Clinical significance of CYP11B2 immunostaining in unilateral primary aldosteronism

Objective

The associations between adrenal histopathology, lateralization studies, and surgical outcomes in primary aldosteronism remain poorly characterized. We examined the value of immunohistochemical analysis of CYP11B2 for evaluation of adrenalectomy outcomes after anatomical versus functional subtyping.

Design

A retrospective multicenter study of 277 patients operated for primary aldosteronism who had an adrenalectomy sample available in the Finnish biobanks from 1 January 2000 to 31 December 2019. Adrenal slides from biobanks were analyzed centrally after CYP11B2 and CYP11B1 staining. Clinical data were obtained from patient registries. Histopathological diagnosis and cure after surgery were assessed as outcome measures.

Results

Re-evaluation with CYP11B2 staining changed the histopathological diagnosis in 91 patients (33%). The presence of a CYP11B2-positive adenoma and the use of functional subtyping independently predicted clinical cure of primary aldosteronism. CYP11B2-positive <7 mm nodules were more frequent in patients without clinical cure, whereas CYP11B2-positive micronodules were common in all patients and had no impact on adrenalectomy outcomes. Small CYP11B2-positive nodules and micronodules were equally prevalent regardless of the subtyping method applied. Clinical cure rates were lower and CYP11B2-negative adenomas more common after adrenalectomy based on anatomical imaging than functional studies.

Conclusions

Incorporating CYP11B2 staining in histopathological diagnosis enhances the prediction of surgical outcomes in primary aldosteronism. A finding of CYP11B2-positive adenoma is indicative of cure of primary aldosteronism, whereas smaller CYP11B2-positive nodules associate with poorer results at postoperative evaluation. Functional subtyping methods decrease the operations of CYP11B2-negative adenomas and are superior to anatomical imaging in identifying unilateral primary aldosteronism.

The use of isCGM leads to marked reduction in severe hypoglycemia requiring emergency medical service or hospital admission and diabetic ketoacidosis in adult type 1 diabetes patients

AIMS

To determine the effect of the use of intermittently scanned continuous glucose monitoring (isCGM) on acute diabetes-related complications in adult type 1 diabetes patients.

METHODS

Six hundred and forty-two adult type 1 diabetes patients with isCGM were identified from electronic health records in Siun sote region in Eastern Finland. A retrospective real-world analysis was conducted combining hospital admission and prehospital emergency service data to compare incidences of hypoglycemia requiring emergency medical support (EMS) involvement or hospital admission and diabetic ketoacidosis (DKA) before and after the start of isCGM. Data were collected from January 2015 to April 2020. Primary outcome was the rate of hypoglycemia requiring EMS involvement or hospital admission and DKA events. HbA1c was recorded at the start of isCGM and was compared with the last known HbA1c during the use of isCGM. The isCGM used in the study did not contain alarm functions.

RESULTS

Altogether 220 hypoglycemic events were identified during the study period. Incidence rate of hypoglycemic events decreased after the start of isCGM (72 events, incidence rate 50 events/1000 person-years) compared with the time before the start (148 events, incidence rate 76 events/1000 person-years) (p = 0.043). The incidence rate of DKA decreased after the start of isCGM compared with time before isCGM use (4 and 15 events/1000 person-years, respectively; p = 0.002). The change in mean HbA1c was - 0.28% (- 3.1 mmol/mol) between baseline and the last HbA1c measurement (p < 0.001).

CONCLUSIONS

In addition to lowering HbA1c in type 1 diabetes patients, isCGM is also effective in preventing acute diabetes-related complications such as hypoglycemia requiring EMS involvement or hospital admission and DKA.

Mode of treatments and achievement of treatment targets among type 2 diabetes patients with different comorbidities - a register-based retrospective cohort study in Finland

AIMS

Type 2 diabetes (T2D) is a progressive disease often associated with comorbidities that complicate the management of T2D and affect the achievement of treatment targets. However, adherence to guidelines and individualized treatments can potentially improve treatment outcomes. This study assessed the association between different glucose lowering and lipid lowering medication lines and the achievement of treatment targets with different comorbidities among a T2D cohort in North Karelia, Finland (2011-12 to 2015-16).

METHODS

The data on all diagnosed T2D patients (n = 10,190) in North Karelia were collated retrospectively from regional electronic health records (EHRs). Analyses were performed considering the age, sex, and comorbidities such as cardiovascular diseases (CVD) and any mental disorders (AMD). We analyzed the trends in using glucose lowering and lipid lowering medications and the effect of changes in medication on the achievement of treatment targets among different patient groups.

RESULTS

Metformin was the most common treatment in all patient groups. The use of only metformin declined and the use of metformin and/or other non-insulin medications increased during the follow-up. A Combination of insulin and non-insulin medication was mostly used by T2D patients with both cardiovascular diseases and mental disorders (T2D + CVD + AMD), and the use of insulin increased among this group in follow-up. Achievement of the glucose treatment target deteriorated even after the intensification of medication among all patient groups during the follow-up. A considerably higher number of patients with T2D + AMD and T2D + CVD + AMD did not use lipid lowering medication when compared to the T2D + CVD patients both at baseline and follow-up. However, the achievement of the LDL treatment target improved during the follow-up.

CONCLUSION

Achievement of the glucose target deteriorated even after the intensification of treatment, and especially among patients with multiple diseases. Many T2D patients with AMD and CVD remained without lipid lowering medication, which needs further attention.

