation (CV) and mortality and disease severity in hospitalized patients with coronavirus disease-19 (COVID-19).

Subjects and Methods

Retrospective cohort study in a tertiary center of patients with COVID-19 admitted to designated departments between March 11^th, 2020, and November 2^nd, 2020. We divided patients based on quartiles of glucose CV after stratification to those with and without diabetes mellitus (DM). Main outcomes were length of stay and in-hospital mortality.

Results

The cohort included 565 patients with a mean age of 67.71 ± 15.45 years, and 62.3% were male. Of the entire cohort, 44.4% had DM. The median glucose CV was 32.8% and 20.5% in patients with and without DM, respectively. In patients with DM, higher glucose CV was associated with a longer hospitalization in the unadjusted model (OR = 2.7, 95% CI [1.3,5.6] for Q4), and when adjusted for age, sex, comorbidities, and laboratory markers, this association was no longer statistically significant (OR = 1.3, 95% CI [0.4,4.5] for Q4). In patients with and without DM, higher glucose CV was associated with higher rates of in-hospital mortality in the unadjusted model, but adjustment for comorbidities and laboratory markers eliminated the association (OR = 0.5, 95% CI [0.1,3.4] for Q4 in patients with DM).

Conclusion

Higher glucose CV was associated with increased in-hospital mortality and length of stay, but this association disappeared when the adjustment included laboratory result data. Glucose CV can serve as a simple and cheap marker for mortality and severity of disease in patients with COVID-19.

Determinants of initial insulin therapy for hospitalized patients with diabetes mellitus

AIMS

Glycemic control immediately after hospital admission is difficult. This study aimed to develop an algorithm-based approach to initiate insulin therapy on admission.

METHODS

Patients with history of diabetes mellitus admitted at UC Davis medical center, with any blood glucose (BG) value ≥ 180 mg/dL, or who received any insulin within the first 24 h of hospitalization were selected for a retrospective chart review.

RESULTS

Total of 315 patient records were studied. Patients prescribed insulin prior to admission had higher 24-hour average BG and higher corrected total daily dose of insulin (CxTDD), compared with the patients who were not prescribed insulin prior to admission. For the patients not receiving home insulin and not given new glucocorticoids, first BG upon presentation correlated with the risk of first 24-hour average BG > 180 mg/dL. Factors associated with CxTDD were first BG, weight, oral intake, and glucocorticoid dose. Home insulin daily dose, opiate/intravenous pain medication and systemic inflammatory response syndrome were associated with CxTDD only in the patients receiving home insulin.

CONCLUSIONS

A subgroup of patients can be given correction insulin as a sole initial treatment on admission. For patients requiring basal-bolus insulin, several factors associated with the initial insulin requirements are identified.

Serum glycated albumin is associated with in-stent restenosis in patients with acute coronary syndrome after percutaneous coronary intervention with drug-eluting stents: An observational study

Background

Previous studies have confirmed the predicted value of serum glycated albumin (GA) in atherosclerotic cardiovascular disease. However, the relationship between GA and the development of in-stent restenosis (ISR) after drug-eluting stent (DES) implantation has not been verified in patients with acute coronary syndrome (ACS).

Materials and methods

In this study, 797 patients diagnosed with ACS who underwent re-coronary angiography more than 6 months after the first successful DES-based percutaneous coronary intervention (PCI) were eventually included. Patients were categorized into two groups based on the median GA levels of 14.94%. Moreover, multivariate logistic regression analysis models and the net reclassification improvement and integrated differentiation improvement risk models were constructed to assess the relationship between the GA and DES-ISR in patients with ACS.

Results

The GA was significantly associated with an increased risk of DES-ISR, upon adjusting for confounding factors (as nominal variate: OR 1.868, 95% CI 1.191-2.932, P = 0.007; as continuous variate: OR 1.109, 95% CI 1.040-1.183, P = 0.002). The addition of GA to a baseline risk model had an incremental effect on the predictive value for DES-ISR (AUC: GA vs. baseline model, 0.714 vs. 0.692, comparison P = 0.017; category-free net reclassification improvement (NRI) 0.080, P = 0.035; integrated discrimination improvement (IDI) 0.023, P < 0.001).

