Hyperglycaemia in COVID-19: improving recognition and management in a single centre

Background: Hyperglycaemia is a recognised complication of COVID-19 disease and is associated with increased morbidity and mortality. Effects are noted in individuals with and without diabetes and potentiated by the use of recognised COVID-19 treatments such as corticosteroids. Early glycaemic control in the inpatient with COVID-19 disease impacts significantly on outcomes. Methods: A three-phase improvement project evaluated the recognition and management of hyperglycaemia in 120 adult inpatients with COVID-19 disease over a 4-month period. A local guideline and a separate acute care ‘bundle’ were implemented to improve performance. The main outcomes of the project were evaluated in a repeated cross- sectional design; assessing the performance of regular capillary blood glucose monitoring and appropriate treatment of hyperglycaemia where indicated. Results: Prior to intervention, 78.6% of patients had appropriate capillary blood glucose monitoring and no patients were deemed to receive appropriate treatment. Following interventions, 83–100% of patients had appropriate monitoring and 75–100% received appropriate treatment. Conclusions: In this setting, implementation of a guideline and a care bundle contributed towards improved recognition and management of hyperglycaemia in patients with COVID-19 disease. Future study could assess the impact of interventions on a larger scale whilst investigating variation in the subtype of diabetes, patient sex and other demographics on outcomes such as length of stay, morbidity and mortality.

The Efficacy of Follow-up Phone Calls for Capillary Blood Glucose Lowering in Diabetic Patients in Primary Care Unit

Objective: To study the effect of telephone call intervention on glycemic control in diabetic patients for 2 monthsMaterials and Methods: The quasi-experimental research included 130 Patients from January 2020 to March 2020 in primary care. The 115 patients were divided into 2 groups through a simple randomization process, 61 in experimental group and 54 in control group after exclusion. 115 Patients will be tested for Capillary blood glucose (CBG) level at a period of 0-month, 1-month and 2-months. CBG level were presented in mean ± SD, mean difference ± SD and analyzed by Independent t-test and Paired t-test.Results: The phone call intervention can lower CBG level compared to the control group. Mean difference of CBG between 0 month and 2 months follow-up in phone calls group vs control group (-6.80 ± 4.86 vs -2.96 ± 4.82 mg/dL) and mean difference CBG level between 1 month and 2 months follow-up in phone calls group vs control group (-5.77 ± 4.09 vs -4.22 ± 5.10 mg/dL) but had no significant difference (p >0.05)Conclusion: The follow-up phone calls can lower CBG level in the experimental group more than the control group, but there is no significant difference.

Good Metabolic Control in Children with Type 1 Diabetes Mellitus: Does Glycated Hemoglobin Correlate with Interstitial Glucose Monitoring Using FreeStyle Libre?

Background: Good metabolic control of Type 1 diabetes (T1D) leads to a reduction in complications. The only validated parameter for establishing the degree of control is glycated hemoglobin (HbA1c). We examined the relationship between HbA1c and a continuous glucose monitoring (CGM) system. Materials and methods: A cohort prospective study with 191 pediatric patients with T1D was conducted. Time in range (TIR), time below range (TBR), coefficient of variation (CV), number of capillary blood glucose tests, and HbA1c before sensor insertion and at one year of use were collected. Results: Patients were classified into five groups according to HbA1c at one year of using CGM. They performed fewer capillary blood glucose test at one year using CGM (−6 +/− 2, p < 0.0001). We found statistically significant differences in TIR between categories. Although groups with HbA1c < 6.5% and HbA1c 6.5–7% had the highest TIR (62.214 and 50.462%), their values were highly below optimal control according to CGM consensus. Groups with TBR < 5% were those with HbA1c between 6.5% and 8%. Conclusions: In our study, groups classified as well-controlled by guidelines were not consistent with good control according to the CGM consensus criteria. HbA1c should not be considered as the only parameter for metabolic control. CGM parameters allow individualized targets.