Type 2 diabetes medication and HbA1c levels in North Karelia Finland, 2013-2019

AIMS

To analyse the prevalence of prescribed medications among people with type 2 diabetes, their relationship to HbA1c levels and transitions between medications.

METHODS

The data included all 18- to 85-year-old adults with type 2 diabetes (identified from the electronic health records), who lived in North Karelia, Finland, between 2013 and 2019. Type 2 diabetes medication was defined based on prescriptions. Logistic and linear regressions with generalized estimating equations were used to assess the differences between years.

RESULTS

Metformin as a monotherapy was the most used medication (33%-35%) with the largest percentage of those in good glycaemic control. After metformin, the most used medications were long-acting and short-acting insulin and gliptin (16%-24% per group). In insulin groups, there were the smallest percentage of people in good glycaemic control. The use of SGLT2-i increased most during the follow-up (from 1.6% to 11%), but at the same time the percentage of those meeting the target HbA1c level decreased the most (from 83% to 53%). The use of GLP-1 RA and other medications were under 3.5%. SGLT2-i and insulin were the most stable medication groups. The most common transitions were from SGLT2-i to long-acting insulin and between insulin groups.

CONCLUSIONS

The sequencing of prescribing additional type 2 diabetes medication or replacing current medication with new ones seems to occur according to guidelines. However, more attention should be paid to the intensification of treatment and the possibilities for new treatment choices in the management of T2D taking into account the persons' characteristics.

Data-driven long-term glycaemic control trajectories and their associated health and economic outcomes in Finnish patients with incident type 2 diabetes

Background

Treatments should be customized to patients to improve patients’ health outcomes and maximize the treatment benefits. We aimed to identify meaningful data-driven trajectories of incident type 2 diabetes patients with similarities in glycated haemoglobin (HbA1c) patterns since diagnosis and to examine their clinical and economic relevance.

Materials and methods

A cohort of 1540 patients diagnosed in 2011–2012 was retrieved from electronic health records covering primary and specialized healthcare in the North Karelia region, Finland. EHRs data were compiled with medication purchase data. Average HbA1c levels, use of medications, and incidence of micro- and macrovascular complications and deaths were measured annually for seven years since T2D diagnosis. Trajectories were identified applying latent class growth models. Differences in 4-year cumulative healthcare costs with 95% confidence intervals (CIs) were estimated with non-parametric bootstrapping.

Results

Four distinct trajectories of HbA1c development during 7 years after T2D diagnosis were extracted: patients with “Stable, adequate” (66.1%), “Slowly deteriorating” (24.3%), and “Rapidly deteriorating” glycaemic control (6.2%) as well as “Late diagnosed” patients (3.4%). During the same period, 2.2 (95% CI 1.9–2.6) deaths per 100 person-years occurred in the “Stable, adequate” trajectory increasing to 3.2 (2.4–4.0) in the “Slowly deteriorating”, 4.7 (3.1–6.9) in the “Rapidly deteriorating” and 5.2 (2.9–8.7) in the “Late diagnosed” trajectory. Similarly, 3.5 (95% CI 3.0–4.0) micro- and macrovascular complications per 100 person-years occurred in the “Stable, adequate” trajectory increasing to 5.1 (4.1–6.2) in the “Slowly deteriorating”, 5.5 (3.6–8.1) in the “Rapidly deteriorating” and 7.3 (4.3–11.8) in the “Late diagnosed” trajectory. Patients in the “Stable, adequate” trajectory had lower accumulated 4-year medication costs than other patients.

Conclusions

Data-driven patient trajectories have clinical and economic relevance and could be utilized as a step towards personalized medicine instead of the common “one-fits-for-all” treatment practices.

International comparison of glycaemic control in people with type 1 diabetes: an update and extension

AIMS

To update and extend a previous cross-sectional international comparison of glycaemic control in people with type 1 diabetes.

METHODS

Data were obtained for 520,392 children and adults with type 1 diabetes from 17 population and five clinic-based data sources in countries or regions between 2016 and 2020. Median HbA_1c (IQR) and proportions of individuals with HbA_1c < 58 mmol/mol (<7.5%), 58-74 mmol/mol (7.5-8.9%) and ≥75 mmol/mol (≥9.0%) were compared between populations for individuals aged <15, 15-24 and ≥25 years. Logistic regression was used to estimate the odds ratio (OR) of HbA_1c < 58 mmol/mol (<7.5%) relative to ≥58 mmol/mol (≥7.5%), stratified and adjusted for sex, age and data source. Where possible, changes in the proportion of individuals in each HbA_1c category compared to previous estimates were calculated.

RESULTS

Median HbA_1c varied from 55 to 79 mmol/mol (7.2 to 9.4%) across data sources and age groups so a pooled estimate was deemed inappropriate. OR (95% CI) for HbA_1c < 58 mmol/mol (<7.5%) were 0.91 (0.90-0.92) for women compared to men, 1.68 (1.65-1.71) for people aged <15 years and 0.81 (0.79-0.82) aged15-24 years compared to those aged ≥25 years. Differences between populations persisted after adjusting for sex, age and data source. In general, compared to our previous analysis, the proportion of people with an HbA_1c  < 58 mmol/l (<7.5%) increased and proportions of people with HbA_1c ≥ 75 mmol/mol (≥9.0%) decreased.

CONCLUSIONS

Glycaemic control of type 1 diabetes continues to vary substantially between age groups and data sources. While some improvement over time has been observed, glycaemic control remains sub-optimal for most people with Type 1 diabetes.