Conclusion

GA level was significantly associated with a high risk of DES-ISR in patients with ACS treated with PCI. Moreover, the addition of the GA to a baseline risk model has an incremental effect on the predictive potential for DES-ISR.

Association of admission hyperglycemia and all-cause mortality in acute myocardial infarction with percutaneous coronary intervention: A dose–response meta-analysis

Objective

The aim of this study is to evaluate the associations between admission hyperglycemia and the risk of all-cause mortality in patients with acute myocardial infarction (AMI) with or without diabetes, to find optimal admission glucose intervention cut-offs, and to clarify the shape of the dose–response relations.

Methods

Medline/PubMed and EMBASE were searched from inception to 1 April 2022. Cohort studies reporting estimates of all-cause mortality risk in patients with admission hyperglycemia with AMI were included. The outcomes of interest include mortality and major adverse cardiac events (MACEs). A random effect dose–response meta-analysis was conducted to access linear trend estimations. A one-stage linear mixed effect meta-analysis was used for estimating dose–response curves. Relative risks and 95% confidence intervals were pooled using a random-effects model.

Results

Of 1,222 studies screened, 47 full texts were fully reviewed for eligibility. The final analyses consisted of 23 cohort studies with 47,177 participants. In short-term follow-up, admission hyperglycemia was associated with an increased risk of all-cause mortality (relative risk: 3.12, 95% confidence interval 2.42–4.02) and MACEs (2.34, 1.77–3.09). In long-term follow-up, admission hyperglycemia was associated with an increased risk of all-cause mortality (1.97, 1.61–2.41) and MACEs (1.95, 1.21–3.14). A linear dose–response association was found between admission hyperglycemia and the risk of all-cause mortality in patients with or without diabetes.

Conclusion

Admission hyperglycemia was significantly associated with higher all-cause mortality risk and rates of MACEs. However, the association between admission hyperglycemia and long-term mortality risk needs to be determined with caution. Compared with current guidelines recommendations, a lower intervention cut-off and more stringent targets for admission hyperglycemia may be appropriate.

Systematic review registration

[https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022317280], identifier [CRD42022317280].

Stress Hyperglycemia Ratio as a Prognostic Marker in Diabetic Patients Hospitalized with COVID-19

Evidence is conflicting about the diabetes characteristics associated with worse outcome among hospitalized COVID-19 patients. We aimed to assess the role of stress hyperglycemia ratio (SHR) as a prognostic marker among them. In our retrospective cohort study, patients were stratified according to SHR, admission glucose, and glycated hemoglobin tertiles. The primary outcome was a composite endpoint of invasive mechanical ventilation, intensive care unit admission, and in-hospital mortality. The study included 395 patients with a mean age of 59 years, and 50.1% were males. Patients in the third tertile of SHR developed more primary events, and the difference was significant compared to the first tertile (p = 0.038) and close to significance compared to the second tertile (p = 0.054). There was no significant difference in the outcomes across admission glucose and glycated hemoglobin tertiles. A higher SHR tertile was an independent risk factor for the primary outcome (OR, 1.364; 95% CI: 1.014–1.836; p = 0.040) after adjustment for other covariables. In hospitalized COVID-19 diabetic patients, SHR third tertile was significantly associated with worse outcome and death. SHR can be a better prognostic marker compared to admission glucose and glycated hemoglobin. A higher SHR was an independent risk factor for worse outcome and in-hospital mortality.

Electronic Health Record-Based Decision-Making Support in Inpatient Diabetes Management

PURPOSE OF REVIEW

This review discusses ways in which the electronic health record (EHR) can offer clinical decision support (CDS) tools for management of inpatient diabetes and hyperglycemia.

