Cost-effectiveness of a Novel Hypoglycaemia Programme: The 'HARPdoc vs BGAT' RCT.

AIMS: To assess the cost-effectiveness of HARPdoc (Hypoglycaemia Awareness Restoration Programme for adults with type 1 diabetes and problematic hypoglycaemia despite optimised care), focussed upon cognitions and motivation, versus BGAT (Blood Glucose Awareness Training), focussed on behaviours and education, as adjunctive treatments for treatment-resistant problematic hypoglycaemia in type 1 diabetes, in a randomised controlled trial. METHODS: Eligible adults were randomised to either intervention. Quality of life (QoL, measured using EQ-5D-5L); cost of utilisation of health services (using the adult services utilization schedule, AD-SUS) and of programme implementation and curriculum delivery were measured. A cost-utility analysis was undertaken using quality-adjusted life years (QALYs) as a measure of trial participant outcome and cost-effectiveness was evaluated with reference to the incremental net benefit (INB) of HARPdoc compared to BGAT. RESULTS: Over 24 months mean total cost per participant was £194 lower for HARPdoc compared to BGAT (95% CI: -£2498 to £1942). HARPdoc was associated with a mean incremental gain of 0.067 QALYs/participant over 24 months post-randomisation: an equivalent gain of 24 days in full health. The mean INB of HARPdoc compared to BGAT over 24 months was positive: £1521/participant, indicating comparative cost-effectiveness, with an 85% probability of correctly inferring an INB > 0. CONCLUSIONS: Addressing health cognitions in people with treatment-resistant hypoglycaemia achieved cost-effectiveness compared to an alternative approach through improved QoL and reduced need for medical services, including hospital admissions. Compared to BGAT, HARPdoc offers a cost-effective adjunct to educational and technological solutions for problematic hypoglycaemia.

Equitable Machine Learning for Hypoglycaemia Risk Management.

We developed a machine learning (ML) model for the detection of patients with high risk of hypoglycaemic events during their hospital stay to improve the detection and management of hypoglycaemia. Our model was trained on data from a regional local health care district in Australia. The model was found to have good predictive performance in the general case (AUC 0.837). We conducted subgroup analysis to ensure that the model performed in a way that did not disadvantage population subgroups, in this case based on gender or indigenous status. We found that our specific problem domain assisted us in reducing unwanted bias within the model, because it did not rely on practice patterns or subjective judgements for the outcome measure. With careful analysis for equity there is great potential for ML models to automate the detection of high-risk cohorts and automate mitigation strategies to reduce preventable errors.

Follow up care for adults with diabetes treated for severe hypoglycemia by emergency medical Services, 2013-2019.

AIMS: To capture the types and content of healthcare encounters following severe hypoglycemia requiring emergency medical services (EMS) and to correlate their features with subsequent risk of severe hypoglycemia. METHODS: A retrospective cohort was obtained by linking data from a multi-state health system and an advanced life support ambulance service. This identified 1977 EMS calls by 1028 adults with diabetes experiencing hypoglycemia between 1/1/2013-12/31/2019. We evaluated the healthcare engagement over the following 7 days to identify rates of discussion of hypoglycemia, change of diabetes medications, glucagon prescribing, and referral for diabetes. RESULTS: Rates of hypoglycemia discussion increased with escalating levels of care, from 11.5 % after EMS calls without emergency department (ED) transport or outpatient clinical encounters to 98 % among hospitalized patients with outpatient follow-up. EMS transport and outpatient follow-up were associated with significantly higher odds of discussion of hypoglycemia (OR 60 and OR 22.1, respectively). Interventions were not impacted by previous severe hypoglycemia within 30 days. Prescription of glucagon was rare among all patients. CONCLUSIONS: Interventions to prevent recurrent hypoglycemia increase with escalating levels of care but remain inadequate and inconsistent with clinical guidelines. Greater attention is needed to ensure timely diabetes-related follow-up and treatment modification for patients experiencing severe hypoglycemia.

FREE: A randomized controlled feasibility trial of a cognitive behavioral therapy and technology-assisted intervention to reduce fear of hypoglycemia in young adults with type 1 diabetes.

