The Calculation of the Glucose Management Indicator Is Influenced by the Continuous Glucose Monitoring System and Patient Race.

Objective: To determine whether the glucose management indicator (GMI), an estimate of hemoglobin A1c (HbA1c) derived from continuous glucose monitoring (CGM) mean glycemia, differs by CGM system and patient race. Methods: One hundred three patients with prediabetes or stable diabetes and a minimum of 10 days of CGM data collected with the FreeStyle Libre CGM system immediately before measurement of HbA1c were included in this clinic-based observational study that used data from electronic health records in an academic endocrinology clinic. HbA1c and Libre CGM-measured mean glucose were plotted to derive a race-agnostic and race-specific regression equations to calculate a Libre-specific GMI (GMILi). The mean GMI derived from the published formula (GMIP) was compared with GMILi. Results: Mean ± SD (standard deviation) age of patients was 61.9 ± 13.3 years; 50% were of nonwhite race and 77% had type 2 diabetes; mean HbA1c was 62 mmol/mol (7.8%). The mean (range) number of days with available CGM data was 26 (10-90). The mean ± SD GMILi was higher than the GMIP in the entire cohort (7.9% ± 1.0% vs. 7.5% ± 1.0%, respectively; P = 0.01) and among Asian patients (7.9% ± 0.9% vs. 7.2% ± 1.0%, respectively; P = 0.03). Conclusions: In a cohort with prediabetes or stable diabetes, the regression equation to calculate GMI varied by CGM system and patient race. The development of device- and race-specific regression equations for GMI may be warranted.

Surgical management of an atypical presentation of a thyroid storm.

INTRODUCTION: Thyroid storm is a rare complication of Graves' disease that can carry a poor prognosis. In order to prevent major complications, thyroid storm must be quickly identified in patients and treatment must be promptly implemented. Medical treatment is usually initiated with antithyroid medications, such as propylthiouracil (PTU), methimazole, and beta-blockers. However, some patients may experience adverse reactions to these medications and alternate treatment options must be explored. CASE PRESENTATION: We report a case of a 30-year-old female initiated on PTU after diagnosis with Graves' disease that later presented an acute thyroid storm. DISCUSSION: Therapy was changed to methimazole, yet the patient subsequently developed angioedema and dyspnea. Medical management was discontinued and emergent thyroidectomy was performed without complication.

Inpatient medical errors involving glucose-lowering medications and their impact on patients: review of 2,598 incidents from a voluntary electronic error-reporting database.

OBJECTIVE: To describe characteristics of inpatient medical errors involving hypoglycemic medications and their impact on patient care. METHODS: We conducted a cross-sectional analysis of medical errors and associated adverse events voluntarily reported by hospital employees and staff in 21 nonprofit, nonfederal health-care organizations in the United States that implemented a Web-based electronic error-reporting system (e-ERS) between August 1, 2000, and December 31, 2005. Persons reporting the errors determined the level of impact on patient care. RESULTS: The median duration of e-ERS use was 3.1 years, and 2,598 inpatient error reports involved insulin or orally administered hypoglycemic agents. Nursing staff provided 59% of the reports; physicians reported <2%. Approximately two-thirds of the errors (1,693 of 2,598) reached the patient. Errors that caused temporary harm necessitating major treatment or that caused permanent harm accounted for 1.5% of reports (40 of 2,598). Insulin was involved in 82% of reports, and orally administered hypoglycemic agents were involved in 18% of all reports (473 of 2,598). Sulfonylureas were implicated in 51.8% of reports involving oral hypoglycemic agents (9.4% of all reports). CONCLUSION: An e-ERS provides an accessible venue for reporting and tracking inpatient medical errors involving glucose-lowering medications. Results are limited by potential underreporting of events, particularly by physicians, and variations in the reporter perception of patient harm.

Insulin therapy and in-hospital mortality in critically ill patients: systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Hyperglycemia is common in critically ill hospitalized patients and has been associated with adverse outcomes, including increased mortality. In this review, we examine the effect of insulin therapy on mortality in critically ill patients. METHODS: We updated our previous systematic review and meta-analysis to include recently published trials that report data on the effect of insulin therapy initiated during hospitalization on mortality in adult patients with a critical illness. We also include a short primer on the methods of systematic reviews and meta-analyses, outlining the specific steps and challenges of this methodology. We performed an electronic search in the English language of MEDLINE and the Cochrane Controlled Clinical Trials Register and a hand search of key journals and relevant review articles for randomized controlled trials that reported mortality data on critically ill hospitalized adult patients treated with insulin (regardless of method of administration). RESULTS: We identified 38 relevant studies that entered the analysis. We found that therapy with insulin in adult patients hospitalized for a critical illness, other than hyperglycemic crises, may decrease mortality in certain groups of patients. The beneficial effect of insulin was evident in the surgical intensive care unit (relative risk [RR], 0.58; confidence interval [CI], 0.22-0.62) and in patients with diabetes (RR, 0.76; CI, 0.62-0.92). There was a trend toward benefit in patients with acute myocardial infarction (RR, 0.89; CI, 0.76-1.03). Targeting euglycemia appears to be the main determinant of the benefit of insulin therapy (RR, 0.73; CI, 0.57-0.94). CONCLUSIONS: Insulin therapy in adult patients hospitalized for a critical illness, other than hyperglycemic crises, may decrease mortality in certain groups of patients.

