Trabecular bone score and bone mineral density as indices of skeletal fragility in endogenous Cushing's syndrome

OBJECTIVE

Endogenous Cushing's syndrome (CS) is a known cause of secondary osteoporosis. Vertebral fractures (VFs) in endogenous CS may occur despite normal bone mineral density (BMD). Trabecular bone score (TBS) is a relatively new, non-invasive technique to assess bone microarchitecture. The objective of our study was to analyse the BMD and bone microarchitecture using TBS in endogenous CS and compare it with a group of age and sex-matched healthy controls, and also analyse the factors predicting BMD and TBS.

DESIGN

Cross-sectional study of cases and controls.

PATIENTS AND MEASUREMENTS

We included 40 female patients with overt endogenous CS, out of which 32 were adrenocorticotropic hormone (ACTH)-dependent CS and 8 were ACTH-independent. We also included 40 healthy, female controls. Both patients and controls were subjected to an assessment of biochemical parameters and BMD and TBS.

RESULTS

Patients with endogenous CS had significantly lower BMD at the lumbar spine, femoral neck, and total hip and significantly lower TBS than healthy controls (all p < .001), while no significant difference was noted in the distal radius BMD (p = .055). In endogenous CS, a large proportion of patients, n = 13 (32.5%) had normal BMD for age (BMD Z-score ≥ -2.0) with low TBS (L₁ -L₄ TBS ≤ 1.34). TBS correlated negatively with HbA1c (p = .006), and positively with serum T4 (p = .027).

CONCLUSION

TBS should be considered an important complementary tool in addition to BMD for the routine assessment of skeletal health in CS.

Comparison of Accuracy of Freestyle Libre Pro and Medtronic iPro2 Continuous Glucose Monitoring Systems in Pregnancy

There are limited data on head-to-head performance of Freestyle Libre Pro (FSL-Pro) and blinded Medtronic iPro2 CGMS in pregnancy. In this prospective observational study, women with hyperglycemia in pregnancy (n=42) underwent simultaneous FSL-Pro and Medtronic iPro2 sensor insertion and SMBG using Contour Plus meter (reference). The overall MARD for iPro2 and FSL-Pro systems were 8.0 ± 9.2% and 19.0 ± 12.8%, respectively. At hypoglycemic range, both sensors performed less accurately (MARD: 18.1% and 16.8%, respectively), while iPro2 showed higher accuracy at euglycemic (8.2% and 19.3%, respectively) and hyperglycemic (6.8% and 18.0%, respectively) ranges. On Bland-Altman analysis, iPro2 and FSL-Pro underestimated glucose by 0.01 and 1.09 mmol/L, respectively. The ISO criteria were fulfilled for 83.4% and 36.2% of all values, respectively. To conclude, iPro2 was more accurate, however, both sensors demonstrated inaccuracy at hypoglycemic range, highlighting the need for refinements in the current generation of sensors to address this problem.

A practical guidance on the use of intravenous insulin infusion for management of inpatient hyperglycemia: Intravenous Insulin Infusion for Management of Inpatient Hyperglycemia

BACKGROUND

We aim to provide a practical guidance on the use of intravenous insulin infusion for managing inpatient hyperglycemia.

METHODS AND RESULTS

This document was formulated based on the review of available literature and personal experience of authors. We have used various case scenarios to illustrate variables which should be taken into account when deciding adjustments in infusion rate, including but not restricted to ambient blood glucose level and magnitude of blood glucose change in the previous hour.

CONCLUSION

The guidance can be generalized to any situation where dedicated protocols are lacking, trained manpower is not available and resource constraints are present.

A guidance on diagnosis and management of hyperglycemia at COVID care facilities in India

BACKGROUND AND AIMS

Diabetes and coronavirus disease 2019 (COVID-19) share a bidirectional relationship. Hyperglycemia occurring in the setting of either previously diagnosed or undiagnosed diabetes is known to be associated with poor outcomes. Here, we aim to provide a simple and practical guidance on the diagnosis and management of hyperglycemia in admitted patients with COVID-19.

METHODS

The guidance is formulated based on experience of authors and relevant literature on the subject searched using Pubmed.

RESULTS

Every patient admitted to a COVID care facility should be investigated for hyperglycemia using a combination of tests including capillary blood glucose, fasting plasma glucose and HbA1c. Oral glucose lowering drugs can be considered in patients with mild COVID illness who have mild hyperglycemia [pre-meal blood glucose of <180 mg/dl (10 mmol/L) and post-meal blood glucose of <250 mg/dl (13.9 mmol/L)] and no contraindication to the use of these agents.. All patients with moderate-severe disease and/or hyperglycemia of greater severity should be initiated on insulin therapy. Hyperglycemia should be aggressively screened for and managed in patients receiving systemic glucocorticoids.

CONCLUSION

This document provides a broad overview on the diagnosis and management of hyperglycemia at COVID care facilities and should be useful to a wide range of healthcare personnel involved in care of patients with COVID-19.