Development and Implementation of a Subcutaneous Insulin Clinical Decision Support Tool for Hospitalized Patients.

BACKGROUND: Insulin is one of the highest risk medications used in hospitalized patients. Multiple complex factors must be considered in determining a safe and effective insulin regimen. We sought to develop a computerized clinical decision support (CDS) tool to assist hospital-based clinicians in insulin management. METHODS: Adapting existing clinical practice guidelines for inpatient glucose management, a design team selected, configured, and implemented a CDS tool to guide subcutaneous insulin dosing in non-critically ill hospitalized patients at two academic medical centers that use the EpicCare® electronic medical record (EMR). The Agency for Healthcare Research and Quality (AHRQ) best practices in CDS design and implementation were followed. RESULTS: A CDS tool was developed in the form of an EpicCare SmartForm, which generates an insulin regimen by integrating information about the patient's body weight, diabetes type, home and hospital insulin requirements, and nutritional status. Total daily recommended insulin doses are distributed into respective basal and nutritional doses with a tailored correctional insulin scale. Preimplementation, several approaches were used to communicate this new tool to clinicians, including emails, lectures, and videos. Postimplementation, a support team was available to address user technical issues. Feedback from stakeholders has been used to continuously refine the tool. Inclusion of the programming in the EMR vendor's community library has allowed dissemination of the tool outside our institution. CONCLUSIONS: We have developed an EMR-based tool to guide SQ insulin dosing in non-critically ill hospitalized patients. Further studies are needed to evaluate adoption and clinical effectiveness of this intervention.

Association of Hemoglobin A1c and Wound Healing in Diabetic Foot Ulcers.

OBJECTIVE: This study evaluated the association between hemoglobin A1c (A1C) and wound outcomes in patients with diabetic foot ulcers (DFUs). RESEARCH DESIGN AND METHODS: We conducted a retrospective analysis of an ongoing prospective, clinic-based study of patients with DFUs treated at an academic institution during a 4.7-year period. Data from 270 participants and 584 wounds were included in the analysis. Cox proportional hazards regression was used to assess the incidence of wound healing at any follow-up time in relation to categories of baseline A1C and the incidence of long-term (≥90 days) wound healing in relation to tertiles of nadir A1C change and mean A1C change from baseline, adjusted for potential confounders. RESULTS: Baseline A1C was not associated with wound healing in univariate or fully adjusted models. Compared with a nadir A1C change from baseline of -0.29 to 0.0 (tertile 2), a nadir A1C change of 0.09 to 2.4 (tertile 3) was positively associated with long-term wound healing in the subset of participants with baseline A1C <7.5% (hazard ratio [HR] 2.07; 95% CI 1.08-4.00), but no association with wound healing was seen with the mean A1C change from baseline in this group. Neither nadir A1C change nor mean A1C change were associated with long-term wound healing in participants with baseline A1C ≥7.5%. CONCLUSIONS: There does not appear to be a clinically meaningful association between baseline or prospective A1C and wound healing in patients with DFUs. The paradoxical finding of accelerated wound healing and increase in A1C in participants with better baseline glycemic control requires confirmation in further studies.

Debate position: cognition and mood are not improved in men administered exogenous testosterone therapy.

PURPOSE OF REVIEW: The purpose of this article is to provide an overview of the increasing evidence suggesting that exogenous testosterone therapy is not associated with improvements in cognition or mood. This article is part of a series, in this issue, in which authors are assigned opinion pieces on controversial topics pertaining to testosterone replacement. RECENT FINDINGS: Testosterone is increasingly being prescribed. Particularly in the setting of recent data suggestive of possible cardiovascular risk associated with its use; a clear understanding of the domains of health that improve with exogenous testosterone use is important. Data on endogenous and exogenous testosterone with cognition and mood are mixed, likely partly related to methodological differences of type of testosterone, patient population, and dosing. SUMMARY: Overall, available data are not suggestive of a clear benefit of testosterone supplementation in multiple domains of cognition and in mood. Supraphysiologic testosterone has been associated with adverse psychological outcomes, albeit not uniformly in studies.

Changes in Visceral Adiposity, Subcutaneous Adiposity, and Sex Hormones in the Diabetes Prevention Program.

Context: The degree to which changes in visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) relate to corresponding changes in plasma sex steroids is not known. Objective: We examined whether changes in VAT and SAT areas assessed by computed tomography were associated with changes in sex hormones [dehydroepiandrosterone sulfate (DHEAS), testosterone, estradiol, estrone, and sex hormone binding globulin (SHBG)] among Diabetes Prevention Program participants. Design: Secondary analysis of a randomized trial. Participants: Overweight and glucose-intolerant men (n = 246) and women (n = 309). Interventions: Intensive lifestyle change with goals of weight reduction and 150 min/wk of moderate intensity exercise or metformin administered 850 mg twice a day or placebo. Main Outcome Measures: Associations between changes in VAT, SAT, and sex hormone changes over 1 year. Results: Among men, reductions in VAT and SAT were both independently associated with significant increases in total testosterone and SHBG in fully adjusted models. Among women, reductions in VAT and SAT were both independently associated with increases in SHBG and associations with estrone differed by menopausal status. Associations were similar by race/ethnicity and by randomization arm. No significant associations were observed between change in fat depot with change in estradiol or DHEAS. Conclusions: Among overweight adults with impaired glucose intolerance, reductions in either VAT and SAT were associated with increased total testosterone in men and higher SHBG in men and women. Weight loss may affect sex hormone profiles via reductions in visceral and subcutaneous fat.