OBJECTIVE: The purpose of this study was to test the preliminary effectiveness of a cognitive behavioral therapy intervention (Fear Reduction Efficacy Evaluation [FREE]) designed to reduce fear of hypoglycemia in young adults with type 1 diabetes. The primary outcome was fear of hypoglycemia, secondary outcomes were A1C, and glycemic variability. METHODS: A randomized clinical trial was used to test an 8-week intervention (FREE) compared to an attention control (diabetes education) in 50 young adults with type 1 diabetes who experienced fear of hypoglycemia at baseline. All participants wore a continuous glucose monitor for the 8-week study period. Self-reported fear of hypoglycemia point-of-care A1C testing, continuous glucose monitor-derived glucose variability were measured at baseline, Week 8, and Week 12 (post-program). RESULTS: Compared to controls, those participating in the FREE intervention experienced a reduction in fear of hypoglycemia (SMD B = -8.52, p = 0.021), change in A1C (SMD B = 0.04, p = 0.841) and glycemic variability (glucose standard deviation SMD B = -2.5, p = 0.545) by the end of the intervention. This represented an 8.52% greater reduction in fear of hypoglycemia. CONCLUSION: A cognitive behavioral therapy intervention (FREE) resulted in improvements in fear of hypoglycemia. CLINICALTRIALS: govNCT03549104.

Conhecimento sobre o diabetes e atitude para o autocuidado de idosos na atenção primária à saúde / Knowledge and attitude about diabetes self-care of older adults in primary health care

Resumo Objetivou-se avaliar o conhecimento sobre o diabetes, a atitude para o autocuidado e os fatores associados, por meio de estudo transversal, na linha de base de um ensaio clínico randomizado, com idosos diabéticos na atenção primária de saúde do Recife, Nordeste do Brasil. Utilizou-se o Diabetes Knowledge Scale (DKN-A) e o Diabetes Attitudes Questionnaire (ATT-19). Dos 202 idosos, 77,7% apresentaram conhecimento insuficiente sobre a doença, com destaque para a cetonúria, substituição de alimentos e desconhecimento das causas e dos cuidados com a hipoglicemia. Quanto à atitude, 85,6% tiveram ajustamento psicológico negativo em relação ao diabetes. O modelo de regressão logística mostrou que morar sozinho foi fator de proteção (OR = 0,24; IC95% 00,9-0,65; OR = 0,22; IC95% 0,07-0,71) e baixa escolaridade fator de risco (OR = 7,78; IC95% 3,36-18,01; OR = 13,05; IC95% 4,63-36,82) para conhecimento insuficiente e atitude negativa para o autocuidado, respectivamente. Os achados reforçam a necessidade de ações educativas interdisciplinares que incluam aspectos socioeconômicos, psicoemocionais e educacionais na gestão do diabetes com vistas à manutenção da autonomia e funcionalidade do idoso.

Abstract This study aimed to assess the knowledge about diabetes, the attitude for self-care and associated factors through a cross-sectional study, the baseline of a randomized clinical trial with elderly diabetic in primary health care in Recife, Northeastern Brazil. We used the Diabetes Knowledge Scale (DKN-A) and Diabetes Attitudes Questionnaire (ATT-19). Of the 202 elderly, 77.7% had insufficient knowledge of the disease, especially for ketonuria, food replacement and were unaware of the causes and care of hypoglycemia. As for attitude, 85.6% had a negative psychological adjustment for diabetes. The logistic regression model showed that living alone was a protective factor (OR = 0.24; 95% CI 0.09-0.65; OR = 0.22; 95% CI 0.07 to 0.71), and low education, a risk factor (OR = 7.78; 95% CI 3.36-18.01; OR = 13.05; 95% CI 4.63-36.82) for the insufficient knowledge and the negative attitude for self-care, respectively. The findings reinforce the need for interdisciplinary educational actions that include socioeconomic, psycho-emotional and educational aspects in diabetes management to maintain elderly autonomy and functionality.