Executive dysfunction in homebound older people with diabetes mellitus.

OBJECTIVES: To describe patterns of cognitive deficits and activities of daily living (ADLs) in older people with diabetes mellitus. DESIGN: Cross-sectional, population-based study. SETTING: Three homecare agency areas in Boston, Massachusetts. PARTICIPANTS: Two hundred ninety-one homebound people aged 60 and older; 40% with diabetes mellitus. MEASUREMENTS: Demographic data; evidence of diabetes mellitus and other diseases; Mini-Mental State Examination and tests of memory and executive function; ADLs. RESULTS: Executive and visuospatial functions were more impaired in individuals with diabetes mellitus than in those without, as assessed using Block Design (mean score+/-standard deviation 17.1+/-8.6 vs 20.5+/-9.6, P=.003) and Trails B (median seconds to accomplish the task: 255 vs 201, P=.03). For memory, word retention score was lower in those with diabetes mellitus than without (39.1+/-28.9 vs 48.0+/-29.7, P=.01), but the other memory tests did not show a difference between these two subgroups. More individuals with diabetes mellitus suffered from depressive symptoms than those without (55% vs 42%, P=.03). The ADL scores of those with diabetes mellitus were higher than those without. CONCLUSION: The pattern of cognitive deficits in people with diabetes mellitus suggests frontal-subcortical dysfunction, as seen in microvascular disease of the brain. The impairment in ADLs may be associated with this executive dysfunction, which cerebral microvascular disease in diabetes mellitus may cause.

Profound hypokalemia in diabetic ketoacidosis: a therapeutic challenge.

OBJECTIVE: To describe profound hypokalemia in a comatose patient with diabetic ketoacidosis. METHODS: We present a case report, review the mechanisms for the occurrence of hypokalemia in diabetic ketoacidosis, and discuss its management in the setting of hyperglycemia and hyperosmolality. RESULTS: A 22-year-old woman with a history of type 1 diabetes mellitus was admitted in a comatose state. Laboratory tests revealed a blood glucose level of 747 mg/dL, serum potassium of 1.9 mEq/L, pH of 6.8, and calculated effective serum osmolality of 320 mOsm/kg. She was intubated and resuscitated with intravenously administered fluids. Intravenous administration of vasopressors was necessary for stabilization of the blood pressure. Intravenous infusion of insulin was initiated to control the hyperglycemia, and repletion of total body potassium stores was undertaken. A total of 660 mEq of potassium was administered intravenously during the first 12.5 hours. Despite such aggressive initial repletion of potassium, the patient required 40 to 80 mEq of potassium daily for the next 8 days to increase the serum potassium concentration to normal. CONCLUSION: Profound hypokalemia, an uncommon initial manifestation in patients with diabetic ketoacidosis, is indicative of severe total body potassium deficiency. Under such circumstances, aggressive potassium repletion in a comatose patient must be undertaken during correction of other metabolic abnormalities, including hyperglycemia and hyperosmolality. Intravenously administered insulin should be withheld until the serum potassium concentration is (3)3.3 mEq/L.

Insulin therapy for critically ill hospitalized patients: a meta-analysis of randomized controlled trials.

BACKGROUND: Hyperglycemia is common in critically ill hospitalized patients, and it is associated with adverse outcomes, including increased mortality. The objective of this meta-analysis was to determine the effect of insulin therapy initiated during hospitalization on mortality in adult patients with a critical illness. METHODS: An electronic search in the English-language articles of MEDLINE and the Cochrane Controlled Clinical Trials Register and a hand search of key journals and relevant review articles were performed. Randomized controlled trials that reported mortality data on critically ill hospitalized adult patients who were treated with insulin were selected. Data on patient demographics, hospital setting, intervention (formulation and dosage of insulin, delivery method, and duration of therapy), mortality outcomes, adverse events, and methodological quality were extracted. RESULTS: Thirty-five trials met the inclusion criteria. Combining data from all trials using a random-effects model showed that insulin therapy decreases short-term mortality by 15% (relative risk [RR], 0.85; 95% confidence interval [CI], 0.75-0.97). In subgroup analyses, insulin therapy decreased mortality in the surgical intensive care unit (RR, 0.58; 95% CI, 0.22-0.62), when the aim of therapy was glucose control (RR, 0.71; 95% CI, 0.54-0.93), and in patients with diabetes mellitus (RR, 0.73; 95% CI, 0.58-0.90). A near-significant trend toward decreasing mortality was seen in patients with acute myocardial infarction who did not receive reperfusion therapy (RR, 0.84; 95% CI, 0.71-1.00). No randomized trials of insulin in the medical intensive care unit were identified. CONCLUSION: Insulin therapy initiated in the hospital in critically ill patients has a beneficial effect on short-term mortality in different clinical settings.

Pharmacotherapy of obesity: an update.

There has been an epidemic of obesity in the last decade. In spite of the rising numbers of people who are overweight and obese, medical treatment of obesity is currently where medical treatment of hypertension was in the 1950s with only two Food and Drug Administration-approved medications for chronic weight loss and maintenance, sibutramine and orlistat. This article reviews these medications and others currently being used for weight loss and weight maintenance. Available medications for obesity include drugs that affect caloric intake and appetite and alter energy expenditure and nutrient absorption, as well as some with an unclear mechanism of action at present. Dozens of drugs in different phases of clinical investigation could be available in the next decade.