Dulaglutide-combined basal plus correction insulin therapy contributes to ideal glycemic control in non-critical hospitalized patients

AIMS/INTRODUCTION

We investigated whether dulaglutide (DU)-combined conventional insulin therapy is beneficial for glycemic control in non-critically ill hospitalized patients with type 2 diabetes.

MATERIALS AND METHODS

This study was a prospective, randomized controlled pilot study. Participants were randomized to either basal-plus (BP) therapy, where basal insulin and corrective doses of regular insulin were administered before meals, or BP + DU therapy, where BP therapy was combined with DU. Blood glucose (BG) levels before and after every meal were measured for 7 days after assignment to groups. Because we consider the ideal BG during hospitalization to be within 100-180 mg/dL, we defined this range as the hospitalized ideal glucose range (hIGR). We compared the percentage of BG measurements within the hIGR among all BG measurements (%hIGR), mean BG, glucose variability and insulin dose between the two groups.

RESULTS

Of 54 patients, 27 were assigned to the BP group and 27 to the BP + DU group. The %hIGR was significantly higher (44% vs 56%, P < 0.001), and the frequency of BG >240 mg/dL and BG <70 mg/dL was significantly lower in the BP + DU group than in the BP group (both P < 0.001). The mean BG (183 ± 29 vs 162 ± 30 mg/dL, P < 0.05), standard deviation (P < 0.01), coefficient of variation (P < 0.01) and total regular insulin dose (P < 0.05) in the BP + DU group were significantly lower than those in the BP group. No significant side-effects were observed in either group.

CONCLUSIONS

BP + DU therapy reduced the frequency of hyperglycemia and hypoglycemia, and resulted in a lower glucose variability.

Luseogliflozin improves liver fat deposition compared to metformin in type 2 diabetes patients with non-alcoholic fatty liver disease: A prospective randomized controlled pilot study

This study aimed to assess the effect of luseogliflozin on liver fat deposition and compare luseogliflozin to metformin in type 2 diabetes (T2D) patients with non-alcoholic fatty liver disease (NAFLD). Thirty-two T2D patients with NAFLD diagnosed by computed tomography or abdominal sonography were recruited. Participants were randomly assigned to receive either luseogliflozin (2.5 mg, newly administered) or metformin (1500 mg, newly or additionally administrated). Data on the liver-to-spleen attenuation ratio (L/S), visceral fat area, body mass index, glycated hemoglobin (HbA1c), alanine aminotransferase (ALT), fasting plasma glucose, C-peptide immunoreactivity (CPR), and CPR index were collected at baseline and after 6 months. The change in L/S was significantly greater in the luseogliflozin group than in the metformin group. Similarly, the changes in the visceral fat area, HbA1c, and body mass index were significantly greater in the luseogliflozin group than in the metformin group. The changes in ALT, fasting glucose, CPR, and CPR index were not significant in both groups. In conclusion, luseogliflozin significantly reduced liver fat deposition as compared to metformin, which may indicate clinical relevant benefits for NAFLD.

Development of an external-to-internal convertible endoscopic biliary drainage device - a preliminary prospective feasibility study

BACKGROUND AND STUDY AIMS

 Endoscopic nasobiliary drainage (ENBD) for a malignant stricture in the bile duct has some advantages over endoscopic biliary stenting (EBS). However, ENBD may cause nasopharyngeal discomfort. We developed an external-to-internal convertible endoscopic biliary drainage (ETI-EBD) device that enables both internal and external drainage to occur during a single endoscopy.

PATIENTS AND METHODS

This device consists of three parts, comprising a 5-Fr ENBD tube (250 cm) (ENBD-t), an 8.5-Fr EBS tube (7 cm) (EBS-t), and an 8-Fr pusher tube for EBS (230 cm) (P-t). The EBS-t is mounted over the ENBD-t at the distal end of the ENBD-t. The P-t is also placed over the ENBD-t. After an endoscopic sphincterotomy, the EBS-t of the device is inserted into the papilla, then the duodenal endoscope is withdrawn, leaving the device in place. After ENBD, only the ENBD-t was withdrawn from the P-t. At this point, the EBS-t was isolated and left without endoscopy or radiography.