Aspectos metodológicos de los procesos asistenciales integrados (PAI) / Methodological aspects of integrated care pathways

Un proceso asistencial integrado (PAI) es una herramienta cuyo propósito es aumentar la efectividad de las actuaciones clínicas a través de una mayor coordinación y garantía de continuidad asistencial. Los PAI sitúan al paciente como el eje central de la organización asistencial. Se definen como el conjunto de actividades que realizan los proveedores de la atención sanitaria con la finalidad de incrementar el nivel de salud y el grado de satisfacción de la población que recibe los servicios. La elaboración de un PAI precisa analizar el flujo de actividades, la interrelación entre profesionales y dispositivos asistenciales y las expectativas del paciente. En este artículo se presenta y se discute la metodología para la elaboración de un PAI, así como los factores de éxito para su definición y su efectiva implantación. Se explica también, a modo de ejemplo, el reciente PAI para hipoglucemias en personas con diabetes mellitus tipo 2 elaborado por un equipo multidisciplinar y avalado por varias sociedades científicas (AU)

An Integrated Healthcare Pathway (PAI) is a tool which has as its aim to increase the effectiveness of clinical performance through greater coordination and to ensure continuity of care. PAI places the patient as the central focus of the organisation of health services. It is defined as the set of activities carried out by the health care providers in order to increase the level of health and satisfaction of the population receiving services. The development of a PAI requires the analysis of the flow of activities, the inter-relationships between professionals and care teams, and patient expectations. The methodology for the development of a PAI is presented and discussed in this article, as well as the success factors for its definition and its effective implementation. It also explains, as an example, the recent PAI for Hypoglycaemia in patients with Type 2 Diabetes Mellitus developed by a multidisciplinary team and supported by several scientific societies (AU)

Caracterización de eventos de hipoglicemia en pacientes diabéticos y no diabéticos atendidos en un servicio de urgencia / Hypoglycemia in an emergency room: review of 251 cases

Background Hypoglycemia is the main limitation for the achievement of glycemic goals in the treatment of diabetes. Aim To assess the incidence of hypoglycemia in an emergency department. To characterize and identify which patients are at higher risk of having it. Material and Methods We reviewed the electronic records of patients discharged from an adult emergency room with the diagnosis of hypoglycemia between May 2011 and December 2014. Age, sex, diagnosis of diabetes (DM), antidiabetic therapy, glycosylated hemoglobin, creatinine, destination at time of discharge, blood glucose, impairment of conscience, treatment of the event and predictions were recorded. Results Of 175,244 attentions analyzed, 251 in patients aged 69 ± 17 years (54% women) consulted for hypoglycemia (0.14%). Eighty one percent had a type 2 diabetes, 6% a type 1 diabetes and 12% were non-diabetic. Mean blood glucose was 44.1 mg/dl. In diabetic patients, mean glycosylated hemoglobin was 6.5%. Ninety seven percent had impairment of conscience and 77% were admitted to the hospital. Among patients without diabetes, the main comorbidity was the history of a gastric bypass surgery. In type 2 diabetes, glibenclamide used alone or with other medications was involved in 59% of the events, 87% of patients were older than 65 years with a mean glycosylated hemoglobin of 6.3% and 32% had renal failure. Conclusions The incidence of hypoglycemia was low. There were a significant number of events in older patients with type 2 diabetes mellitus and renal failure, who were treated with glibenclamide. Most of these patients had a glycosylated hemoglobin below accepted recommendations.

Autoadministración de insulina en deportistas no diabéticos / No disponible

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Primers auxilis 2015 / No disponible

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Distensión abdominal y estancamiento ponderoestatural como forma de presentación de diferentes tipos de glucogenosis / Different glycogen storage diseases presenting as abdominal distention and growth and weight retardation

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Fatores predisponentes para hipoglicemia: aumentando a segurança do paciente crítico que utiliza insulina intravenosa / Predisposing factors for hypoglycemia: security measures for critical patients on intravenous insulin / Factores predisponentes para hipoglucemia: aumentando la seguridad del paciente crítico que utiliza la insulina intravenosa

Pesquisa com o objetivo de identificar os fatores predisponentes para hipoglicemia nos pacientes críticos que receberam infusão contínua de insulina. Estudo documental, retrospectivo, se rastrearam 550 prontuários dos anos de 2012 e 2013 de pacientes do pós-operatório de cirurgia cardíaca, dos quais 168 receberam insulina intravenosa e 74 apresentaram hipoglicemia grave. Os resultados principais apontam que entre os pacientes que apresentaram hipoglicemia grave, a maioria erado sexo masculino (60,11%), idosos (md=61,78), com sobrepeso (26,75Kg/m2,), hipertensos (78,57%) e isquêmicos (52,38%). Os fatores predisponentes encontrados para hipoglicemia, com significado estatístico foram ser diabético (OR=3,6), ter insuficiência renal (OR=5,4), em uso de aminas vasoativas (OR=3,1). Conclui-se que uma medida de segurança, para pacientes com estes fatores, é a coleta de amostras de sangue venoso e o uso de hemogasometros para a aferição da medida glicêmica.