Safe threshold of capillary blood glucose for predicting early future neonatal hypoglycaemia in babies born to mothers with gestational diabetes mellitus, an observational, retrospective cohort study

Background There is increasing pressure to get women and babies home rapidly after birth. Babies born to mothers with gestational diabetes mellitus (GDM) currently get 24-h inpatient monitoring. We investigated whether a low-risk group of babies born to mothers with GDM could be defined for shorter inpatient hypoglycaemia monitoring. Methods Observational, retrospective cohort study conducted in a tertiary maternity hospital in 2018. Singleton, term babies born to women with GDM and no other risk factors for hypoglycaemia, were included. Capillary blood glucose (BG) testing and clinical observations for signs of hypoglycaemia during the first 24-h after birth. BG was checked in all babies before the second feed. Subsequent testing occurred if the first result was < 2.0 mmol/L, or clinical suspicion developed for hypoglycaemia. Neonatal hypoglycaemia, defined as either capillary or venous glucose ≤ 2.0 mmol/L and/or clinical signs of neonatal hypoglycaemia requiring oral or intravenous dextrose (lethargy, abnormal feeding behaviour or seizures). Results Fifteen of 106 babies developed hypoglycaemia within the first 24-h. Maternal and neonatal characteristics were not predictive. All babies with hypoglycaemia had an initial capillary BG ≤ 2.6 mmol/L (Area under the ROC curve (AUC) 0.96, 95% Confidence Interval (CI) 0.91–1.0). This result was validated on a further 65 babies, of whom 10 developed hypoglycaemia, in the first 24-h of life. Conclusion Using the 2.6 mmol/L threshold, extended monitoring as an inpatient could have been avoided for 60% of babies in this study. Whilst prospective validation is needed, this approach could help tailor postnatal care plans for babies born to mothers with GDM.

INTRAOPERATIVE GLUCOSE LEVELIN NON-DIABETIC PATIENT UNDERGOING ELECTIVE MAJOR SURGERY UNDER GENERALANAESTHESIA RECEIVING DIFFERENT CRYSTALLOID SOLUTIONS AS MAINTENANCE FLUID (A COMPARISON BETWEEN NS AND RL)

INTRODUCTION: The present study was undertaken to observe the effect of different maintenance uid regimen on intraoperative blood glucose levels in non-diabetic patients undergoing elective major surgery under general anesthesia. AIMS AND OBJECTIVES: This study was conducted to observe the effect of different maintenance uids in intraoperative blood glucose levels of non-diabetic patients undergoing elective major non-cardiac surgery under general anesthesia. MATERIALS AND METHODS: The present study was conducted in the Department of Anesthesiology of Assam Medical College, Dibrugarh for a period of one year. Hospital based observational study. Patients undergoing elective major surgeries at operation theatres of Department of General Surgery of Assam Medical College & Hospital, Dibrugarh. One (1) year from July 2015 to June 2016. RESULT: The mean difference of capillary blood glucose level between baseline and 1.5 hours after intubation for those procedures lasted that long in Group N was 22.87 mg/dl with a 95% condence interval of 103.83-108.61 while in Group R it was 26.82 mg/dl with a 95% condence interval of 108.41-111.59. The mean difference of capillary blood glucose level between baseline and 2 hours after intubation for those procedures lasted that long in Group N was 34.14 mg/dl with a 95% condence interval of 117.29–117.71 while in Group R it was 34.07 with a 95% condence interval of 116.38–118.12. CONCLUSION: This study we can come to a conclusion that though there is a rising trend in change in intraoperative capillary blood glucose level in both the solutions used perioperatively, yet the mean change in intraoperative capillary blood glucose level in non-diabetic patients undergoing major surgeries under general anaesthesia receiving either 0.9% sodium chloride or Ringer's lactate solutions as maintenance uid perioperatively, is comparable, yet needs larger groups of study

Hypoglycemia Caused by Endogenous Hyperinsulinism: A Case Study

Hypoglycemia in the absence of diabetes mellitus in a healthy individual needs’ evaluation. We report a case of 45 years old female who presented with restlessness, anxiety, palpitations, excessive sweating followed by dizziness, and tremors in her hand. Eating sugar or consuming glucose water alleviated symptoms. During one such episode, the patient was taken to a nearby clinic and her capillary blood glucose was 43 mg/dl. The patient was admitted for the 72 hours supervised fast after ruling out other systemic causes of hypoglycemia. Evaluation of critical sample showed elevated levels of insulin, c-peptide, proinsulin, as well as a decreased value of beta-hydroxybutyrate and a negative urine screen for oral anti-diabetic agents, a diagnosis of endogenous hyperinsulinism, was made.