RECENT FINDINGS

The use of electronic order sets can help providers order comprehensive basal bolus insulin regimens that are consistent with current guidelines. Order sets have been shown to reduce insulin errors and hypoglycemia rates. They can also help set glycemic targets, give hemoglobin A1C reminders, guide weight-based dosing, and match insulin regimen to nutritional profile. Glycemic management dashboards allow multiple variables affecting blood glucose to be shown in a single view, which allows for efficient evaluation of glucose trends and adjustment of insulin regimen. With the use glycemic management dashboards, active surveillance and remote management also become feasible. Hypoglycemia prevention and management are another part of inpatient diabetes management that is enhanced by EHR CDS tools. Furthermore, diagnosis and management of diabetic ketoacidosis and hyperglycemia hyperosmolar state are improved with the aid of EHR CDS tools. The use of EHR CDS tools helps improve the care of patients with diabetes and hyperglycemia in the inpatient hospital setting.

Perioperative Fully Closed-Loop Insulin Delivery in Patients Undergoing Elective Surgery: An Open-Label, Randomized Controlled Trial

OBJECTIVE

Perioperative management of glucose levels remains challenging. We aimed to assess whether fully closed-loop subcutaneous insulin delivery would improve glycemic control compared with standard insulin therapy in insulin-requiring patients undergoing elective surgery.

RESEARCH DESIGN AND METHODS

We performed a single-center, open-label, randomized controlled trial. Patients with diabetes (other than type 1) undergoing elective surgery were recruited from various surgical units and randomly assigned using a minimization schedule (stratified by HbA1c and daily insulin dose) to fully closed-loop insulin delivery with fast-acting insulin aspart (closed-loop group) or standard insulin therapy according to local clinical practice (control group). Study treatment was administered from hospital admission to discharge (for a maximum of 20 days). The primary end point was the proportion of time with sensor glucose in the target range (5.6-10.0 mmol/L).

RESULTS

Forty-five patients were enrolled and assigned to the closed-loop (n = 23) or the control (n = 22) group. One patient (closed-loop group) withdrew from the study before surgery and was not analyzed. Participants underwent abdominal (57%), vascular (23%), orthopedic (9%), neuro (9%), or thoracic (2%) surgery. The mean proportion of time that sensor glucose was in the target range was 76.7 ± 10.1% in the closed-loop and 54.7 ± 20.8% in the control group (mean difference 22.0 percentage points [95% CI 11.9; 32.0%]; P < 0.001). No episodes of severe hypoglycemia (<3.0 mmol/L) or hyperglycemia with ketonemia or any study-related adverse events occurred in either group.

CONCLUSIONS

In the context of mixed elective surgery, the use of fully closed-loop subcutaneous insulin delivery improves glucose control without a higher risk of hypoglycemia.

CGM in the Hospital: Is It Ready for Prime Time?

PURPOSE OF REVIEW

The use of continuous glucose monitoring (CGM) in the hospital setting is growing with more patients using these devices at home and when admitted to the hospital, especially during the COVID-19 pandemic.

RECENT FINDINGS

Historically, most evidence for CGM use in the inpatient setting was limited to small studies utilizing outdated CGM technology and analyzing accuracy of sensor measurements. Previous studies have shown reduced sensor accuracy during extreme hypo- or hyperglycemia, rapid fluctuations of glucose, compression of the sensor itself, and in those who are critically ill. Studies that are more recent have shown CGM to have adequate accuracy and may be effective in reducing hypoglycemia in hospitalized patients; some studies have also showed improvement in time in target glycemic range. Furthermore, CGM may reduce nursing workload, cost of inpatient care, and use of personal protective equipment and face-to-face patient care especially for patients during the COVID-19 pandemic. This review will describe the evidence for use of CGM in hospitalized critically ill or non-critically ill patients, address accuracy and safety considerations, and outline paths for future implementation.