Documentary, retrospective cross research aiming at describing the predisposing factors studied in critically ill patients receiving continuous insulin infusion. Tracking was made of five hundred and fifty (550) medical records for the years 2012 and 2013 of post-operative cardiac surgery patients who received intravenous insulin. Main results show that nearly half of the patients had at least one record of hypoglycemia, the majority were male (60.11%), elderly (md = 61.78), overweight (26,75Kg / m2), hypertense (78.57%), and ischemic (52.38%). Predisposing factors for hypoglycemia, with statistical significance identified among patients were as follows: diabetes (OR = 3.6); renal failure (OR = 5.4); and use of vasoactive amines (OR = 3.1). Conclusions identified security actions for patients in those conditions such as venous blood collection as well as the use of blood meters to assess glycemic levels.

Investigación con el objetivo de identificar los factores predisponentes para hipoglucemia en los pacientes críticos que recibieron infusión continua de insulina. Estudio documental, retrospectivo, se rastrearon 550 historiales de los años 2012 a 2013 de pacientes del posoperatorio de cirugía cardíaca, de los cuales 168 recibieron insulina intravenosa y 74 presentaron hipoglucemia grave. Los resultados principales apuntan que entre los pacientes que presentaron hipoglucemia grave, la mayoría era del sexo masculino (60,11%), ancianos (MD=61,78), con sobrepeso (26,75Kg/m2), hipertensos (78,57%) e isquémicos (52,38%). Los factores predisponentes encontrados para hipoglucemia, con significado estadístico fueron ser diabético (OR=3,6), tener insuficiencia renal (OR=5,4), en empleo de aminas vasoactivas (OR=3,1). Se llega a la conclusión de que una medida deseguridad, para pacientes con estos factores, es la recolecta de muestras de sangre venosa y el empleo de hemogasometría para la verificación de la medida glucémica.

Hipoglucemia severa intradiálisis asociada a marihuana / Severe intradialytic hypoglycemia associated with marijuana use

No disponible

Diagnóstico y manejo de la hipoglicemia en adultos diabéticos hospitalizados: evaluación de competencias en un equipo profesional multidisciplinario de salud / Competences on hypoglycemia management among healthcare professionals in a clinical hospital

Background: A tight glycemic control of hospitalized patients increases the risk of hypoglycemia, whose management is not always optimal. Aim: To assess the hypoglycemia management competences of a multidisciplinary team in a clinical hospital. Material and Methods: An anonymous questionnaire about hypoglycemia management was answered by 11 staff physicians, 42 residents and 28 nurses of the department of medicine and critical care unit ofa university hospital. Results: Respondents had a mean of 60 percent of correct answers, without significant differences between groups. The capillary blood glucose level that defines hypoglycemia was known by most of the respondents, but the value that defines severe episodes was known only by 60 percent. The initial management and follow up was well known only for severe episodes. Less than 50 percento knew the blood glucose value that required continuing with treatment. Conclusions: Although most professionals are able to recognize hypoglycemia, the knowledge about is management if insufficient.

