Insulin management in hospitalized patients with diabetes mellitus on high-dose glucocorticoids: Management of steroid-exacerbated hyperglycemia.

BACKGROUND: Glucocorticoid (GC)-exacerbated hyperglycemia is prevalent in hospitalized patients with diabetes mellitus (DM) but evidence-based insulin guidelines in inpatient settings are lacking. METHODS AND FINDINGS: Retrospective cohort study with capillary blood glucose (CBG) readings and insulin use, dosed with 50% basal (glargine)-50% bolus (lispro) insulin, analyzed in hospitalized patients with insulin-treated DM given GC and matched controls without GC (n = 131 pairs). GC group (median daily prednisone-equivalent dose: 53.36 mg (IQR 30.00, 80.04)) had greatest CBG differences compared to controls at dinner (254±69 vs. 184±63 mg/dL, P<0.001) and bedtime (260±72 vs. 182±55 mg/dL, P<0.001). In GC group, dinner CBG was 30% higher than lunch (254±69 vs. 199±77 mg/dL, P<0.001) when similar lispro to controls given at lunch. Bedtime CBG not different from dinner when 20% more lispro given at dinner (0.12 units/kg (IQR 0.08, 0.17) vs. 0.10 units/kg (0.06, 0.14), P<0.01). Despite receiving more lispro, bedtime hypoglycemic events were lower in GC group (0.0% vs. 5.9%, P = 0.03). CONCLUSIONS: Since equal bolus doses inadequately treat large dinner and bedtime GC-exacerbated glycemic excursions, initiating higher bolus insulin at lunch and dinner with additional enhanced GC-specific insulin supplemental scale may be needed as initial insulin doses in setting of high-dose GC.

Reverse shock index multiplied by Glasgow Coma Scale (rSIG) predicts mortality in severe trauma patients with head injury.

The reverse shock index (rSI), a ratio of systolic blood pressure (SBP) to heart rate (HR), is used to identify prognosis in trauma patients. Multiplying rSI by Glasgow Coma Scale (rSIG) can possibly predict better in-hospital mortality in patients with trauma. However, rSIG has never been used to evaluate the mortality risk in adult severe trauma patients (Injury Severity Score [ISS] ≥ 16) with head injury (head Abbreviated Injury Scale [AIS] ≥ 2) in the emergency department (ED). This retrospective case control study recruited adult severe trauma patients (ISS ≥ 16) with head injury (head AIS ≥ 2) who presented to the ED of two major trauma centers between January 01, 2014 and May 31, 2017. Demographic data, vital signs, ISS scores, injury mechanisms, laboratory data, managements, and outcomes were included for the analysis. Logistic regression and receiver operating characteristic analysis were used to evaluate the accuracy of rSIG score in predicting in-hospital mortality. In total, 438 patients (mean age: 56.48 years; 68.5% were males) were included in this study. In-hospital mortality occurred in 24.7% patients. The median (interquartile range) ISS score was 20 (17-26). Patients with rSIG ≤ 14 had seven-fold increased risks of mortality than those without rSIG ≤ 14 (odds ratio: 7.64; 95% confidence interval: 4.69-12.42). Hosmer-Lemeshow goodness-of-fit test and area under the curve values for rSIG score were 0.29 and 0.76, respectively. The sensitivity, specificity, positive predictive value, and negative predictive values of rSIG ≤ 14 were 0.71, 0.75, 0.49, and 0.89, respectively. The rSIG score is a prompt and simple tool to predict in-hospital mortality among adult severe trauma patients with head injury.

Variation in Maturity-Onset Diabetes of the Young Genes Influence Response to Interventions for Diabetes Prevention.

Context: Variation in genes that cause maturity-onset diabetes of the young (MODY) has been associated with diabetes incidence and glycemic traits. Objectives: This study aimed to determine whether genetic variation in MODY genes leads to differential responses to insulin-sensitizing interventions. Design and Setting: This was a secondary analysis of a multicenter, randomized clinical trial, the Diabetes Prevention Program (DPP), involving 27 US academic institutions. We genotyped 22 missense and 221 common variants in the MODY-causing genes in the participants in the DPP. Participants and Interventions: The study included 2806 genotyped DPP participants randomized to receive intensive lifestyle intervention (n = 935), metformin (n = 927), or placebo (n = 944). Main Outcome Measures: Association of MODY genetic variants with diabetes incidence at a median of 3 years and measures of 1-year ß-cell function, insulinogenic index, and oral disposition index. Analyses were stratified by treatment group for significant single-nucleotide polymorphism × treatment interaction (Pint < 0.05). Sequence kernel association tests examined the association between an aggregate of rare missense variants and insulinogenic traits. Results: After 1 year, the minor allele of rs3212185 (HNF4A) was associated with improved ß-cell function in the metformin and lifestyle groups but not the placebo group; the minor allele of rs6719578 (NEUROD1) was associated with an increase in insulin secretion in the metformin group but not in the placebo and lifestyle groups. Conclusions: These results provide evidence that genetic variation among MODY genes may influence response to insulin-sensitizing interventions.

Gender differences in orthostatic hypotension.

Orthostatic hypotension is a decrease in systolic blood pressure of more than 20 mm Hg or a decrease in diastolic blood pressure of at least 10 mm Hg, within 3 minutes of changing from a supine to an upright position. The typical clinical presentation of orthostatic hypotension includes dizziness, syncope, blurry vision and loss of balance. Symptoms may be more frequent in women, but the complicating roles played by comorbid factors and the estrogen mechanisms are not well understood. Women have a more active parasympathetic system, higher estrogen levels and a lower center of gravity. Thus, women less effectively compensate for the drop of blood pressure in response to positional change. An understanding of these mechanisms contributing to orthostatic hypotension may improve diagnosis and treatment of the problem.