How do individuals with alcohol problems use social and healthcare services in Finland? Comparison of service use patterns between two high-need patient groups

Aims:

Alcohol use disorders (AUDs) are associated with high risk of comorbidities and excess use of social and healthcare services. We examined health service use (HSU) frequencies of patients with AUD in comparison to those with type 2 diabetes mellitus (T2DM).

Design:

A random sample of individuals with AUD (n = 396) were identified based on ICD-10 codes and HSU patterns, morbidity and mortality were compared with age- and gender-matched T2DM controls (n = 792) using logistic regression analysis. Six years (2011–2016) of electronic health record (EHR) data from the North Karelia district in Finland were used.

Results:

Similarities in comorbidity patterns existed, although mental health comorbidity (odds ratio [OR] 1.86) was more prevalent in the AUD group. The average annual HSU varied according to the groups: T2DM patients had more continuous contact with public health nurses in primary care, whereas AUD patients were more likely to experience somatic specialised care hospitalisations (OR 11.30) and have frequent somatic primary healthcare doctor visits (OR 3.30) and frequent emergency room doctor visits in specialised care (OR 8.89). Furthermore, patients with AUD had a 7.5 times higher risk of death compared with T2DM patients.

Conclusions:

This study identified rather similar comorbidity status for the AUD and T2DM patients, but their HSU patterns differed noticeably. AUD patients had higher frequencies of hospitalisation periods and emergency service use and were at a higher risk of death compared with T2DM patients, indicating greater challenges in the organisation of care for AUD patients compared with those having T2DM.

Marked Improvement in A1C Levels After Initiation of Intermittently Scanned Continuous Glucose Monitoring Is Maintained Over 4 Years in Patients With Type 1 Diabetes

OBJECTIVE

This study aimed to demonstrate the effectiveness of long-term use of intermittently scanned continuous glucose monitoring (isCGM) in adult patients with type 1 diabetes.

DESIGN AND METHODS

In this retrospective real-world study, 689 patients with type 1 diabetes who were >18 years of age and using isCGM were identified from the electronic patient records in North Karelia, Finland. A1C data were collected before and after the initiation of isCGM. The primary outcome was a change in the mean A1C over time after isCGM started.

RESULTS

The greatest reductions in the mean A1C levels were observed 6 months (-0.54% [-5.9 mmol/mol], P <0.001) and 12 months (-0.42% [-4.6 mmol/mol], P <0.001) after the initiation of isCGM. Reduction in A1C remained significant for 4 years, although the mean reduction in A1C was -0.18% (-2.05 mmol/mol) (P = 0.009) at 48 months compared with baseline. In a subgroup analysis, patients with a baseline A1C >9% (75 mmol/mol) benefited the most from initiation of isCGM (reduction -0.97% [-10.6 mmol/mol], P <0.001, at 12 months and -0.92% [-10.1 mmol/mol], P <0.001, at 48 months). Neither sex nor age at the start of isCGM were correlated with A1C reduction.

CONCLUSION

Use of isCGM improves A1C levels significantly in adult patients with type 1 diabetes. Significant reduction in A1C persisted over 4 years of use, although the effect diminished over time.

Characteristics and outcomes of the Finnish ectopic ACTH syndrome cohort

PURPOSE

Ectopic ACTH syndrome (EAS) is rare. We established a national cohort to increase awareness and address unmet needs.

METHODS

The Finnish national EAS cohort includes 60 patients diagnosed in 1997-2016. We assessed clinical features, diagnostic work-ups, treatments, incidence, and outcomes of subgroups occult tumor (OT), well-differentiated neuroendocrine tumor G1/G2 (NETG1/G2) and NET G3/neuroendocrine carcinoma (NETG3/NEC).

RESULTS

The distribution of OT, NETG1/G2, and NETG3/NEC was 10 (17%), 20 (33%), and 30 (50%), respectively; and median follow-up 22 months (0-249). Annual incidence (0.20-0.93 per million inhabitants) and tumor subgroups (OT vs. NEC) varied across the country. The longest diagnostic delay from EAS onset to radiological tumor identification was 48 months. In NET/NEC, 6/50 (12%) were diagnosed 1-24 years before EAS onset. Osteoporotic fractures (32%) and severe infections (55%) were common. The CRH stimulation test accurately diagnosed EAS in 25/31 (81%). Metyrapone (≤6 g daily, prescribed in 88%) was well tolerated. In NETG1/G2, 13/20 (65%) underwent curative resection of the primary tumor; four experienced recurrence within 2-12 years. In OT, 70% underwent bilateral adrenalectomy. Five-year overall survival in OT, NETG1/G2, and NETG3/NEC was 90%, 55%, and 0%, respectively (P < 0.001). Morning cortisol, hypokalemia, infections, metastatic disease, and acute onset were negative, whereas resection of the primary tumor and bilateral adrenalectomy were positive predictors of survival.

CONCLUSIONS

NET/NEC may precede EAS onset by several years. In NETG1/G2, recurrences may occur > 10 years after successful primary surgery. Tumor subgroup (OT, NETG1/G2, NEC) was an independent predictor of survival.

The effect of the integration of health services on health care usage among patients with type 2 diabetes in North Karelia, Finland

BACKGROUND

The need to improve the care of people with complex care requirements has been driving the reforms integrating care processes. This study examines the effect of the integration of health services on health care usage and the processes and outcomes of care among type 2 diabetes patients.

METHODS

Data include all type 2 diabetes patients who lived in North Karelia, Finland, between 2014 and 2018. Health care contacts and glycated haemoglobin (HbA1c) measurements were obtained from the electronic health records. Logistic, Poisson and linear models with generalised estimating equations and the Friedman test were used to study the differences between years.