RESULTS

ETI-EBD was successfully placed in all consecutive 21 patients (100 %). The release of EBS-t from ENBD-t wit was successfully completed in 19 patients (90.5 %). There were 4 patients with kink of P-t when exchanging this device from the mouth to the nose. It was difficult for 2 patients to withdraw the ENBD-t because of poor lubrication performance. There were no significant complications associated with the use of the device.

CONCLUSION

This device allows for both external and internal biliary drainage with a single endoscopy.

Effects of two different glutamine-containing enteral supplements on stool frequency and density in elderly patients recovering from acute critical illness

AIM

Glutamine has various beneficial functions in the gastrointestinal tract. The present study was designed to investigate the effect of two different glutamine supplements on bowel movement at the start of enteral feeding in elderly inpatients.

METHODS

This was a double-blind, prospective, randomized comparison study. A total of 25 patients aged >75 years recovering from a critical illness in a non-intensive care unit and scheduled for tube feeding were recruited. Of them, 22 consenting patients were randomly assigned to two groups: glutamine-fiber-oligosaccharide treatment group (n = 11) and glutamine F treatment group (n = 11). They were given glutamine three times daily at a dosage of 9 g/day. Enteral nutrition was given at the same dosage to both groups for the duration of the study. The end-points were stool frequency, Bristol Scale Form Score, bowel function index (Bristol Scale Form Score × stool frequency), the percentage of patients with stool frequency over three per day and those with a BSFS of 6 or 7 in each group.

RESULTS

There were no significant differences between the two groups in terms of patient characteristics before the study. All the end-points in the glutamine F group were significantly lower than those in the glutamine-fiber-oligosaccharide group.

CONCLUSIONS

Compared with glutamine-fiber-oligosaccharide, glutamine F administration resulted in stool hardening and reduced stool frequency in elderly inpatients recovering from acute critical illness in non-intensive care units. The effects might be caused by the different additive components of glutamine supplements. Geriatr Gerontol Int 2017; 17: 2514-2519.

Investigating the Relationship between Morning Glycemic Variability and Patient Characteristics Using Continuous Glucose Monitoring Data in Patients with Type 2 Diabetes

Objective To investigate the relationship between patient characteristics and morning glycemic variability. Methods We retrospectively evaluated 106 patients with type 2 diabetes who underwent continuous glucose monitoring during admission. The highest postprandial glucose level (within 3 hours after breakfast; 'highest level'), the time from the start of breakfast to the highest postprandial glucose level ('highest time'), the difference between the pre-breakfast and highest postprandial breakfast glucose level ('increase'), the area under the curve (AUC; ≥180 mg/dL) for the glycemic variability within 3 hours after breakfast ('morning AUC'), and the post-breakfast glucose gradient ('gradient') were calculated. We analyzed the associations between these factors and nocturnal hypoglycemia and the patients' characteristics by using a regression analysis. Results After stepwise multivariate adjustment, significant independent associations were found between 'highest level' and high age, low BMI, and high HbA1c; 'highest time' and high HbA1c, low C-peptide immunoreactivity (CPR), and low fasting plasma glucose (FPG); the 'increase' and high age, low BMI, high HbA1c, low FPG and hypoglycemia; 'morning AUC' and high age, high HbA1c and hypoglycemia; and 'gradient' and long duration of diabetes and low BMI. Conclusion Higher age and lower BMI are associated with higher 'highest' and 'increase' levels. Higher HbA1c levels were linked to a longer 'highest time', and longer durations of the diabetes, while lower BMI values were related to a higher 'gradient'.

Major Increases between Pre- and Post-breakfast Glucose Levels May Predict Nocturnal Hypoglycemia in Type 2 Diabetes

