A Pharmacist-Driven Glycemic Control Protocol to Reduce the Rate of Severe Hypoglycemia in High-Risk Patients

Purpose: Hospital pharmacists contribute to patient safety and quality initiatives by overseeing the prescribing of antidiabetic medications. A pharmacist-driven glycemic control protocol was developed to reduce the rate of severe hypoglycemia events (SHE) in high-risk hospitalized patients. Methods: We retrospectively analyzed the rates of SHE (defined as blood glucose ≤40 mg/dL), before and after instituting a pharmacist-driven glycemic control protocol over a 4-year period. A hospital glucose management team that included a lead Certified Diabetes Educator Pharmacist (CDEP), 5 pharmacists trained in diabetes, a lead hospitalist, critical care and hospital providers established a process to first identify patients at risk for severe hypoglycemia and then implement our protocol. Criteria from the American Diabetes Association and the American Association of Clinical Endocrinologists was utilized to identify and treat patients at risk for SHE. We analyzed and compared the rate of SHE and physician acceptance rates before and after protocol initiation. Results: From January 2015 to March 2019, 18 297 patients met criteria for this study; 139 patients experienced a SHE and approximately 80% were considered high risk diabetes patients. Physician acceptance rates for the new protocol ranged from 77% to 81% from the year of initiation (2016) through 2018. The absolute risk reduction of SHE was 9 events per 1000 hospitalized diabetic patients and the relative risk reduction was 74% SHE from the start to the end of the protocol implementation. Linear regression analysis demonstrated that SHE decreased by 1.5 events per 1000 hospitalized diabetic patients (95% confidence interval, −1.54 to −1.48, P < .001) during the 2 years following the introduction of the protocol. This represents a 15% relative reduction of SHE per year. Conclusion: The pharmacist-driven glycemic control protocol was well accepted by our hospitalists and led to a significant reduction in SHE in high-risk diabetes patient groups at our hospital. It was cost effective and strengthened our physician-pharmacist relationship while improving diabetes care.

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Identifying older diabetic patients at risk of poor glycemic control

BMC Geriatrics ◽

10.1186/1471-2318-2-4 ◽

2002 ◽

Vol 2 (1) ◽

Cited By ~ 2

Author(s):

Raffaele Antonelli Incalzi ◽

◽

Andrea Corsonello ◽

Claudio Pedone ◽

Francesco Corica ◽

...

Keyword(s):

At Risk ◽

Glycemic Control ◽

Poor Glycemic Control ◽

Diabetic Patients ◽

Patients At Risk

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A preliminary study on diabetes self-management education and glycemic control among patients with diabetes mellitus

Journal of Nursing Education and Practice ◽

10.5430/jnep.v9n9p98 ◽

2019 ◽

Vol 9 (9) ◽

pp. 98 ◽

Cited By ~ 1

Author(s):

Kisokanth G. ◽

Indrakumar J. ◽

Prathapan S. ◽

Joseph J. ◽

Ilankoon I.M.P.S.

Keyword(s):