RESULTS

The health care usage was highest in 2017, the first year of a new organisation, and smallest in the following year. Before the new organisation, the health care usage was lowest in 2014, being slightly higher compared with 2018. Between the last two years, the mean number of contacts per person declined from 3.25 to 2.88 (-0.37, p < 0.001). The decreasing pattern seen in total health care usage was most obvious among contacts with primary health care nurses. The number of contacts increased only among specialised care nurses between the last two years. The number of HbA1c measurements was also in its lowest in 2018 but in its highest in 2015. Between the years 2014 and 2018, the difference in the mean number of contacts was - 0.05 (p = 0.011) for those not measured, -0.02 (p = 0.225) for those measured and within the target level of HbA1c, and 0.12 (p = 0.001) for those measured and not at the target level of HbA1c.

CONCLUSIONS

Health care integration first increased the health care usage but then brought it to a slightly lower level than before. The changes were most obvious in primary health care nurses' appointments, and no decline was observed in secondary-level care. Even though the numbers of HbA1c measurements and the proportion measured declined, measurements increased among those with poor glycaemic control. The observed changes might reflect the better targeting and more concordant services in different service units.

Trends in the process and outcome indicators of type 2 diabetes care: a cohort study from Eastern Finland, 2012-2017

Background

Evidence-based guidelines include concrete treatment targets that can be used as process and outcome indicators in the evaluation of the quality of healthcare services and diabetes care. Quality improvement can be evaluated by monitoring longitudinal trends in the care indicators on the system level. The aim of this study is to describe trends in the processes and outcomes of care among people with type 2 diabetes in North Karelia, Finland.

Methods

The data consist of all adults with type 2 diabetes (identified from the EHRs using ICD-10 codes) who used primary or specialized care services in North Karelia during 2012–2017. The diabetes care was evaluated using the measurement activity, treatment levels, and the achievement of the treatment targets for HbA1c and LDL as care indicators. Logistic and linear models with generalized estimating equations were used to assess the differences between years, sexes, and age groups.

Results

The proportion of patients with annual measurement varied between 75.8 and 78.1% for HbA1c and between 67.4 and 69.1% for LDL during a five-year follow-up. The changes in average levels were moderate: a 0.2% (2 mmol/mol) increase for HbA1c and a 0.1 mmol/l decrease for LDL. Anyway, the proportion of patients meeting the treatment target for HbA1c decreased from 72.7 to 67.3% (age-adjusted decrease: 5.7%p, 95% CI: 4.5–6.9) and for LDL it increased from 53.4 to 59.5% (age-adjusted increase: 5.6%p, 95% CI: 4.2–7.0). Women were measured and met the HbA1c target level more often compared with men. Conversely, men met the LDL target level more often than women, and the age-adjusted difference between sexes increased smoothly from 7.9%p to 11.7%p.

Conclusions

The achievements in relation to type 2 diabetes care in North Karelia are very good, but no major improvement was observed during follow-up. HbA1c levels had a rising tendency and LDL levels declining tendency indicating quality improvement in LDL management, but challenges in further improvement in glucose control.

Impact of co-payment level increase of antidiabetic medications on glycaemic control: an interrupted time-series study among Finnish patients with type 2 diabetes

Background

A new special reimbursement scheme (SRS) for non-insulin medications used for treatment of hyperglycaemia in type 2 diabetes (T2D) was implemented in Finland on January 1, 2017. The new SRS affected all community-dwelling Finnish T2D patients as all community-dwelling residents are eligible for reimbursement for prescription medications. The aim of the study was to evaluate the impact of this co-payment increase on glycaemic control among Finnish T2D patients.

Methods

Data on glycaemic control were collected with HbA1c measures from electronic health records from primary health care and specialized care in the North Karelia region, Finland, from patients with a confirmed T2D diagnosis in 2012 who were alive on January 1, 2017 (n = 8436). Average HbA1c levels were measured monthly 36 months before and 33 months after the policy change. Consumption of diabetes medications was measured with defined daily doses (DDDs) based on reimbursed medication purchases. Interrupted time series design analysed with segmented regression model was applied to examine the effect of the policy change on average HbA1c levels.

Results

Eight thousand one hundred forty-three T2D patients had at least one HbA1c measurement within 01/2014–9/2019. Mean age of the patients was 68.1 (SD 11.3) years and 53.0% were women. Average time since T2D diagnosis was 11.5 (SD 6.1) years. An estimated increase of 0.81 (95% confidence interval, CI, 0.04–1.58) mmol/mol in average HbA1c levels was detected at the time of the policy change. In subgroup analyses, strongest effects were detected among patients who used only other diabetes medications than insulin or metformin in 2016 (3.56 mmol/mol, 95% CI 2.50–4.62). Meanwhile, yearly consumption of diabetes medications decreased slightly from 618.9 (SD 487.8) DDDs/patient in 2016 to 602.9 (SD 475.6) DDDs/patient in 2017 (p = 0.048).

Conclusions

Simultaneously with the increase of the co-payment level, the average HbA1c level increased among T2D patients from the North Karelia region, Finland. This may be explained by the decreased consumption of diabetes medications between 2016 and 2017. Special attention should be allocated to glycaemic control of patients utilizing only other antidiabetic medications than metformin or insulin.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-05952-6.

Association of mental disorders and quality of diabetes care - A six-year follow-up study of type 2 diabetes patients in North Karelia, Finland

AIMS

To compare the quality of diabetes care among type 2 diabetes patients with and without mental disorders during six-year follow-up in North Karelia, Finland.