Objective The aim of this study was to determine whether nocturnal hypoglycemia may be predicted according to morning glucose levels. Methods We retrospectively evaluated 106 patients with type 2 diabetes who underwent continuous glucose monitoring during admission. The pre-breakfast glucose level (Pre-breakfast level), highest postprandial glucose level within 3 hours after breakfast (Highest level), time from the start of breakfast to the highest postprandial glucose level (Highest time), difference between the pre-breakfast and highest postprandial breakfast glucose levels (Increase), area under the glucose curve (≥180 mg/dL) within 3 hours after breakfast (Morning AUC), post-breakfast glucose gradient (Gradient), and the increase-to-pre-breakfast ratio (Increase/Pre-breakfast) were calculated. The subjects were divided into hypoglycemic and non-hypoglycemic patients and compared for the above parameters using the t-test. A receiver operating characteristic analysis was used to determine the optimal cut-off values to predict nocturnal hypoglycemia (Hypoglycemia). Results Twenty-eight patients (26.4%) had hypoglycemia. The Pre-breakfast levels were significantly lower in patients with hypoglycemia than those without (p=0.03). The Increases were significantly higher in patients with hypoglycemia than those without (p=0.047). The Increase/Pre-breakfast ratio were significantly larger in patients with hypoglycemia than those without (p=0.0002). Their cut-off values were as follows (level, sensitivity, specificity, and area under the curve): 123 mg/dL, 0.89, 0.55, and 0.78 (p<0.0001); 90.5 mg/dL, 0.75, 0.64, and 0.76 (p<0.0001); and 90.2%, 0.75, 0.76, and 0.78 (p<0.0001), respectively. Conclusion Major increases between the pre- and post-breakfast glucose levels may predict nocturnal hypoglycemia in patients with type 2 diabetes.

Hypoglycemia and glycemic variability are associated with mortality in non-intensive care unit hospitalized infectious disease patients with diabetes mellitus

AIMS/INTRODUCTION

We aimed to identify factors - glycemic control, reactive inflammatory biomarkers or vital signs - associated with mortality in diabetic patients admitted to hospital for various infections (non-intensive care unit).

MATERIALS AND METHODS

We retrospectively analyzed the cases of 620 diabetic patients admitted to hospital for various infections (non-intensive care unit) who underwent glucose monitoring >3 times per day. We extracted data regarding reactive inflammatory biomarkers and vital signs recorded on day 1 of hospital stay, and data on bacteremia and hypoglycemia status, glycemic variability (GV; coefficient of variation and standard deviation) and mean glucose concentrations during the entire hospital stay. Univariate and stepwise multivariate logistic regression analyses were carried out to determine the association between these factors and mortality.

RESULTS

The mortality rate was 10.1%. Reactive inflammatory biomarkers, vital signs and bacteremia were not associated with mortality. According to the results of the adjusted analysis, hypoglycemia showed a significant positive association with mortality, increasing death risk by 266% (odds ratio [OR] 2.66, 95% confidence interval [95% CI] 1.22-5.83; P = 0.0006). High coefficient of variation and standard deviation values were significantly associated with increased mortality, increasing death risk by 18% (OR 1.18, 95% CI 1.01-1.38; P = 0.03) and 9% (OR 1.09, 95% CI 1.01-1.18; P = 0.03), respectively. Mean glucose concentrations were also significantly associated with mortality, increasing death risk by 5% (OR 1.05, 95% CI 1.02-1.08; P = 0.0008).

CONCLUSIONS

Glycemic indices (especially hypoglycemia and GV), rather than reactive inflammatory biomarkers or vital signs, were associated with mortality in non-intensive care unit diabetes mellitus patients with infections.

Evaluation of safety of insulin degludec on undergoing total colonoscopy using continuous glucose monitoring

AIMS/INTRODUCTION

There is little information regarding how to use insulin degludec (D) when diabetic patients are preparing for total colonoscopy (TCS).

MATERIALS AND METHODS

A total of 12 patients with type 2 diabetes treated with insulin D and scheduled to undergo TCS were enrolled in the present study. A continuous glucose monitoring device was attached to each patient for 4 days, from two evenings before TCS to the morning after the procedure. The patients fasted for 24 h, starting after 18.00 h the day before TCS. Insulin D was only discontinued the morning of the day TCS was carried out.

RESULTS

No patients experienced hypoglycemia during the daytime fasting period (08.00-18.00 h the day of TCS); the hypoglycemic index, mean glucose level, and standard deviation were 0, 141.3 ± 31.5 mg/dL and 15.6 ± 6.5 mg/dL. The mean glucose level and standard deviation during the daytime fasting period were significantly lower than during the daytime control period (08.00-18.00 h the day before TCS; P = 0.003, P = 0.001, respectively). The mean fasting glucose and fasting plasma glucose levels were significantly correlated (r = 0.78, P = 0.002), as were both the mean glucose level and standard deviation during the daytime control period, and the change in the mean glucose level (fasting period minus control period; r = -0.79, P = 0.002, and r = -0.69, P = 0.01, respectively).