Nuevas insulinas en la diabetes tipo 1 / New insulin types in type 1 diabetes mellitus

Transcurrido casi un siglo desde el descubrimiento de la insulina, sigue siendo en la actualidad la base del tratamiento de los pacientes con diabetes mellitus de tipo 1. Aunque los progresos en la síntesis de nuevas formulaciones han sido notables, el perfil fisiológico de la insulina es aún distinto del que se obtiene con las preparaciones disponibles en la actualidad. En la última década, la incorporación a la práctica clínica de los análogos de insulina ha permitido mejorar de forma importante el control glucémico de los diabéticos y ha facilitado la generalización de las pautas bolo/basal, las más fisiológicas hasta estos momentos. A pesar de las ventajas de los análogos basales, en muchas ocasiones las glucemias oscilan considerablemente cuando se utilizan en forma de inyección única diaria, y es por ello que se han seguido investigando nuevas moléculas que mejoren las existentes, especialmente en cuanto a duración y para evitar la presencia de hipoglucemias, el factor limitante fundamental de las pautas intensificadas. En el presente artículo se revisan los datos disponibles referentes a los nuevos análogos de insulina basal, la insulina degludec, la insulina lispro pegilada y la insulina glargina U300, y de las nuevas formulaciones actualmente en fase de desarrollo (AU)

Since its discovery almost a century ago, insulin remains the mainstay of treatment of patients with type 1 diabetes mellitus. Although progress in the synthesis of new formulations has been remarkable, the physiological profile of insulin is still different from that observed with preparations available nowadays. In the last decade, the introduction into clinical practice of insulin analogues has allowed significantly improvement in glycemic control and has facilitated the spread of basal/bolus patterns, the most physiological ones until now. Despite the benefits of basal analogues, glycemia often varies considerably when used as a single daily injection and this is why new molecules have been further investigated. Improvement has been achieved especially in terms of duration and rate of hypoglycemia, the main limiting factor of intensive therapy. This article reviews the available data concerning the new basal insulin analogues, degludec, pegylated lispro and glargine U300, and new formulations currently under development (AU)

Insulinoma, presentación y evolución de dos casos clínicos / Insulinoma, evolution and presentation of 2 clinical cases

Insulinoma is a very uncommon tumor in children, with an incidence in adults of 2 per million inhabitants. Clinical manifestations include neuroglycopenic or autonomic manifestations due to hypoglycemia. We describe 2 pediatric patients with insulinoma, characterized by repeated episodes of hypoglycemia associated to high insulin serum levels and presence of a small mass in the pancreas by imaging studies. The diagnosis was very prompt in one case and delayed in the other, emphasizing the need for an appropriate diagnosis of hypoglycemia during childhood.

El insulinoma es un tumor muy infrecuente en la edad pediátrica y la incidencia reportada en adultos es de 2 casos por millón de habitantes. La presentación de la enfermedad consiste en la presencia de síntomas neuroglicopénicos y autonómicos desencadenados por los episodios de hipoglicemia. Se describen dos pacientes con insulinoma esporádico. El cuadro clínico consistió en episodios repetidos de hipoglicemia asociados a niveles aumentados de insulina sérica y a imágenes sugerentes de un tumor pancreático. El diagnóstico fue muy oportuno en uno de los casos y muy tardío en el otro, lo que resalta la necesidad de estar muy alerta ante casos de hipoglicemia durante la niñez.

Hipoglicemia em adultos / Hypoglycemia in adults

A hipoglicemia é um evento potencialmente grave, com significativa morbidade. É rara em indivíduos sem diabetes, e pode ocorrer com frequência variável em pacientes com diabetes mellitus, especialmente naqueles que utilizam insulina. Para minimizar esse risco é imprescindível que se individualize o tratamento, estabelecendo metas glicêmicas de acordo com a idade, expectativa de vida, comorbidades e estilo de vida

Hypoglycemia is a potentially serious event with significant morbidity. It is rare in individuals without diabetes and can occur in a quite variable frequency in diabetic patients, especially in those that use insulin. In order to minimize its risk in these groups, it is essential to individualize treatment, establishing glycemic targets according to age, life expectancy, comorbidities and lifestyle

Estados hiper e hipoglicêmicos agudos: conduta atual / Acute hyper and hypoglycaemic states: current conduct

Os estados hiperglicêmicos e hipoglicêmicos agudos são exemplos das mais comuns emergências médicas com que nos deparamos no campo das alterações do metabolismo. Os estados hiperglicêmicos agudos compreendem a cetoacidose diabética e o coma hiperosmolar hiperglicêmico não cetótico. Neste artigo, analisamos essas condições hiperglicêmicas, que representam um desafio para o clínico e o médico generalista que trabalham no terreno nas emergências médicas