Diabetes Mellitus ◽

Glycemic Control ◽

Management Education ◽

Self Management ◽

Rank Test ◽

Diabetic Patients ◽

Effective Measure ◽

Before And After ◽

Patients With Diabetes ◽

Preliminary Study

This study was aimed to assess the effectiveness of diabetes self-management education (DSME) in the improvement of glycemic control among patients with type 2 Diabetes Mellitus (T2DM) in Batticaloa District, Sri Lanka. The study was a prospective interventional study and conducted as a preliminary study at medical clinic, Base hospital, Kaluwanchikudy, Batticaloa. Thirty patients with T2DM were included based on inclusion and exclusion criteria. A structured individual diabetes self-management education for 10 hours (one hour per week) was delivered to diabetic patients by the trained Nurse Health Educator. Glycosylate hemoglobin (HbA1c) was assessed as a main outcome measure and Fasting Blood Sugar (FBS), Body Mass Index (BMI) of each patient were also measured and recorded before and after the intervention. The respondent rate was 96.7% (n = 29). Majority of them were females (n = 25, 86.2%). A Wilcoxon signed rank test showed that DSME had a statistically significant reduction in HbA1c [8.60 (IQR 2.60) vs. 7.40 (IQR 2.10), p = .000] and FBS level [159.00 (IQR 77.50) vs. 134.00 (IQR 40.50), p = .002] at 3 months of intervention. The mean BMI at baseline was higher compared to 3 months of intervention [24.88 (SD ± 3.06) vs. 24.19 (SD ± 2.79)] which was statistically significant (p = .000). Majority of participants (n = 22, 75.9%) had improved their HbA1c level by ≥ 0.5% in 3 months. The diabetes self-management education is an effective measure in improving glycemic control and other clinical parameters among patients with T2DM. Thus, DSME needs to be implemented among clinic patients with T2DM for the better outcome and the preventions of complications.

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Trastuzumab-Induced Cardiotoxicity: Clinical and Prognostic Implications of Troponin I Evaluation

Journal of Clinical Oncology ◽

10.1200/jco.2009.27.3615 ◽

2010 ◽

Vol 28 (25) ◽

pp. 3910-3916 ◽

Cited By ~ 385

Author(s):

Daniela Cardinale ◽

Alessandro Colombo ◽

Rosalba Torrisi ◽

Maria T. Sandri ◽

Maurizio Civelli ◽

...

Keyword(s):

At Risk ◽

Cardiac Dysfunction ◽

Troponin I ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Ventricular Ejection Fraction ◽

Trastuzumab Therapy ◽

Before And After ◽

Patients At Risk ◽

Prognostic Implications

Purpose Treatment of breast cancer with trastuzumab is complicated by cardiotoxicity in up to 34% of the patients. In most patients, trastuzumab-induced cardiotoxicity (TIC) is reversible: left ventricular ejection fraction (LVEF) improves after trastuzumab withdrawal and with, or sometimes without, initiation of heart failure (HF) therapy. The reversibility of TIC, however, is not foreseeable, and identification of patients at risk and of those who will not recover from cardiac dysfunction is crucial. The usefulness of troponin I (TNI) in the identification of patients at risk for TIC and in the prediction of LVEF recovery has never been investigated. Patients and Methods In total, 251 women were enrolled. TNI was measured before and after each trastuzumab cycle. LVEF was evaluated at baseline, every 3 months during trastuzumab therapy, and every 6 months afterward. In case of TIC, trastuzumab was discontinued, and HF treatment with enalapril and carvedilol was initiated. TIC was defined as LVEF decrease of > 10 units and below 50%. Recovery from TIC was defined as LVEF increase above 50%. Results TIC occurred in 42 patients (17%) and was more frequent in patients with TNI elevation (TNI+; 62% v 5%; P < .001). Twenty-five patients (60%) recovered from TIC. LVEF recovery occurred less frequently in TNI+ patients (35% v 100%; P < .001). At multivariate analysis, TNI+ was the only independent predictor of TIC (hazard ratio [HR], 22.9; 95% CI, 11.6 to 45.5; P < .001) and of lack of LVEF recovery (HR, 2.88; 95% CI,1.78 to 4.65; P < .001). Conclusion TNI+ identifies trastuzumab-treated patients who are at risk for cardiotoxicity and are unlikely to recover from cardiac dysfunction despite HF therapy.