Glycemic Effects and Predictors of Increased Time-in-Range After Initiating MiniMed 670G: A 12-Month Observational Study

We aimed to evaluate the glycemic effect and detect any predictors of improved time-in-range (TIR) in persons with type 1 diabetes after initiating hybrid closed-loop (HCL) treatment with MiniMed 670G in a 12-month retrospective observational study. Before starting HCL treatment, the 62 participants followed a Steno-developed training program; 7 participants (6.5%) discontinued the HCL therapy; the remaining 55 (58% female) had an age (mean ± standard deviation) of 45.6 ± 12.6 years and diabetes duration of 28.2 ± 10.9 years. After 12 months' HCL therapy, glycated hemoglobin A1c decreased from 7.4% +0.7% to 7.1% +0.5%, TIR increased from 59.3% ± 13.5% to 72% ± 9.3%, time in 54-70 mg/dL (3.0-3.9 mM) decreased from 2.4% ± 2.0% to 1.4% ± 1.0%, and time in 180-250 mg/dL (10.0-13.9 mM) decreased from 26.4% ± 8.3% to 20.8% ± 5.5%, all P < 0.001. Improvement in TIR was significantly associated with lower total daily insulin dose, higher amount of total carbohydrate, and more time spent in Auto Mode. Our findings support the promising results on glycemic outcomes seen with HCL treatment.

Predicting Sensitivity to Adverse Lifestyle Risk Factors for Cardiometabolic Morbidity and Mortality

People appear to vary in their susceptibility to lifestyle risk factors for cardiometabolic disease; determining a priori who is most sensitive may help optimize the timing, design, and delivery of preventative interventions. We aimed to ascertain a person’s degree of resilience or sensitivity to adverse lifestyle exposures and determine whether these classifications help predict cardiometabolic disease later in life; we pooled data from two population-based Swedish prospective cohort studies (n = 53,507), and we contrasted an individual’s cardiometabolic biomarker profile with the profile predicted for them given their lifestyle exposure characteristics using a quantile random forest approach. People who were classed as ‘sensitive’ to hypertension- and dyslipidemia-related lifestyle exposures were at higher risk of developing cardiovascular disease (CVD, hazards ratio 1.6 (95% CI: 1.3, 1.91)), compared with the general population. No differences were observed for type 2 diabetes (T2D) risk. Here, we report a novel approach to identify individuals who are especially sensitive to adverse lifestyle exposures and who are at higher risk of subsequent cardiovascular events. Early preventive interventions may be needed in this subgroup.

Admission Hyperglycemia as a Predictor of COVID-19 Pneumonia, Cytokine Release Syndrome Progression, and Clinical Outcomes in a Tertiary Care Hospital

Introduction

Diabetes and coronavirus disease 2019 (COVID-19) are interrelated. The presence of hyperglycemia per se during COVID-19 infection regardless of diabetes status has been associated with poor prognosis and increased risk of mortality.

Objectives

The main aim of the current study was to assess the association between admission hyperglycemia and COVID-19 outcomes.

Methods

This is a retrospective cohort study including 315 patients, mainly employed in the facility, who presented to the emergency department or were admitted with confirmed COVID-19 infection from April 2020 to August 2021.

Results

The mean age of the studied cohort was 40.2±12.5 years, where 59.68% were males and 37.7% were symptomatic. Older age, male gender, history of diabetes and hypertension, and elevated C-reactive protein (CRP) and lactate dehydrogenase (LDH) levels were associated with a significantly increased risk of developing cytokine release syndrome (CRS). Admission hyperglycemia was significantly associated with poor outcomes. The time to negativity was 9.30±0.1 days for asymptomatic patients; however, it increased significantly according to clinical presentation, presence of comorbidities, and severe outcomes, in patients with cytokine release syndrome.

Conclusions

Admission hyperglycemia was associated with an increased risk of progression to critical condition in patients hospitalized with COVID-19 independent of the history of diabetes. Therefore, it should not be overlooked but instead should be detected and appropriately treated to improve outcomes. In addition, post-COVID-19 care should be individualized, where severe cases require almost double the time needed by mild cases to convert to negative.