METHODS

All type 2 diabetes patients (n = 10190) were analysed using the electronic health records data from 2011-12 to 2015-16. The diabetes care was evaluated using the measurement activity and the achievement of the treatment targets for HbA1c and LDL.

RESULTS

Monitoring of HbA1c and LDL levels improved among all patient groups, except the dementia patients. The proportion of those achieving the HbA1c target declined and those achieving the LDL target improved in all patient groups. Differences in the changes of achievement of the target HbA1c level among patients with dementia and depression were observed when compared with those having only type 2 diabetes.

CONCLUSIONS

This study highlights the challenge of glucose level management as the age and comorbidities of the patients related to the care and achievements of the treatment targets. Mental disorders that are likely to affect patients' adherence to medication and other treatments should be taken into account and more support for self-care should be provided to such patients. Improvement in the achievement of LDL target address the progress in the prevention of macrovascular complications.

Electronic Health Records as Valuable Data Sources in the Health Care Quality Improvement Process

Background

In North Karelia, Finland, the regional electronic health records (EHRs) enable flexible data retrieval and area-level analyses. The aim of this study was to assess the early detection of type 2 diabetes (T2D) in the region and to evaluate the performed activities in order to improve the processes between the years 2012 and 2017.

Methods

Patients with T2D were identified from the EHRs using the ICD-10 codes registered during any visit to either primary or specialized care. The prevalence of T2D was calculated for the years 2012, 2015, and 2017 on the municipality level. The number of people found in the EHRs with diabetes was compared with the number found in the national register of medication reimbursement rights.

Results

In 2012, the age-adjusted prevalence of T2D in North Karelia varied considerably between municipalities (5.5%-8.6%). These differences indicate variation in the processes of early diagnosis. The findings were discussed in the regional network of health professionals treating patients with T2D, resulting in sharing experiences and best practices. In 2017, the differences had notably diminished, and in most municipalities, the prevalence exceeded 8%. The regional differences in the prevalence and their downward trend were observed both in the EHRs and in the medication reimbursement rights register.

Conclusion

Clear differences in the prevalence of T2D were detected between municipalities. After visualizing these differences and providing information for the professionals, the early detection of T2D improved and the regional differences decreased. The EHRs are a valuable data source for knowledge-based management and quality improvement.

Maintenance of good glycaemic control is challenging - A cohort study of type 2 diabetes patient in North Karelia, Finland

AIMS

This study assessed type 2 diabetes treatment outcomes and process indicators using a comprehensive type 2 diabetes patient cohort in North Karelia, Finland, from 2011 to 2016.

METHODS

Data from all diagnosed type 2 diabetes patients (n = 8429) living in North Karelia were collated retrospectively from regional electronic patient records. We assessed whether HbA1c and low-density lipoprotein (LDL) were measured and managed as recommended.

RESULTS

The HbA1c measurement rate improved (78% vs 89%) during 2011-2012 and 2015-2016, but a gradual deterioration in glycaemic control (HbA1c < 7.0% or 53 mmol/mol) was observed among both females (75% vs 67%) and males (72% vs 64%). The LDL measurement rate initially improved from the baseline. LDL control (<2.5 mmol/L) improved among both females (52% vs 59%) and males (58% vs 66%). A gender difference was observed in the achievement of the treatment target for LDL, with females showing worse control.

CONCLUSIONS

Low-density lipoprotein (LDL) control in type 2 diabetes patients has improved, but the existence of gender disparities needs further attention. Maintaining appropriate HbA1c control among type 2 diabetes patients over time appears to be difficult. Active follow-up and tailored treatment have the potential to improve the quality of care. Electronic patient records could be more efficiently used to improve the quality of care and to support decision-making.

Glycemic Control in Adult Type 1 Diabetes Patients with Insulin Glargine, Insulin Detemir, or Continuous Subcutaneous Insulin Infusion in Daily Practice

BACKGROUNDS

This study aims to compare glycemic control of persons with type 1 diabetes using multiple daily injections (MDI) with insulin glargine versus insulin detemir or with continuous subcutaneous insulin infusion (CSII) in daily practice.

SUBJECTS AND METHODS

All adult individuals with type 1 diabetes (n = 1053) were identified from the electronic patient database in North Karelia, Finland. The persons' individual data for insulin treatment, diabetic ketoacidosis (DKA), and hemoglobin A_1c (HbA1c) measurements during the year 2014 were obtained from medical records. Persons using long-acting insulin analogs or CSII were included in the analyses (n = 1004).

RESULTS

Altogether, 47.7% used glargine, 43.9% used detemir, and 8.4% used CSII. The mean HbA1c was lower in the CSII group (63 mmol/mol [7.9%]) compared with the glargine group (66 mmol/mol [8.2%]) or the detemir group (67 mmol/mol [8.3%]). The overall rate of DKA was 5.1% per year. The rate of DKA was higher in the detemir group compared with the glargine group (6.3% per year vs. 3.8% per year, respectively, P < 0.049). In logistic regression analyses, the higher rate of DKA with detemir use was explained by HbA1c.

CONCLUSIONS

In daily practice, the glycemic control of type 1 diabetes patients with MDI was similar regardless of basal insulin, glargine, or detemir, whereas CSII allowed better glycemic control than MDI. The rate of DKA was higher with detemir than with glargine, but this is likely related to higher HbA1c rather than insulin regimen.