CONCLUSIONS

Patients can safely undergo TCS when insulin D is discontinued only once on the day of the procedure.

l-Menthol sprayed on gastric mucosa causes edematous change

BACKGROUND AND STUDY AIMS

l-Menthol (LM), sprayed on the distal gastric mucosa, is a safe antispasmodic agent used during esophagogastroduodenoscopy (EGD). However, it seems to affect gastric mucosal endoscopic findings. Therefore, we evaluated whether LM causes specific changes and impacts the endoscopic morphology of gastric lesions.

PATIENTS AND METHODS

A total of 98 patients scheduled to undergo EGD were randomly assigned to receive LM solution (160 mg of 0.8 % LM added to 2.5 mL of indigo carmine [IC]; n = 49; LM group) or decuple-diluted IC solution without LM (n = 49; placebo group). We compared the incidence of specific mucosal changes and the difference in the endoscopic findings of several gastric lesions between these groups.

RESULTS

Annular-reticular - like mucosal changes appeared immediately after the administration of LM solution. This change was observed in 71.4 % of the LM group compared with 12.2 % of the placebo group (P < 0.01). In the placebo group, this change was observed in 14.7 % of subjects with atrophic gastritis compared with 6.7 % of those without atrophic gastritis (P = 0.39), whereas in the LM group, this change was observed in 84.8 % of subjects with atrophic gastritis compared with 43.8 % of those without atrophic gastritis (P < 0.01). Most early gastric cancers, erosions, and ulcers observed in this study became well demarcated after LM administration, although the incidence of gastric lesions did not differ significantly between the two groups.

CONCLUSION

LM changes the gastric mucosa into edematous mucosa, and this occurs more frequently in atrophic gastric mucosa than in pathologic lesions. LM may facilitate the demarcation of pathologic gastric lesions without intestinal metaplasia.

Application of a microbial sensor to the quality control of meat freshness

Samples of fresh meat stored at 5 degrees C were periodically removed from storage and washed with water for periods of up to 2 weeks. The amount of amino acids, polyamines and viable counts (number of bacteria) in the washed water were measured by using an HPLC system and a colony counting method. At the same time, the washed water was charged into a flow injection analysis (FIA) system combined a microbial sensor using yeast (Trichosporon cutaneum), which was developed in this work for monitoring the freshness of meat. A relationship between the sensor signals obtained by the FIA system and the amounts of polyamines and amino acids produced from the meat and the number of bacteria which had multiplied in the meat during the aging process was investigated. The sensor signal was found to correspond to increases in amino acid levels and viable counts in the meat with the storage time in the course of the first stage of aging. This is due to the fact that amino acids produced initially by enzymes in the meat serve as a source of nutrition for septic bacteria during the aging process, and as a result, the level of bacterial cells increases with increasing amounts of amino acids with the passage of days. A good correlation, with a correlation factor of 0.908, was obtained between the sensor signal and viable counts obtained by the colony counting method. The present sensor method was more sensitive than the colony counting method at the early stage of the aging process, where viable counts were in the vicinity of 10(4) g(-1).

Electrocardiographic characteristics of left ventricular outflow tract tachycardia