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Guidelines for the Management of Pediatric and Adult Tumor Lysis Syndrome: An Evidence-Based Review

Journal of Clinical Oncology ◽

10.1200/jco.2007.15.0177 ◽

2008 ◽

Vol 26 (16) ◽

pp. 2767-2778 ◽

Cited By ~ 406

Author(s):

Bertrand Coiffier ◽

Arnold Altman ◽

Ching-Hon Pui ◽

Anas Younes ◽

Mitchell S. Cairo

Keyword(s):

At Risk ◽

High Risk ◽

Tumor Lysis Syndrome ◽

The United States ◽

Standards Of Care ◽

Close Monitoring ◽

Tumor Lysis ◽

High Risk Patients ◽

Patients At Risk ◽

Risk Patients

PurposeTumor lysis syndrome (TLS) has recently been subclassified into either laboratory TLS or clinical TLS, and a grading system has been established. Standardized guidelines, however, are needed to aid in the stratification of patients according to risk and to establish prophylaxis and treatment recommendations for patients at risk or with established TLS.MethodsA panel of experts in pediatric and adult hematologic malignancies and TLS was assembled to develop recommendations and guidelines for TLS based on clinical evidence and standards of care. A review of relevant literature was also used.ResultsNew guidelines are presented regarding the prevention and management of patients at risk of developing TLS. The best management of TLS is prevention. Prevention strategies include hydration and prophylactic rasburicase in high-risk patients, hydration plus allopurinol or rasburicase for intermediate-risk patients, and close monitoring for low-risk patients. Primary management of established TLS involves similar recommendations, with the addition of aggressive hydration and diuresis, plus allopurinol or rasburicase for hyperuricemia. Alkalinization is not recommended. Although guidelines for rasburicase use in adults are provided, this agent is currently only approved for use in pediatric patients in the United States.ConclusionThe potential severity of complications resulting from TLS requires measures for prevention in high-risk patients and prompts treatment in the event that symptoms arise. Recognition of risk factors, monitoring of at-risk patients, and appropriate interventions are the key to preventing or managing TLS. These guidelines should assist in the prevention of TLS and improve the management of patients with established TLS.

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Atenolol before and after non-cardiac surgery reduced mortality and cardiovascular morbidity in patients at risk of acute coronary events

Evidence-based Cardiovascular Medicine ◽

10.1016/s1361-2611(97)80047-4 ◽

1997 ◽

Vol 1 (2) ◽

pp. 55-56

Author(s):

Valerie A. Palda ◽

Allan S. Detsky

Keyword(s):

At Risk ◽

Cardiac Surgery ◽

Cardiovascular Morbidity ◽

Before And After ◽

Patients At Risk ◽

Coronary Events

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Identifying patients at risk of futile resuscitation: palliative care indicators in out-of-hospital cardiac arrest

BMJ Supportive & Palliative Care ◽

10.1136/bmjspcare-2019-001828 ◽

2019 ◽

pp. bmjspcare-2019-001828

Author(s):

Mia Cokljat ◽

Adam Lloyd ◽

Scott Clarke ◽

Anna Crawford ◽

Gareth Clegg

Keyword(s):

At Risk ◽

Palliative Care ◽

Cardiac Arrest ◽

High Risk ◽

Low Risk ◽

Intermediate Risk ◽

Patients At Risk ◽

Risk Patients ◽

Record Review ◽

Hospital Cardiac Arrest

ObjectivesPatients with indicators for palliative care, such as those with advanced life-limiting conditions, are at risk of futile cardiopulmonary resuscitation (CPR) if they suffer out-of-hospital cardiac arrest (OHCA). Patients at risk of futile CPR could benefit from anticipatory care planning (ACP); however, the proportion of OHCA patients with indicators for palliative care is unknown. This study quantifies the extent of palliative care indicators and risk of CPR futility in OHCA patients.MethodsA retrospective medical record review was performed on all OHCA patients presenting to an emergency department (ED) in Edinburgh, Scotland in 2015. The risk of CPR futility was stratified using the Supportive and Palliative Care Indicators Tool. Patients with 0–2 indicators had a ‘low risk’ of futile CPR; 3–4 indicators had an ‘intermediate risk’; 5+ indicators had a ‘high risk’.ResultsOf the 283 OHCA patients, 12.4% (35) had a high risk of futile CPR, while 16.3% (46) had an intermediate risk and 71.4% (202) had a low risk. 84.0% (68) of intermediate-to-high risk patients were pronounced dead in the ED or ED step-down ward; only 2.5% (2) of these patients survived to discharge.ConclusionsUp to 30% of OHCA patients are being subjected to advanced resuscitation despite having at least three indicators for palliative care. More than 80% of patients with an intermediate-to-high risk of CPR futility are dying soon after conveyance to hospital, suggesting that ACP can benefit some OHCA patients. This study recommends optimising emergency treatment planning to help reduce inappropriate CPR attempts.