Elevated levels of trypsinogen-2 and trypsin-2-alpha1-antitrypsin in sera of infants and children after cardiac surgery

Acute pancreatitis is a known complication of cardiac surgery with cardiopulmonary bypass but amylase is not a reliable marker in infants. We evaluated whether the serum concentrations of trypsinogen-2 and trypsin-2-alpha1-antitrypsin (AAT) can be used to study disturbances in pancreatic function in children and infants undergoing cardiac surgery. The study comprised 21 infants < 1 year and 25 children aged 1-16 years undergoing cardiopulmonary bypass at the Children's Hospital, Helsinki University Central Hospital. Consecutive serum samples were taken before surgery, at 12 h, 1, 2 and 3 days after surgery, and before discharge from the hospital. A moderate increase in trypsinogen-2 and trypsin-2-AAT in serum was found in more than two-thirds of the patients. On day 3, there was a 4.3-fold mean increase (CI 95% 2.8-6.5) in trypsinogen-2 and a 2.4-fold mean increase (CI 95% 1.8-3.1) in trypsin-2-AAT. In 4 patients trypsinogen-2 was elevated by more than 20-fold. One patient had clinical pancreatitis, but there were no clinical signs of pancreatitis in the other three patients. The changes in trypsinogen-2 and trypsin-2-AAT were similar in infants and children. The moderate increase in the serum concentrations of trypsinogen-2 and trypsin-2-AAT after cardiac surgery in the absence of signs of pancreatitis may be due to a subclinical pancreatic disturbance, but it could also be caused by an inflammatory response and expression of extrapancreatic trypsin. Contrary to amylase, trypsinogen-2 is expressed in the pancreas of infants.

Pharmacokinetics of amrinone in neonates and infants

OBJECTIVE

To evaluate the pharmacokinetics of amrinone and its metabolites in neonates and infants after reconstructive surgery for congenital heart disease.

DESIGN

Prospective study.

SETTING

Pediatric intensive care unit in a university hospital.

PARTICIPANTS

Fifteen neonates aged less than 1 month with transposition of the great arteries and 14 infants aged 2 to 6 months with complete atrioventricular septal defect.

INTERVENTIONS

Amrinone, loading dose of 2 mg/kg, was administered before weaning from cardiopulmonary bypass, followed by a maintenance infusion of 7.5 microg/kg/min.

MEASUREMENTS AND MAIN RESULTS

Blood samples to determine plasma concentrations of amrinone, N-acetylamrinone, and N-glycolylamrinone were drawn before amrinone administration, frequently after the loading dose, every 6 hours during the maintenance infusion, and until 48 hours after the end of the infusion. Amrinone clearance was 2.4 +/- 0.9 mL/kg/min in neonates and 3.2 +/- 1.2 mL/kg/min in infants (p < 0.05). The volume of distribution at steady-state was smaller (p < 0.05) in neonates than in infants. The elimination half-life of amrinone was 10.7 +/- 6.7 hours in neonates and 6.1 +/- 1.4 hours in infants (p < 0.05). There was a linear correlation between the clearance of amrinone and the body surface area (r = 0.67; p < 0.05). The ratio of the plasma concentration of N-acetylamrinone to that of amrinone did not differ between neonates and infants.

CONCLUSIONS

Amrinone is eliminated at a slower rate in neonates than in infants. The rate of acetylation of amrinone appears to be similar; the differences in the elimination capacity of amrinone are mainly due to the immature renal function in neonates.

In situ hybridization detection of human herpesvirus 6 in brain tissue from fatal encephalitis

A 23-month-old girl died after 2 days' illness with rash, fever, and convulsions. Neuropathologic findings were consistent with viral hemorrhagic encephalitis in pontine tegmentum and medial thalamic areas. Human herpesvirus 6 (HHV-6) DNA was detected in pontine nuclei by in situ hybridization. In addition, polymerase chain reaction for HHV-6 of serum and paraffin-embedded pontine tissue was positive, and serology indicated an acute primary infection. This is the first case showing HHV-6 DNA in the brain cells of an immunocompetent patient with acute encephalitis.

Amrinone versus dopamine and nitroglycerin in neonates after arterial switch operation for transposition of the great arteries

OBJECTIVE

To compare the efficacy and safety of amrinone and a combination of dopamine and nitroglycerin in neonates after reconstructive surgery for transposition of the great arteries.

DESIGN

A prospective, randomized, double-blind study.

SETTING

Pediatric intensive care unit in a university hospital.

PARTICIPANTS

Thirty-five neonates with transposition of the great arteries.

INTERVENTIONS

A loading dose of amrinone, 2 mg/kg, followed by a maintenance infusion of 7.5 microg/kg/min, were administered to 16 neonates before separation from cardiopulmonary bypass. The remaining 19 patients were administered a combination of dopamine, 5 microg/kg/min, and nitroglycerin, 1 microg/kg/min. An open-label epinephrine infusion was administered in both groups as required.

MEASUREMENTS AND MAIN RESULTS

The circulatory state of the patients was evaluated from 4 to 18 hours after cardiopulmonary bypass. The systemic blood flow index, calculated using the Fick principle, was higher in the amrinone group (1.7+/-0.5 L/min/m2 [mean +/- SD]) compared with the dopamine-nitroglycerin group (1.4+/-0.4 L/min/m2; p < 0.04). The systemic vascular resistance in the amrinone group was lower (26+/-8 Wood units x m2) than in the dopamine-nitroglycerin group (35+/-12 Wood units x m2; p < 0.02). The oxygen extraction ratio was higher in the dopamine-nitroglycerin group (0.34+/-0.08) compared with the amrinone group (0.28+/-0.06; p < 0.02). Lower platelet counts were observed in the amrinone group, but no difference in hemorrhagic complications was seen between the groups.