Heart Failure: An Underappreciated Complication of Diabetes. A Consensus Report of the American Diabetes Association

Heart failure (HF) has been recognized as a common complication of diabetes, with a prevalence of up to 22% in individuals with diabetes and increasing incidence rates. Data also suggest that HF may develop in individuals with diabetes even in the absence of hypertension, coronary heart disease, or valvular heart disease and, as such, represents a major cardiovascular complication in this vulnerable population; HF may also be the first presentation of cardiovascular disease in many individuals with diabetes. Given that during the past decade, the prevalence of diabetes (particularly type 2 diabetes) has risen by 30% globally (with prevalence expected to increase further), the burden of HF on the health care system will continue to rise. The scope of this American Diabetes Association consensus report with designated representation from the American College of Cardiology is to provide clear guidance to practitioners on the best approaches for screening and diagnosing HF in individuals with diabetes or prediabetes, with the goal to ensure access to optimal, evidence-based management for all and to mitigate the risks of serious complications, leveraging prior policy statements by the American College of Cardiology and American Heart Association.

Generation of post-meal insulin correction boluses in type 1 diabetes simulation models for in-silico clinical trials: More realistic scenarios obtained using a decision tree approach

BACKGROUND AND OBJECTIVE

In type 1 diabetes (T1D) research, in-silico clinical trials (ISCTs) notably facilitate the design/testing of new therapies. Published simulation tools embed mathematical models of blood glucose (BG) and insulin dynamics, continuous glucose monitoring (CGM) sensors, and insulin treatments, but lack a realistic description of some aspects of patient lifestyle impacting on glucose control. Specifically, to effectively simulate insulin correction boluses, required to treat post-meal hyperglycemia (BG > 180 mg/dL), the timing of the bolus may be influenced by subjects' behavioral attitudes. In this work, we develop an easily interpretable model of the variability of correction bolus timing observed in real data, and embed it into a popular simulation tool for ISCTs.

METHODS

Using data collected in 196 adults with T1D monitored in free-living conditions, we trained a decision tree (DT) model to classify whether a correction bolus is injected in a future time window, based on predictors collected back in time, related to CGM data, previous insulin boluses and subject's characteristics. The performance was compared to that of a logistic regression classifier with LASSO regularization (LC), trained on the same dataset. After validation, the DT was embedded within a popular T1D simulation tool and an ISCT was performed to compare the simulated correction boluses against those observed in a subset of data not used for model training.

RESULTS

The DT provided better classification performance (accuracy: 0.792, sensitivity: 0.430, specificity: 0.878, precision: 0.455) than the LC and presented good interpretability. The most predictive features were related to CGM (and its temporal variations), time since the last insulin bolus, and time of the day. The correction boluses simulated by the DT, after implementation in the simulation tool, showed a good agreement with real-world data.

CONCLUSIONS

The DT developed in this work represents a simple set of rules to mimic the same timing of correction boluses observed on real data. The inclusion of the model in simulation tools allows investigators to perform ISCTs that more realistically represent the patient behavior in taking correction boluses and the post-prandial BG response. In the future, more complex models can be investigated.

Effect of the Concomitant Use of Subcutaneous Basal Insulin and Intravenous Insulin Infusion in the Treatment of Severe Hyperglycemic Patients

BACKGRUOUND

No consensus exists regarding the early use of subcutaneous (SC) basal insulin facilitating the transition from continuous intravenous insulin infusion (CIII) to multiple SC insulin injections in patients with severe hyperglycemia other than diabetic ketoacidosis. This study evaluated the effect of early co-administration of SC basal insulin with CIII on glucose control in patients with severe hyperglycemia.

METHODS

Patients who received CIII for the management of severe hyperglycemia were divided into two groups: the early basal insulin group (n=86) if they received the first SC basal insulin 0.25 U/kg body weight within 24 hours of CIII initiation and ≥4 hours before discontinuation, and the delayed basal insulin group (n=79) if they were not classified as the early basal insulin group. Rebound hyperglycemia was defined as blood glucose level of >250 mg/dL in 24 hours following CIII discontinuation. Propensity score matching (PSM) methods were additionally employed for adjusting the confounding factors (n=108).

