Insulin Requirements in Patients With Type 2 Diabetes Undergoing Bariatric Surgery in the Inpatient Setting and Upon Discharge: A Single-Center Retrospective Analysis of Insulin Management Strategies.

OBJECTIVE: Rapid improvement in blood glucose (BG) after weight-loss surgery (WLS) can make postoperative glucose management challenging in patients with type 2 diabetes mellitus (T2DM). Our study examined the safety and efficacy of insulin management strategies during hospitalization and after discharge following WLS. METHODS: This single-center retrospective cohort study included 160 adult patients with type 2 diabetes mellitus undergoing WLS. Patients with glycated hemoglobin A1C (HbA1C) level <7% (53 mmol/mol) and not on antihyperglycemic medications or metformin monotherapy were excluded. BG and insulin dosing during hospitalization and at 2-week follow-up, and impact of preoperative HbA1C level were analyzed. RESULTS: Mean age was 46.3 years. Median preoperative HbA1C level was 8% (64 mmol/mol). Postoperatively, most patients received basal insulin plus sliding-scale insulin (SSI; 79/160, 49%) or SSI alone (77/160, 48%). The initial postoperative basal dose was 0.23 units/kg/day. The median basal insulin dose at discharge was 61% lower than preoperative dose. At 2-week follow-up, 34 of 44 patients (77%) had BG levels between 70-200 mg/dL and 1 of 44 (2.2%) had BG levels >200 mg/dL, with no hypoglycemia. Patients with HbA1C level >9% (75 mmol/mol) had higher BG on admission and during hospitalization, required higher insulin doses while hospitalized, and were more frequently discharged on insulin. CONCLUSION: SSI is effective in managing BG in some patients immediately after WLS. However, about half of the patients may require basal insulin at doses similar to those required by other inpatients. Preoperative hyperglycemia may affect inpatient insulin needs and BG. Low-dose basal insulin appears safe and effective upon discharge for select patients.

Whey Protein Supplementation Improves Body Composition and Cardiovascular Risk Factors in Overweight and Obese Patients: A Systematic Review and Meta-Analysis.

BACKGROUND: Previous literature shows possible benefits of whey protein supplementation in promoting weight loss. However, most studies do not have enough power to show beneficial effects on body composition and cardiovascular disease (CVD) risk factors. This meta-analysis evaluated effects of whey protein in individuals who are overweight and obese. METHODS: We comprehensively searched the databases of MEDLINE, Embase, and Cochrane databases. The inclusion criteria were published randomized control trials (RCTs) comparing whey protein supplementation to placebo or controls in individuals who are overweight or obese. The primary outcome was the differences in the change in body composition (body weight, waist circumference, total fat mass, body lean mass). We also examined the changes in CVD risk factors as secondary outcomes. We calculated pooled mean difference (MD) with 95% confidence intervals (CIs) using a random effects model. RESULTS: Nine RCTs were included in the meta-analysis. There was a significant reduction of body weight (MD = 0.56, 95% CI: 0.30-0.81), lean mass (MD = 0.77, 95% CI: 0.59-0.96), and fat mass (MD = 1.12, 95% CI: 0.77-1.47) favoring the whey protein group. There were improvements in multiple CVD risk factors including levels of systolic blood pressure, diastolic blood pressure, glucose, high-density lipoprotein, and total cholesterol (all p values <0.05). CONCLUSIONS: Whey protein supplementation seems to improve body weight, total fat mass, and some CVD risk factors in overweight and obese patients. Further studies regarding optimal dosage and duration of whey protein supplementation would be helpful to assess potential favorable effects in individuals who are overweight or obese.

Racial Disparities in Diabetes Technology Use and Outcomes in Type 1 Diabetes in a Safety-Net Hospital.