CONCLUSION

With the dosage regimen used, supplemented with epinephrine, amrinone provides a higher cardiac output and more favorable oxygen dynamics than a combination of dopamine and nitroglycerin.

Amrinone versus dopamine-nitroglycerin after reconstructive surgery for complete atrioventricular septal defect

OBJECTIVES

To compare the effectiveness and safety of amrinone and a combination of dopamine and nitroglycerin in infants after reconstructive surgery for congenital heart disease.

DESIGN

A prospective, randomized, double-blind study.

SETTING

Pediatric intensive care unit in a university hospital.

PARTICIPANTS

Thirty-two infants with complete atrioventricular septal defect.

INTERVENTIONS

Amrinone loading dose, 2 mg/kg, followed by a maintenance infusion, 7.5 micrograms/kg/min, was given to 17 infants before separation from cardiopulmonary bypass. The remaining 15 patients received a combination of dopamine, 5 micrograms/kg/min, and nitroglycerin, 1 microgram/kg/min.

MEASUREMENTS AND MAIN RESULTS

The circulatory state of the patients was evaluated from 4 to 18 hours after cardiopulmonary bypass. The systemic blood flow index, calculated using the Fick principle, was higher in the amrinone group (2.5 +/- 0.7 L/min/m2) compared with the dopamine-nitroglycerin group (2.0 +/- 0.6 L/min/m2, mean +/- SD). The pulmonary blood flow index in the amrinone group was higher (2.9 +/- 0.6 L/min/m2) than in the dopamine-nitroglycerin group (2.2 +/- 0.6 L/min/m2); no significant difference was noted in the mean pulmonary artery pressure. The oxygen extraction ratio was higher in the dopamine-nitroglycerin group (0.41 +/- 0.07) compared with the amrinone group (0.34 +/- 0.08). Despite lower platelet counts in the amrinone group, no hemorrhagic complications were seen in any patient.

CONCLUSIONS

With this dosage regimen, amrinone provides a higher cardiac output, more favorable oxygen dynamics, and lower pulmonary vascular resistance than dopamine and nitroglycerin.

Hyperamylasemia after cardiac surgery in infants and children

OBJECTIVE

This study was conducted to clarify the incidence of hyperamylasemia after cardiac surgery in infants and children.

DESIGN AND PATIENTS

186 infants and children operated on at Children's Hospital. Helsinki, during an 11-month period were enrolled in the study. Serum samples were taken before and on 3 consecutive days after cardiac surgery at the intensive care unit and before discharge from the hospital.

MEASUREMENTS

We measured serum total amylase and serum pancreatic amylase with two different assays (1) reduction of salivary amylase from total amylase activity and (2) measurement of mass concentration with monoclonal antibodies.

RESULTS

Preoperative values for both total amylase and pancreatic isoenzymes were strongly age-related. At least one of the three tests showed postoperative hyperamylasemia (> +/- 2 SD above starting values of the age group and maximal value > 3 times the individual starting value) in 64/186 (34%) patients. 22/186 (12%) patients had abnormal results in all assays. A more than tenfold rise in pancreatic amylase, suggesting pancreatitis, was found in 14 patients (8%). Mortality was 21% in this subgroup, but 5% in the rest of the patients. Hyperamylasemia was more common after 1 year of age, and after open-heart surgery, especially homograft implantation or cardiac transplantation.

CONCLUSIONS

Hyperamylasemia is a common finding after cardiac surgery in pediatric patients. Amylase isoenzyme measurements are needed for clinical decision making. Age-group-related reference values are mandatory for the right interpretation of amylase values.

Prenatal muscle relaxation in congenital diaphragmatic hernia

An infant with congenital diaphragmatic hernia was given 2 mg vecuronium bromide intramuscularly in utero 40 min before vaginal delivery at 40 weeks gestation. At birth the infant had complete muscle relaxation, which facilitated decompression of the bowel and surgical correction. Prenatal muscle relaxation may improve the care of infants with congenital diaphragmatic hernia.

Successful treatment of ARDS with two doses of synthetic surfactant

A 50-year-old man with adult respiratory distress syndrome (ARDS) was successfully treated with synthetic surfactant. The therapy rapidly improved the respiratory function; it also increased the release of endogenous surfactant. Synthetic surfactant may thus be of value in the treatment of ARDS.

Alfentanil sedation for cardiac catheterization of children with Fontan shunts

After Fontan operation, prolonged invasive cardiac assessment is often needed. This study is a clinical evaluation of the effectiveness of flunitrazepam premedication, EMLA cream, and alfentanil continuous infusion for management of children undergoing such catheterization. Fourteen consecutive subjects aged 5-20 yr with Fontan shunts (right atrium to pulmonary artery) undergoing elective haemodynamic and electrophysiological catheterization were sedated with an individually titrated alfentanil infusion. After oral premedication with flunitrazepam 2 mg, the mean induction dose and mean maintenance requirement of alfentanil were 4.4 +/- 2.7 micrograms.kg-1 and 10.3 +/- 8.6 micrograms.kg-1 x hr-1, respectively. Mean oxygen consumption during haemodynamic catheterization was 4.1 +/- 0.4 ml.kg-1 x min-1 with an average individual variation of 10%. For every patient, tranquil and stable conditions during catheterization could be produced. It is concluded that alfentanil infusion is a method of sedation of children and adolescents with Fontan shunts during haemodynamic and electrophysiologic catheterization. However, continuous monitoring of ventilation and an understanding of the slow circulation time after Fontan operation are essential with such sedation in these patients.