RESULTS

The rebound hyperglycemia incidence was significantly lower in the early basal insulin group than in the delayed basal insulin group (54.7% vs. 86.1%), despite using PSM methods (51.9%, 85.2%). The length of hospital stay was shorter in the early basal insulin group than in the delayed basal insulin group (8.5 days vs. 9.6 days, P=0.027). The hypoglycemia incidence did not differ between the groups.

CONCLUSION

Early co-administration of basal insulin with CIII prevents rebound hyperglycemia and shorten hospital stay without increasing the hypoglycemic events in patients with severe hyperglycemia.

Sustained Hyperglycemia and Its Relationship with the Outcome of Hospitalized Patients with Severe COVID-19: Potential Role of ACE2 Upregulation

Chronic hyperglycemia increases the risk of developing severe COVID-19 symptoms, but the related mechanisms are unclear. A mean glucose level upon hospital admission >166 mg/dl correlates positively with acute respiratory distress syndrome in patients with hyperglycemia. The objective of this study was to evaluate the relationship between sustained hyperglycemia and the outcome of hospitalized patients with severe COVID-19. We also evaluated the effect of high glucose concentrations on the expression of angiotensin-converting enzyme 2 (ACE2). We carried out a case-control study with hospitalized patients with severe COVID-19 with and without sustained hyperglycemia. In a second stage, we performed in vitro assays evaluating the effects of high glucose concentrations on ACE2 gene expression. Fifty hospitalized patients with severe COVID-19 were included, of which 28 (56%) died and 22 (44%) recovered. Patients who died due to COVID-19 and COVID-19 survivors had a high prevalence of hyperglycemia (96.4% versus 90.9%), with elevated central glucose upon admission (197.7 mg/dl versus 155.9 mg/dl, p = 0.089) and at discharge (185.2 mg/dl versus 134 mg/dl, p = 0.038). The mean hypoxemia level upon hospital admission was 81% in patients who died due to COVID-19 complications and 88% in patients who survived (p = 0.026); at the time of discharge, hypoxemia levels were also different between the groups (68% versus 92%, p ≤ 0.001). In vitro assays showed that the viability of A549 cells decreased (76.41%) as the glucose concentration increased, and the ACE2 gene was overexpressed 9.91-fold after 72 h (p ≤ 0.001). The relationship between hyperglycemia and COVID-19 in hospitalized patients with COVID-19 plays an important role in COVID-19-related complications and the outcome for these patients. In patients with chronic and/or sustained hyperglycemia, the upregulation of ACE2, and its potential glycation and malfunction, could be related to complications observed in patients with COVID-19.

Comparison of Glycemic Variability and Hypoglycemic Events in Hospitalized Older Adults Treated with Basal Insulin plus Vildagliptin and Basal-Bolus Insulin Regimen: A Prospective Randomized Study

Background: The basal−bolus insulin regimen is recommended in hospitalized patients with diabetes mellitus (DM), but has an increased risk of hypoglycemia. We aimed to compare dipeptidyl peptidase 4 inhibitors (DPP4-i) and basal−bolus insulin glycemic outcomes in hospitalized type 2 DM patients. Methods and patients: Our prospective randomized study included 102 elderly T2DM patients (82 ± 9 years, HbA1c 6.6% ± 1.9). Glycemic control: A variability coefficient assessed by continuous glucose monitoring (Free Style® sensor), mean insulin dose and hypoglycemia rates obtained with the two treatments were analyzed. Results: No differences were found between groups in glycemic control (mean daily glycemia during the first 10 days: 152.6 ± 38.5 vs. 154.2 ± 26.3 mg/dL; p = 0.8). The total doses Kg/day were 0.40 vs. 0.20, respectively (p < 0.001). A lower number of hypoglycemic events (9% vs. 15%; p < 0.04) and lower glycemic coefficient of variation (22% vs. 28%; p < 0.0002) were observed in the basal−DPP4-i compared to the basal−bolus regimen group. Conclusions: Treatment of inpatient hyperglycemia with basal insulin plus DPP4-i is an effective and safe regimen in old subjects with T2DM, with a similar mean daily glucose concentration, but lower glycemic variability and fewer hypoglycemic episodes compared to the basal bolus insulin regimen.