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Periodontal Disease, Inflammatory Cytokines, and PGE2 in Pregnant Patients at Risk of Preterm Delivery: A Pilot Study

Infectious Diseases in Obstetrics and Gynecology ◽

10.1155/2018/7027683 ◽

2018 ◽

Vol 2018 ◽

pp. 1-7 ◽

Cited By ~ 3

Author(s):

Catalina Latorre Uriza ◽

Juliana Velosa-Porras ◽

Nelly S. Roa ◽

Stephani Margarita Quiñones Lara ◽

Jaime Silva ◽

...

Keyword(s):

At Risk ◽

Pilot Study ◽

High Risk ◽

Periodontal Disease ◽

Preterm Delivery ◽

Inflammatory Cytokines ◽

Inflammatory Responses ◽

Low Risk ◽

Prostaglandin E ◽

Patients At Risk

Periodontal disease is an infection that, in pregnant women, can act as a risk factor for preterm delivery by increasing local and systemic inflammatory responses. Objective. To analyze the presence of periodontal disease, proinflammatory cytokines, and prostaglandin E2 (PGE2) in pregnant patients at high risk for preterm delivery. Materials and Methods. Pilot study for a case-control study. We included 46 pregnant patients (23 patients at risk of preterm delivery as cases and 23 patients without risk of preterm delivery as controls). We excluded patients who received periodontal treatment, antibiotics, or antimicrobials over the last 3 months as well as those with infections or diseases such as diabetes or hypercholesterolemia. The patients underwent a periodontal assessment, and their levels of cytokines (interleukin- [IL-] 2, IL-6, IL-10, and tumor necrosis factor- [TNF-] α) and prostaglandin E2 (PGE2) were quantified. Results. Patients with periodontal disease showed higher levels of cytokines (IL-2, IL-6, IL-10, and TNF-α) and PGE2. Patients at high risk for preterm birth showed higher IL levels compared with patients at low risk for preterm delivery. PGE2 increased with the severity of periodontal disease. PGE2 was higher in patients at low risk for preterm delivery, although this difference was not significant. Conclusion. Periodontal disease can increase the systemic inflammatory response as well as the levels of PGE2 and inflammatory cytokines in pregnant patients.

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Increased Mac-2 binding protein glycan isomer in patients at risk for late nonrelapse mortality after HSCT

Blood Advances ◽

10.1182/bloodadvances.2019000629 ◽

2019 ◽

Vol 3 (21) ◽

pp. 3287-3296

Author(s):

Yu Akahoshi ◽

Hideki Nakasone ◽

Koji Kawamura ◽

Machiko Kusuda ◽

Shunto Kawamura ◽

...

Keyword(s):

At Risk ◽

High Risk ◽

Graft Versus Host Disease ◽

Binding Protein ◽

Liver Graft ◽

Host Disease ◽

Allogeneic Hsct ◽

Graft Versus Host ◽

Key Points ◽

Patients At Risk

Key Points M2BPGi is increased in patients with liver graft-versus-host disease, especially in those at high risk for late NRM after allogeneic HSCT. WFA+-M2BP–positive macrophages are found in liver graft-versus-host disease, supporting these cells as a responder of this glycoprotein.

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