The relationship of fasting hyperglycemia to changes in fat and muscle mass after exercise training in type 2 diabetes.

AIMS: Exercise training (ET) has been variably associated with body composition changes among persons with type 2 diabetes (T2DM). The degree to which these changes are related to hyperglycemia remains unclear. Our objective was to investigate the relationship of baseline fasting glucose (FG) to the magnitude of muscle gains and fat loss after ET in individuals with T2DM. METHODS: Participants were enrolled in the SHAPE-2 trial, a six month supervised aerobic and resistance training intervention (three days/week), at Johns Hopkins. This was a post hoc single arm intervention study of participants who completed the exercise intervention (n=50). Participants were aged 40-65years and had T2DM that was not treated with insulin. Body composition was assessed by DEXA. RESULTS: After 6months of ET, total fat mass decreased (-2.1±3.1kg) and total lean body mass (LBM) increased (0.5±2.0kg) overall, but there was variability among individual participants. There was an increase in % total LBM (1.4±1.9%) and decrease in % total body fat mass (-1.5±2.0%) after ET. Interestingly, each standard deviation (SD) increase in baseline FG (mean=135.5mg/dl; SD=39.0mg/dl) was related to a significant increase in % total LBM (0.54±0.26%, p=0.048) and decrease in % total body fat (-0.57±0.27%, p=0.04) after ET among individual participants. CONCLUSIONS: Our data demonstrate that muscle gains and fat loss after ET are positively related to baseline hyperglycemia. Further studies are needed to characterize differences in metabolic response following ET among persons with diabetes.

Thyroid disorders in pregnancy.

PURPOSE OF REVIEW: Recognition and management of thyroid disease during pregnancy is challenging with conflicting recommendations from various professional organizations. RECENT FINDINGS: We review the literature related to the diagnosis and management of gestational hypothyroidism and hyperthyroidism. We also discuss postpartum thyroiditis, thyroid nodules and thyroid cancer. The evidence clearly demonstrates that both overt hypothyroidism and hyperthyroidism should be treated, but controversy exists regarding the treatment of subclinical hypothyroidism and thyroid antibody positive euthyroidism, and whether pregnant women should be screened for thyroid disease. SUMMARY: Appropriate management of thyroid disease during pregnancy is important for maternal and fetal health, particularly the recognition and management of hypothyroidism and thyrotoxicosis.

Gonadal function and reproductive health in women with human immunodeficiency virus infection.

Most human immunodeficiency virus (HIV) infections among women occur early in reproductive life, which highlights the importance of understanding the impact of HIV on reproductive functions, and also the potential implications of reproductive function and aging on the course of HIV disease. Ovarian function is a crucial component of reproductive biology in women, but standard assessment methods are of limited applicability to women with chronic diseases such as HIV. Pregnancy can now be achieved without transmission of HIV to sexual partner or newborn, but complications of pregnancy may be more common in women infected with HIV than uninfected women.

Patient-centered plan-of-care tool for improving clinical outcomes.

PURPOSE: In developing our Patient-Centered Team Care (PCTC) program, we designed a Plan-of-Care (POC) tool to facilitate the physician-patient discussion for setting health goals. This study aimed to determine the effectiveness of the POC tool in improving clinical outcomes. METHODS: We compared baseline and 6-month or greater follow-up values for hemoglobin A1c (HbA1c), low-density lipoprotein (LDL), systolic blood pressure (SP), diastolic blood pressure (DP), and weight for PCTC patients (intervention group) and non-PCTC patients (control group). For the intervention group, we also compared POC tool completeness scores (1, low and 8, high). RESULTS: Of 1366 patients, 1110 (593 intervention, 517 control) had baseline and follow-up clinical measures for analysis. After adjusting for demographics, significant effects occurred in the intervention group for HbA1c (P = .0067), LDL (P = .012), and DP (P = .091). For completeness of POC, a significant association occurred between more fully completed forms (scores, 5-8) and change in HbA1c (P < .001) and SP (P = .011). CONCLUSION: Patients receiving a POC showed significant improvement in 3 of 5 clinical outcomes compared with those without the tool, and those with more fully completed forms had significant improvement in 2 of 5 clinical outcomes compared with those with partially completed forms.