Sudden and unexpected death of a 6-month-old baby with silent heart failure due to anomalous origin of the left coronary artery from the pulmonary artery

A 6-month-old girl died suddenly without any previous symptoms of heart failure. Autopsy examination showed cardiomegaly (97 g) with a severely fibrotized myocardium. The left coronary artery was originating from the pulmonary artery. Histologically, the myocardium showed myocardial infarcts of different ages, as well as grossly thickened arterial branches due to increased flow in left-right shunt. We suggest that rare anomalies of the coronary arteries should be considered in the autopsies of suspected sudden infant death syndrome cases.

Alfentanil infusion for sedation in infants and small children during cardiac catheterization

We have analyzed several sedation techniques for paediatric cardiac catheterization which offer stable conditions for a few hours investigation, and maintain spontaneous breathing. In the present study, after premedication with oral flunitrazepam 0.1 mg.kg-1, 14 children aged 1-17 mo were sedated with an individually titrated alfentanil infusion. Every patient was sedated to a level which produced no reaction to pain or any discomfort. The induction dose and the maintenance requirement of alfentanil were 24 +/- 8 micrograms.kg-1 and 32 +/- 8 micrograms.kg-1.hr-1 (mean +/- SD), respectively. These doses were less in cyanotic than in acyanotic patients: 21 +/- 6 vs 28 +/- 8 micrograms.kg-1 and 29 +/- 10 vs 34 +/- 3 micrograms.kg-1.hr-1, respectively (P less than 0.05). The mean plasma concentration of alfentanil during maintenance of sedation was 79 +/- 23 ng.ml-1. Ventilation of two children was assisted for a short time after an incremental bolus of alfentanil. It is concluded that an alfentanil infusion technique with close monitoring of breathing is a practical sedation method for paediatric cardiac catheterization.

Haemodynamic responses and prolongation of QT interval of ECG after suxamethonium-facilitated intubation during anaesthetic induction in children: a dose-related attenuation by alfentanil

The haemodynamic response to endotracheal intubation and changes in the QT interval of ECG during anaesthetic induction were studied in 68 healthy children (5.5 years). The children were pretreated double-blindly with either alfentanil 10 micrograms/kg (A10), 25 micrograms/kg (A25), 50 micrograms/kg (A50) or saline (control) (17 children in each group) i.v. 1 min before thiopentone 5 mg/kg. The trachea was intubated after suxamethonium 1.5 mg/kg. Central nervous system excitation was seen in four of 17 and in one of 17 children after alfentanil 50 and 25 micrograms/kg, respectively. After intubation, heart rate increased significantly in the control group, remained at initial levels in the A10 and A25 groups and decreased in the A50 group. A pressor response to intubation was seen in the control and A10 groups. The QT interval was significantly prolonged after suxamethonium in the control and A10 groups, but remained at baseline levels in the A25 and A50 groups. Ventricular ectopic beats were only seen in 2/17 children in the control group. In conclusion, alfentanil 25 microgram/kg is ideal for preventing the haemodynamic response to endotracheal intubation and prolongation of the QT interval, a sign of sympathoadrenal activation, before induction of intravenous anaesthesia in children.

Alfentanil and fentanyl sedation in infants and small children during cardiac catheterization

Thirty patients aged 1-23 mth received either alfentanil or fentanyl for the induction and maintenance of IV sedation during cardiac catheterization following oral flunitrazepam premedication (0.1 mg.kg-1). Patients breathed spontaneously 30 per cent oxygen in air. Both alfentanil and fentanyl abolished all reaction to pain and discomfort with minimal haemodynamic and respiratory changes. Induction doses of alfentanil and fentanyl were 20 +/- 6 and 2.5 +/- 1.1 (mean +/- SD) micrograms.kg-1, respectively, and maintenance requirements 30 +/- 12 and 1.5 +/- 0.6 micrograms.kg-1.h-1, respectively. These requirements were comparable among younger and older as well as cyanotic and acyanotic patients. The IV sedation described adds an effective method to the armamentarium of an anaesthetist working in the cardiac laboratory.

QT interval of the ECG, heart rate and arterial pressure using propofol, methohexital or midazolam for induction of anaesthesia

The effects of propofol 2 mg/kg, methohexital 2 mg/kg or midazolam 0.3 mg/kg were studied on the QT interval of the ECG corrected by the heart rate (QTc), heart rate and arterial pressure during induction of anaesthesia in 87 ASA class I-(II)-patients. The patients were randomly allocated to one of the three anaesthetic groups. The incidence of the patients with a prolonged QTc interval (= more than 440 ms) ranged from 29 to 41% between the groups. In each group these patients were treated separately. After all anaesthetics, the QTc interval was significantly prolonged in the patients with a normal control QTc interval, whereas in the patients with a prolonged control QTc interval, it tended to be shortened both after propofol and methohexital and it was significantly shortened after midazolam. After injection of suxamethonium, no significant QTc interval changes occurred in the patients with a normal control QTc interval in either the propofol or the methohexital groups, whereas in the patients with a prolonged control QTc interval treated with propofol the QTc interval decreased significantly 60 s after suxamethonium when compared with the corresponding preceding values. The mean values in the propofol group in the patients with a normal control QTc interval were always below the upper limit of the normal range.(ABSTRACT TRUNCATED AT 250 WORDS)