BACKGROUND: Limited data exist regarding diabetes technology use among adults with type 1 diabetes (T1D) in urban racially/ethnically diverse safety-net hospitals. We examined racial/ethnic differences in the use of continuous glucose monitor (CGM) and continuous subcutaneous insulin infusion (CSII) in this setting. METHODS: A retrospective review of 227 patients ≥ 18 years of age with T1D seen in an urban, safety-net endocrinology clinic during 2016-2017 was completed (mean age: 39; 80% English-speaking; 50% had public insurance). Diabetes technology use, defined as either CGM or CSII or both CGM and CSII, and clinical outcomes were examined by race/ethnicity. RESULTS: Overall, 30% used CGM and 26% used CSII. After adjusting for age, language, insurance, and annual income, diabetes technology use in non-White patients was significantly lower than in White patients, predominantly lower in Black (aOR 0.25 [95% CI 0.11-0.56]) and patients identified as other race/ethnicity (aOR 0.30 [95% CI 0.11-0.77]). At the highest household income level (≥$75,000/y), Black and Hispanic individuals were significantly less likely than White individuals to use diabetes technology (P < .0007). Mean hemoglobin A1c (HbA1c) was lower in patients using any diabetes technology compared with patients using no technology (P < .0001). Use of CGM and CSII together was associated with the lowest HbA1c across all racial/ethnic groups. CONCLUSIONS: Racial/ethnic disparities in diabetes technology use and glycemic control were observed even after adjusting for sociodemographic factors. Further research should explore barriers to accessing diabetes technology in non-White populations.

Surprising pathological and clinical manifestations of miliary tuberculosis.

We report a surprising pathological finding of miliary tuberculosis (TB) in a 49-year-old Chuukese, immunocompetent woman who was initially admitted to the hospital for a 1-month duration of chronic abdominal pain and intermittent fevers. Her clinical symptoms did not improve despite treatment with vancomycin and piperacillin-tazobactam. Based on the primary abdominal CT findings suggesting advanced ovarian cancer with omental metastatic disease, further workup with omental core biopsy was performed and demonstrated acute neutrophilic necrosis without malignant cells or granulomata. Within the omental tissue, however, many organisms stained positive for acid-fast bacilli despite lack of typical granulomata. The diagnosis of genitourinary TB was confirmed by urine Mycobacterium tuberculosis/rifampin automated molecular rapid nucleic acid amplification test. The chest CT showed a millet seed pattern of infiltration which is a hallmark for miliary TB. After initiation of multidrug TB therapy, her fever and abdominal pain drastically improved.

Effects of statin therapy on arterial stiffness: A systematic review and meta-analysis of randomized controlled trial.

BACKGROUND: Arterial stiffness has been observed to be an independent predictor for cardiovascular events. Effects of cholesterol lowering agents (statins) on arterial stiffness are inconsistent. We conducted a systematic review with a meta-analysis of all RCTs investigating the impact of statin therapy on arterial properties. METHODS: We comprehensively searched the databases of MEDLINE, EMBASE, and Cochrane from their dates of inception through April 2016. The inclusion criteria were published RCTs comparing change in arterial stiffness between statin administration and active control or placebo groups. Arterial stiffness is determined by aortic pulse wave velocity (PWV). We used a random-effects model and calculated pooled standardized mean difference (SMD) with 95% confidence intervals (CI) comparing change in PWV between the statin and control groups. RESULTS: Six studies were included in the meta-analysis. Statin therapy includes simvastatin, rosuvastatin, lovastatin, fluvastatin, and atorvastatin. Compared with the active control or placebo group, the statin therapy group had lower aPWV (SMD=2.31, 95% CI: 1.15-3.45, Pheterogeneity=0.07, I2=93%). CONCLUSION: Our meta-analysis demonstrates that statin therapy has a beneficial effect on aortic arterial stiffness. Further studies should be conducted to assess the effects of this therapy on arterial stiffness at various sites and conditions.

Hyperuricemia is associated with nonalcoholic fatty liver disease activity score in patients with nonalcoholic fatty liver disease: a systematic review and meta-analysis.

