THE EFFICACY AND SAFETY OF CO-ADMINISTRATION OF SITAGLIPTIN WITH METFORMIN IN PATIENTS WITH TYPE 2 DIABETES AT HOSPITAL DISCHARGE.

OBJECTIVE: Few randomized controlled trials have focused on the optimal management of patients with type 2 diabetes (T2D) during the transition from the inpatient to outpatient setting. This multicenter open-label study explored a discharge strategy based on admission hemoglobin A1c (HbA1c) to guide therapy in general medicine and surgery patients with T2D. METHODS: Patients with HbA1c ≤7% (53 mmol/mol) were discharged on sitagliptin and metformin; patients with HbA1c between 7 and 9% (53-75 mmol/mol) and those >9% (75 mmol/mol) were discharged on sitagliptinmetformin with glargine U-100 at 50% or 80% of the hospital daily dose. The primary outcome was change in HbA1c at 3 and 6 months after discharge. RESULTS: Mean HbA1c on admission for the entire cohort (N = 253) was 8.70 ± 2.3% and decreased to 7.30 ± 1.5% and 7.30 ± 1.7% at 3 and 6 months ( P<.001). Patients with HbA1c <7% went from 6.3 ± 0.5% to 6.3 ± 0.80% and 6.2 ± 1.0% at 3 and 6 months. Patients with HbA1c between 7 and 9% had a reduction from 8.0 ± 0.6% to 7.3 ± 1.1% and 7.3 ± 1.3%, and those with HbA1c >9% from 11.3 ± 1.7% to 8.0 ± 1.8% and 8.0 ± 2.0% at 3 and 6 months after discharge (both P<.001). Clinically significant hypoglycemia (<54 mg/dL) was observed in 4%, 4%, and 7% among patients with a HbA1c <7%, 7 to 9%, and >9%, while a glucose <40 mg/dL was reported in <1% in all groups. CONCLUSION: The proposed HbA1c-based hospital discharge algorithm using a combination of sitagliptin-metformin was safe and significantly improved glycemic control after hospital discharge in general medicine and surgery patients with T2D. ABBREVIATIONS: BG = blood glucose; DPP-4 = dipeptidyl peptidase-4; eGFR = estimated glomerular filtration rate; HbA1c = hemoglobin A1c; T2D = type 2 diabetes.

Stress Hyperglycemia During Surgery and Anesthesia: Pathogenesis and Clinical Implications.

Numerous studies have demonstrated an association between hyperglycemia in the perioperative period and adverse clinical outcomes. Many patients who experience hyperglycemia while hospitalized do not have a known history of diabetes and experience a transient phenomenon often described as "stress hyperglycemia" (SH). We discuss the epidemiology and pathogenesis of SH as well as evidence to date regarding predisposing factors and outcomes. Further research is needed to identify the long-term sequelae of SH as well as perioperative measures that may modulate glucose elevations and optimal treatment strategies.

Prevalence and Determinants of Glycemic Abnormalities in Cardiac Surgery Patients without a History of Diabetes: A Prospective Study.

OBJECTIVE: To evaluate the prevalence and persistence of postoperative glycemic abnormalities in patients without a history of diabetes, undergoing cardiac surgery (CS). METHODS: Ninety-two patients without diabetes with planned elective CS procedures at a tertiary institution were evaluated preoperatively and 3 months postoperatively for measures of glucose control including hemoglobin A1c, fasting plasma glucose, 2-h post oral glucose load, and insulin levels. Data from the hospital course were recorded. RESULTS: Valid data were available from 61 participants at 3 months; 59% had prediabetes and 10% had diabetes preoperatively by one or more diagnostic criteria and continued to be dysglycemic at 3 months. Preoperative A1C was an independent predictor of postoperative hyperglycemia (p = 0.02). Insulin resistance and BMI rather than glycemic abnormalities before surgery were associated with a longer duration of the postoperative insulin infusion (p = 0.004, p = 0.048). CONCLUSION: Seventy percent of CS patients without known diabetes met criteria for diabetes or prediabetes preoperatively, and these abnormalities persisted after surgery.

Diabetes and stress hyperglycemia in the intensive care unit: outcomes after cardiac surgery.