Acceptance and Effect of Continuous Glucose Monitoring on Discharge From Hospital in Patients With Type 2 Diabetes: Open-label, Prospective, Controlled Study

Background

Continuous glucose monitors (CGM) can provide detailed information on glucose excursions. There is little information on safe transitioning from hospital back to the community for patients who have had diabetes therapies adjusted in hospital and it is unclear whether newer technologies may facilitate this process.

Objective

Our aim was to determine whether offering CGM on discharge would be acceptable and if CGM initiated on hospital discharge in people with type 2 diabetes (T2DM) would reduce hospital re-presentations at 1 month.

Methods

This was an open-label study. Adult inpatients with T2DM, who were to be discharged home and required postdischarge glycemic stabilization, were offered usual care consisting of clinic review at 2 weeks and at 3 months. In addition to usual care, participants in the intervention arm were provided with a Libre flash glucose monitoring system (Abbott Australia). An initial run-in phase for the first 20 participants was planned, where all consenting participants were enrolled in an active arm. Subsequently, all participants were to be randomized to the active arm or usual care control group.

Results

Of 237 patients screened during their hospital admission, 34 had comorbidities affecting cognition that prevented informed consent and affected their ability to learn to use the CGM device. In addition, 21 were not able to be approached as the material was only in English. Of 101 potential participants who fulfilled eligibility criteria, 19 provided consent and were enrolled. Of the 82 patients who declined to participate, 31 advised that the learning of a new task toward discharge was overwhelming or too stressful and 26 were not interested, with no other details. Due to poor recruitment, the study was terminated without entering the randomization phase to determine whether CGM could reduce readmission rate.

Conclusions

These results suggest successful and equitable implementation of telemedicine programs requires that any human factors such as language, cognition, and possible disengagement be addressed. Recovery from acute illness may not be the ideal time for introduction of newer technologies or may require more novel implementation frameworks.

Continuous Subcutaneous Insulin Infusions vs. Multiple Daily Injections of Insulin in Hospitalized Patients: Glycemic Trends in the First 24 Hours of Admission

BACKGROUND

Continuous subcutaneous insulin infusion (CSII) is a common diabetes treatment modality. Glycemic outcomes of patients using CSII in the first 24 hours of hospitalization have not been well studied. This timeframe is of particular importance because insulin pump settings are programmed to achieve tight outpatient glycemic targets which could result in hypoglycemia when patients are hospitalized.

METHODS

This retrospective cohort study evaluated 216 hospitalized adult patients using CSII and 216 age-matched controls treated with multiple daily injections (MDI) of insulin. Patients using CSII did not make changes to pump settings in the first 24 hours of admission. Blood glucose (BG) values within the first 24 hours of admission were collected. The primary outcome was frequency of hypoglycemia (BG < 70 mg/dL). Secondary outcomes were frequency of severe hypoglycemia (BG < 40 mg/dL) and hyperglycemia (BG ≥ 180 mg/dL).

RESULTS

There were significantly fewer events of hypoglycemia [incident rate ratio (IRR) 0.61, 95% confidence interval (CI) 0.42-0.88, p = 0.007] and hyperglycemia (IRR 0.79, 95% CI 0.65-0.96, p = 0.02) in the CSII group compared to the MDI group. There was a trend toward fewer events of severe hypoglycemia in the CSII group (IRR 0.15, 95% CI 0.02-0.93, p = 0.06).

CONCLUSIONS

Patients using CSII experienced fewer events of both hypoglycemia and hyperglycemia in the first 24 hours of hospital admission than those treated with MDI. Our study demonstrates that CSII use is safe and effective for the treatment of diabetes within the first 24 hours of hospital admission.