The acute hypoglycemic and hyperglycemic situations are examples of the most common medical emergencies that we face in the field of metabolic disorders. The acute hyperglycemic situations include diabetic ketoacidosis and hyperosmolar hyperglycemic coma hyperosmolar nonketotic. In this article, we analyze these two hyperglycemic conditions that represent a challenge to the clinician and general practitioner working in the field in medical emergencies

Infusão contínua de insulina e controle glicêmico em pacientes sépticos: implicações para a enfermagem em terapia intensiva / Continuous infusion of insulin and glycemic control in septic patients: implications for nursing in intensive care

O objeto de estudo é o resultado do controle glicêmico proveniente da infusão contínua de insulina (ICI) em pacientes sépticos da terapia intensiva. Os objetivos foram determinar a incidência de hipoglicemia encontrada entre pacientes de duas Unidades de Terapia Intensiva (UTI), que receberam ICI e sua relação com os valores da faixa-alvo de cada protocolo e discutir as implicações para a prática de enfermagem relacionadas à incidência de hipoglicemia. Trata-se de estudo transversal, bicêntrico, retrospectivo, com técnica de coleta de dados por análise do prontuário e avaliação quantitativa dos mesmos. Desenvolvida em duas UTIs, uma de um hospital de oncologia da rede federal e outra de um hospital geral da rede estadual do estado do Rio de Janeiro. As medidas glicêmicas de pacientes sépticos que utilizaram ICI no ano de 2010 nas duas UTIs foram transcritas para o instrumento de coleta de dados, gerando 2213 medidas em 29 pacientes (11,88%) na UTI 1 e 923 medidas em 20 pacientes (9,85%) na UTI 2. Os registros de hipoglicemia foram divididos em duas categorias: as medidas com valores definidos pelo protocolo adotado e aquelas com valores inferiores a 50mg/dL, caracterizados como hipoglicemia grave pelo Institute for Healthcare Improvement; nas duas categorias houve a necessidade de intervenção com a administração de glicose hipertônica a 50%. Dezesseis pacientes da UTI 1 apresentaram hipoglicemia, sendo quatro (25,00%) com medidas entre 50 e 60mg/dL e doze (75,00%) com medidas inferiores a 50mg/dL; treze pacientes da UTI 2 apresentaram hipoglicemia, sendo dez (76,92%) com medidas entre 50 e 80mg/dL e três (23,08%) com medidas inferiores a 50mg/dL. O cálculo da incidência considerou o total dos episódios de hipoglicemia independente da categoria. Comparando as duas UTIs, foi encontrada na UTI 1 uma incidência global de hipoglicemia quase cinco vezes maior (22,60:4,54)...

This study aims to get the glycemic control result from the insulin continuous infusion (ICI) in septic patients in intensive care. The objectives were to determine the hypoglycemia incidence in patients from two Intensive Care Units (ICU) who received ICI and its relation to the target range values for each protocol, and discuss the implications for nursing practice related to hypoglycemia incidence. It is a bi-centric and retrospective cross-sectional study with data collection technique, by analyzing the records and their quantitative assessment. It was developed in two ICUs, one oncology hospital belonging to Union and another to state of Rio de Janeiro. Glycemic measures from septic patients who used ICI in 2010 in both ICUs were collected to data, yielding two thousand, two hundred and thirteen measured in twenty-nine patients (11.88%) from ICU 1, and nine hundred and twenty-three measures in twenty (9.85%) patients from ICU 2. Hypoglycemia records were divided into two categories, measures with values defined by the adopted protocol and measures with values less than 50mg/dL, characterized as severe hypoglycemia by the Institute for Healthcare Improvement. In both categories, it was necessary to intervene, administering hypertonic glucose of 50%. Sixteen patients from ICU 1 had hypoglycemia, four (25%) measuring between 50 and 60mg/dL and twelve (75%) with measures less than 50mg/dL. Thirteen patients from ICU 2 had hypoglycemia, ten (76.92%) measuring between 50 and 80mg/dL and three (23.08%) with measures less than 50mg/dL. For the incidence calculation, the total hypoglycemia episodes were considered independently of category. Comparing the two ICUs, global incidence of hypoglycemia was found in ICU 1 almost five times higher (22.60:4.54)...