Self-care of users with diabetes mellitus entered into a program of capillary blood glucose self-monitoring / Autocuidado de usuários com diabetes mellitus inseridos em um programa de automonitorização da glicemia capilar

Objetivo: Avaliar o desempenho das atividades de autocuidado de usuários com diabetes mellitus inseridos em um programa de automonitorização da glicemia capilar no domicílio. Método: Estudo transversal, descritivo, com abordagem quantitativa, realizado no domicílio de usuários com diabetes mellitus que realizam a automonitorização da glicemia capilar, totalizando uma amostra de 279 usuários. Na avaliação das atividades de autocuidado utilizou-se o Questionário de Atividades de Autocuidado com o Diabetes, e para coleta dos dados sociodemográficos e clínico foi aplicado um roteiro sistematizado. Resultados: Os dados revelaram que as dimensões alimentação específica, atividade física e monitorização glicêmica demostra comportamento de autocuidado não desejável, enquanto adesão medicamentosa apresentou o melhor comportamento de autocuidado desejável. Conclusão: Os usuários com diabetes mellitus que realizam a automonitorização da glicemia capilar no domicílio necessitam de um acompanhamento específico, acrescido de práticas educativas contínuas que estimulem a participação efetiva nas atividades de autocuidado.

A Case of Non-Islet Cell Tumor Hypoglycemia in Metastatic Solitary Fibrous Tumor

Introduction: Insulin like growth factor (IGF-2) mediated hypoglycemia secondary to solitary fibrous tumor (SFT), also known as Doege-Potter syndrome is a rare paraneoplastic syndrome. The tumor cells produce large amounts of high molecular weight IGF 2 precursor protein called “big IGF-2” which binds to insulin and IGF receptors in liver, muscle and other peripheral tissues. This causes reduced gluconeogenesis and increased uptake of glucose by the muscle and other tissues leading to hypoglycemia. Big IGF-2 also exerts central negative feedback of growth hormone causing reduction of IGF-I production. Most SFTs are benign and localized (approximately 78-88%). As a result, tumor excision alone would often lead to resolution of the hypoglycemia. We present a case of metastatic SFT with multiple metastasis managed with oral prednisone. Clinical Case: A 44-year-old man with metastatic SFT presented with bilateral humeral fractures. He has known metastatic disease to the brain, lung, liver, bony lytic lesions over a course of eleven years. It has progressed despite multiple chemotherapy and radiation therapies. Prior to admission, he had multiple syncopal episodes associated with fasting hypoglycemia. He reported capillary blood glucose values ranging between 30-50 mg/dl during these episodes which would improve after drinking juice or eating candy. There was no history of diabetes mellitus or use of oral hypoglycemic agents or insulin. On admission, he had a capillary blood glucose value of less than 20 mg/dl, which was confirmed by a serum glucose value of 18 mg/dl on basic metabolic panel. His renal, liver and thyroid function tests were normal. Significant labs include: serum glucose 17 mg/dl, C-peptide &lt;0.10 ng/ml (n: 1-4 ng/ml), serum insulin &lt;1.6 Uu/ml (n: &lt;20 Uu/ml), beta-hydroxybutyrate &lt;0.2 mmol/L (n: &lt;0.3), cortisol 10.8 ug/dl(n: 5-15 ug/dl) glucagon 6 pg/ml(ref 8-57 pg/ml), insulin-like growth factor-1 (IGF 1) 20 ng/ml (n: 52-328), and IGF-2 level 380 ng/ml (267-616 ng/ml), improvement in blood glucose from 46 to 111 mg/dl after 1-gram glucagon administration. The IGF-2/IGF-1 ratio of 19 confirmed our clinical suspicion of non-islet cell tumor hypoglycemia (NICTH). He was started on prednisone 20 mg twice daily with marked improvement in hypoglycemia. Conclusion: NICTH is a rare cause of hypoglycemia and should be considered in the differential while evaluating hypoglycemia in malignancy. For diagnosing NICTH, assays for big IGF-II are not commercially available. However, the IGF-II:IGF-I ratio is considered to be a surrogate marker of big IGFII concentration. The normal ratio is 3 and ratio &gt;10 is diagnostic of NICTH. In cases like ours where tumor resection is not possible, glucocorticoids are most effective in management of hypoglycemia by inhibiting big IGF2 production and stimulating gluconeogenesis.