Catheter ablation of idiopathic left ventricular outflow tract tachycardia (LVOT-VT) is rare because a safe ablation technique at this site has not been described, and serious complications may occur. This study compared the QRS morphology of LVOT-VT with that of idiopathic right ventricular outflow tract tachycardia. A comparison was made between the electrocardiographic characteristics of LVOT-VT originating from the supravalvular region of a coronary cusp (Supra-Ao group) with those of LVOT-VT originating from the infravalvular endocardial region of a coronary cusp of the aortic valve within the LV (Infra-Ao group). After precise mapping of the right ventricle, left ventricle, pulmonary artery, coronary cusps, and proximal portion of the anterior interventricular vein, there were 17 patients in whom VT was thought to be located at the LVOT by both activation and pace mapping. They were divided between a Supra-Ao group (n = 8), and an Infra-Ao group (n = 9). Analysis of the 12-lead electrocardiogram (ECG) revealed an S wave in lead I in all 17 patients. A precordial R wave transition was also observed at V1 or V2 in 16 patients (94%). In 7 of 8 patients (88%) with Supra-Ao LVOT-VT, no S wave was observed in either V5 or V6. In contrast, an Rs pattern was observed in both V5 and V6, or in V6 only, in 100% of the patients with Infra-Ao LVOT-VT. A LVOT-VT should be suspected when the ECG shows an S wave in lead I and an R/S ratio greater than 1 in lead V1 or V2, versus a coronary cusp location if there is no S wave in either lead V5 or V6.

Successful radiofrequency catheter ablation from the supravalvular region of the aortic valve in a patient with outflow tract ventricular tachycardia

Outflow tract ventricular tachycardia (OT-VT) was successfully ablated from the right coronary cusp of the aortic valve. The 12-lead ECG was totally different from the typical right ventricular OT-VT because the R/S ratio in precordial lead V1 was equal to 1 and tall R waves in precordial leads V2-6 were seen. Radiofrequency energy application from the right coronary cusp of the aortic valve successfully ablated this VT without complications. Radiofrequency catheter ablation from the right coronary cusp of the aortic valve can be done safely and effectively.

Catheter ablation of ventricular tachycardia in patients with right ventricular dysplasia: Identification of target sites by entrainment mapping techniques

OBJECTIVE

To identify target sites for radiofrequency ablation of ventricular tachycardia (VT) by entrainment mapping techniques in patients with arrhythmogenic right ventricular dysplasia.

METHODS

Entrainment mapping and radiofrequency ablation of eight VTs was performed in seven patients. Radiofrequency ablation was applied at 31 reentry circuits sites that were classified based on findings during entrainment.

RESULTS

By entrainment criteria the 31 sites were classified as: exit sites (n = 12), proximal sites (n = 6), and outer loop sites (n = 13). Radiofrequency current application terminated VT at 7 of 31 sites: 2 of 12 exit sites (17%), 4 of 6 proximal sites (67%), and 1 of 13 outer loop sites (8%).

CONCLUSION

Radiofrequency ablation terminated VTs most often at sites proximal to the exit as opposed to outer loop sites and exit sites (P = 0.05). The critical isthmus for ablation of VT in right ventricular dysplasia often may be distant to the exit.

Pulmonary intralobar sequestration accompanied by aneurysm of an anomalous arterial supply

A 47-year-old woman presented with hemoptysis and her chest X-ray films showed an opacity suggesting a mass in the left lower lung field. Based on radiographic investigations, the mass was diagnosed as an aneurysm develop in an anomalous vessel and was considered to be a Pryce type I pulmonary intralobar sequestration. Resection of the left lower lobes was performed and the aneurysm was found to be filled with thrombus. It is rare for an aneurysm to form in an aberrant vessel. This complication may have been the result of regional sclerosis affecting the anomalous artery as well as systemic atherosclerosis.

Prothrombin Himi; an abnormal prothrombin characterized by a defective thrombin activity

An abnormal prothrombin has been detected in a 26-year-old female, who had no history of excessive bleeding. Prothrombin activity was approximately 10% when measured using either the classical one-stage assay or the assay with Echis carinatus venom, whereas prothrombin antigen level was normal. In keeping with current nomenclature practices, the abnormal prothrombin was designated "Prothrombin Himi". The electrophoretic behavior and calcium binding properties of Prothrombin Himi did not differ significantly from normal. Prothrombin Himi was isolated by chromatography on Q-Sepharose. Electrophoretic migration of the purified abnormal prothrombin on SDS-PAGE was normal. Upon prothrombin activation by Echis carinatus venom, the clotting activity produced from Prothrombin Himi was only 37% of the normal level after 90 minutes of the activation time, where as the amidolytic activity was almost the same as normal. The cleavage patterns of Prothrombin Himi by factor Xa or Echis carinatus venom investigated by SDS-PAGE, were found to be normal. These results indicate that Prothrombin Himi was characterized by a defective thrombin enzymatic activity.