BACKGROUND: Hyperglycemia is common in the post-cardiac surgery population and has been associated with increased mortality rates, surgical length of stay, and infection rates. Although hospitalized patients with diabetes are known to have more complications, recent studies in various hospital settings have reported worse outcomes in patients with stress hyperglycemia than in those with diabetes. AIM: The primary objective of this study was to analyze 30- and 90-day mortality rates in post-cardiac surgery patients with stress hyperglycemia and diabetes who were managed to achieve similar moderate blood glucose goals using the University of Michigan Hospital (Ann Arbor, MI) insulin protocol between 2005 and 2008. The secondary outcomes were rates of postoperative complications, including hypoglycemia. METHODS: A standardized glucose management program was followed to treat all patients in the cardiac intensive care unit, with a blood glucose goal of 100 to 140 mg/dL. Data from 1973 patients with either diabetes or stress hyperglycemia were analyzed to identify associations between mean postoperative blood glucose levels and mortality, incidence of hypoglycemia, and complication rates. RESULTS: Mortality rates did not differ between patients with diabetes and stress hyperglycemia (3.4 and 2.3%; P = 0.2). Rates of severe hypoglycemia were low (1%) for both groups and were not associated with an increase in mortality (P = 0.95). Other complication rates were similar between patients with diabetes and stress hyperglycemia. CONCLUSION: Maintaining a blood glucose range between 100 to 140 mg/dL in post-cardiac surgery patients was associated with a low mortality rate, low risk of hypoglycemia, and with complications rates that were similar in patients with diabetes and stress hyperglycemia.

Evaluation of hemoglobin A1c criteria to assess preoperative diabetes risk in cardiac surgery patients.

OBJECTIVE: Hemoglobin A1c (A1C) has recently been recommended for diagnosing diabetes mellitus and diabetes risk (prediabetes). Its performance compared with fasting plasma glucose (FPG) and 2-h post-glucose load (2HPG) is not well delineated. We compared the performance of A1C with that of FPG and 2HPG in preoperative cardiac surgery patients. METHODS: Data from 92 patients without a history of diabetes were analyzed. Patients were classified with diabetes or prediabetes using established cutoffs for FPG, 2HPG, and A1C. Sensitivity and specificity of the new A1C criteria were evaluated. RESULTS: All patients diagnosed with diabetes by A1C also had impaired fasting glucose, impaired glucose tolerance, or diabetes by other criteria. Using FPG as the reference, sensitivity and specificity of A1C for diagnosing diabetes were 50% and 96%, and using 2HPG as the reference they were 25% and 95%. Sensitivity and specificity for identifying prediabetes with FPG as the reference were 51% and 51%, respectively, and with 2HPG were 53% and 51%, respectively. One-third each of patients with prediabetes was identified using FPG, A1C, or both. When testing A1C and FPG concurrently, the sensitivity of diagnosing dysglycemia increased to 93% stipulating one or both tests are abnormal; specificity increased to 100% if both tests were required to be abnormal. CONCLUSIONS: In patients before cardiac surgery, A1C criteria identified the largest number of patients with diabetes and prediabetes. For diagnosing prediabetes, A1C and FPG were discordant and characterized different groups of patients, therefore altering the distribution of diabetes risk. Simultaneous measurement of FGP and A1C may be a more sensitive and specific tool for identifying high-risk individuals with diabetes and prediabetes.

Micromachined bulk PZT tissue contrast sensor for fine needle aspiration biopsy.

This paper describes a micromachined piezoelectric sensor, integrated into a cavity at the tip of a biopsy needle, and preliminary experiments to determine if such a device can be used for real-time tissue differentiation, which is needed for needle positioning guidance during fine needle aspiration (FNA) biopsy. The sensor is fabricated from bulk lead zirconate titanate (PZT), using a customized process in which micro electro-discharge machining is used to form a steel tool that is subsequently used for batch-mode ultrasonic micromachining of bulk PZT ceramic. The resulting sensor is 50 microm thick and 200 microm in diameter. It is placed in the biopsy needle cavity, against a steel diaphragm which is 300 microm diameter and has an average thickness of 23 microm. Devices were tested in materials that mimic the ultrasound characteristics of human tissue, used in the training of physicians, and with porcine fat and muscle tissue. In both schemes, the magnitude and frequency of an electrical impedance resonance peak showed tissue-specific characteristics as the needle was inserted. For example, in the porcine tissue, the impedance peak frequency changed approximately 13 MHz from the initial 163 MHz, and the magnitude changed approximately 1600 Omega from the initial 2100 Omega, as the needle moved from fat to muscle. Samples including oils and saline solution were tested for calibration, and an empirical tissue contrast model shows an approximately proportional relationship between measured frequency shift and sample acoustic impedance. These results suggest that the device can complement existing methods for guidance during biopsies.