BACKGROUND: Hyperuricemia is a significant risk factor for nonalcoholic fatty liver disease (NAFLD). It may also have an impact on the histologic severity of NAFLD. However, data on this association are limited. We conducted this meta-analysis to investigate the relationship of serum uric acid with liver histologic severity as determined by NAFLD activity score (NAS) in patients with NAFLD. PATIENTS AND METHODS: MEDLINE and EMBASE databases were searched through August 2016 for studies that investigated the association between hyperuricemia and NAS among patients with biopsy-proven NAFLD. Pooled odds ratio and 95% confidence interval were calculated using a random-effects model (generic inverse variance method). The between-study heterogeneity of effect size was quantified using the Q statistic and I. RESULTS: Five observational studies with 777 NAFLD patients were identified. Patients with NAFLD who had hyperuricemia had a high NAS (defined as score of ≥5) significantly more often than did those without hyperuricemia with a pooled odds ratio of 2.17 (95% confidence interval: 1.51-3.12). The statistical heterogeneity was low, with I of 16% (Pheterogeneity=0.31). CONCLUSION: In patients with NAFLD, hyperuricemia is associated with a higher degree of histological liver damage. Further studies are required to establish the role of uric acid-lowering therapy among these patients.

Plasminogen Activator Inhibitor-1 Predicts Negative Alterations in Whole-Body Insulin Sensitivity in Chronic HIV Infection.

Plasminogen activator inhibitor type 1 (PAI-1), a key negative regulator of fibrinolysis, has been investigated to be one of the potential mechanisms of the development of impaired insulin sensitivity, insulin resistance, and diabetes mellitus. Because chronically stable HIV-infected individuals frequently develop abnormal glucose metabolism, including insulin resistance and diabetes mellitus, we postulated that PAI-1 could be one of the multifactorial pathogenic roles in the development of impaired insulin sensitivity and insulin resistance among chronic HIV-infected individuals. From our longitudinal cohort study, we selectively recruited chronically stable HIV-infected individuals without diagnosis of diabetes mellitus at baseline (N = 62) to analyze the correlation of baseline inflammatory cytokines, including PAI-1 and whole-body insulin sensitivity, with 2-year follow-up, as measured by Matsuda Index. We found a negative correlation between baseline PAI-1 and Matsuda Index (r = -0.435, p = .001) and a negative correlation between baseline PAI-1 and Matsuda Index at 2 years (r = -0.377, p = .005). In a linear regression model that included age, total body fat mass percentage, serum amyloid A, and family history of diabetes mellitus, PAI-1 still remained significantly associated with Matsuda Index at 2-year follow-up (ß = -.397, p = .002). Our longitudinal study suggests that PAI-1 is an independent predictor of impaired insulin sensitivity among chronic HIV-infected individuals.

Nonalcoholic fatty liver disease is associated with coronary artery calcification: A systematic review and meta-analysis.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is associated increased cardiovascular events and mortality. Coronary artery calcium scanning (CAC) is the robust predictor of coronary events in the asymptomatic individuals. Several recent studies have investigated the association between NAFLD and this surrogate marker. Thus, we conducted a systematic review and meta-analysis to better characterize the association between NAFLD and CAC. METHODS: MEDLINE and EMBASE were searched through May 2016. Primary outcome was the association between NAFLD and CAC. Pooled odds ratio (OR) and 95% confidence interval (CI) from multivariable-adjusted estimates were calculated using a random-effects model. The between-study heterogeneity of effect-size was quantified using the Q statistic and I2. RESULTS: Data were extracted from 16 studies (all cross-sectional studies) involving 16,433 NAFLD patients and 41,717 controls. NAFLD is significantly associated with CAC score >0 and CAC score >100 with pooled OR of 1.41 (95%CI 1.26-1.57, Pheterogeneity=0.07, I2=66%) and 1.24 (95%CI 1.02-1.52, Pheterogeneity=0.10, I2=42%). CONCLUSIONS: NAFLD is associated with increased coronary artery calcification independent of traditional risk factors. The assessment of coronary artery calcium may be useful in identifying NAFLD patients at risk of future cardiovascular events.