Predictive Factors of the Adherence to Real-Time Continuous Glucose Monitoring Sensors: A Prospective Observational Study (PARCS STUDY)

Background:Information about factors related to better adherence to continuous glucose monitoring (CGM) sensor adherence is quite limited.Materials and Methods:Forty-six participants with type 1 diabetes using continuous subcutaneous insulin infusion (CSII) without CGM were recruited. The participants’ characteristics and diabetes-related quality of life (QOL) were evaluated at baseline and one year after starting to use CGM. Participants wearing the sensor for ≥60% of the time were considered as adherent.Results:The mean age of the 46 participants was 44.1 ± 15.0 years old and the mean glycohemoglobin (HbA1c) was 7.7 ± 1.0%; 60.9% of the participants were classified as adherent. The duration of using CSII was longer in the adherent group, and the degree of diabetic retinopathy was significantly different. There were no significant differences in age, frequency of self-monitoring of blood glucose, or Hypoglycemia Fear Survey (HFS-B for behavior, HFS-W for worry) score at baseline between the adherent and nonadherent groups. The Problem Areas in Diabetes (PAID) score at baseline was significantly higher and the total CSII-QOL score at baseline was significantly lower in the adherent group. The usage of dual-wave bolus was significantly increased in the adherent group (34.6%-61.5%, P = .016), but not in the nonadherent group (33.3%-33.3%, P > .999). The HbA1c level showed a significant improvement in the adherent group (7.8%-7.3%, P < .001), but not in the nonadherent group (7.5%-7.2%, P = .102).Conclusions:Higher adherence to CGM sensors may be associated with a heavier emotional burden of diabetes and a worse QOL in relation to CSII at baseline.     

Racial Disparities in Diabetes Technology Use and Outcomes in Type 1 Diabetes in a Safety-Net Hospital

Background:Limited data exist regarding diabetes technology use among adults with type 1 diabetes (T1D) in urban racially/ethnically diverse safety-net hospitals. We examined racial/ethnic differences in the use of continuous glucose monitor (CGM) and continuous subcutaneous insulin infusion (CSII) in this setting.Methods:A retrospective review of 227 patients ≥ 18 years of age with T1D seen in an urban, safety-net endocrinology clinic during 2016-2017 was completed (mean age: 39; 80% English-speaking; 50% had public insurance). Diabetes technology use, defined as either CGM or CSII or both CGM and CSII, and clinical outcomes were examined by race/ethnicity.Results:Overall, 30% used CGM and 26% used CSII. After adjusting for age, language, insurance, and annual income, diabetes technology use in non-White patients was significantly lower than in White patients, predominantly lower in Black (aOR 0.25 [95% CI 0.11-0.56]) and patients identified as other race/ethnicity (aOR 0.30 [95% CI 0.11-0.77]). At the highest household income level (≥$75,000/y), Black and Hispanic individuals were significantly less likely than White individuals to use diabetes technology (P < .0007). Mean hemoglobin A1c (HbA1c) was lower in patients using any diabetes technology compared with patients using no technology (P < .0001). Use of CGM and CSII together was associated with the lowest HbA1c across all racial/ethnic groups.Conclusions:Racial/ethnic disparities in diabetes technology use and glycemic control were observed even after adjusting for sociodemographic factors. Further research should explore barriers to accessing diabetes technology in non-White populations.     

Pregnancy outcome and glycemic control in women with type 1 diabetes: A retrospective comparison between CSII and MDI treatment

AimPresent study was aimed to evaluate glycemic control and maternal–fetal outcome in pregnant type 1 diabetic patient treated with continuous subcutaneous insulin infusion (CSII) or multiple daily injections of insulin (MDI).Patients and methodsA retrospective observational study included thirty-four pregnant type 1 diabetic patients. Patients were divided into two group, CSII treated group (n = 14) and MDI treated group (n = 20). The HbA1c level and maternal–fetal outcome were evaluated in both the treatment group. Outcome parameters such as glycemic control (HbA1c), hypoglycemic events, time and mode of delivery and labor results (abortion, premature labor, perinatal mortality, neonatal weight, Apgar score, neonatal hypoglycaemia, presence of congenital abnormalities) were analyzed.ResultsPregnancy outcome and glycemic control in pregnant type 1 diabetic patients treated with CSII and MDI were evaluated and compared. Two groups were compared for their epidemiological parameters, although patients on CSII treatment had longer duration of diabetes compared to MDI treated group. Reduction in HbA1c level was higher in CSII treated patients at first (CSII: 0.9% vs MDI: 0.46%), second (CSII: 1.58% vs MDI: 0.78%) and third trimester (CSII: 1.74% vs MDI: 1.09%) of pregnancy compared to MDI treated patients. Duration of pregnancy and new born baby weight were founded similar in both group. Moreover, the rate of abortion, preterm labor, cesarean section and hypoglycemia in new born were founded less in CSII treated group compared to MDI treated group and Apgar score was significantly (p < 0.05) higher in CSII treated group compared to MDI treated group.ConclusionResults of present study revealed that the CSII gives better glycemic control and pregnancy outcome in pregnant type 1 diabetic patients compared to MDI treatment. CSII also decreases the daily insulin requirement compared MDI.     

Patient Controlled,Off-label Use of Continuous Glucose Monitoring: Real-World Medical Costs and Effects of Patient Controlled Sensor Augmented Pump Therapy in Adult Patients Type 1 Diabetes

Background:Continuous glucose monitoring (CGM) has shown promise to reduce glycated hemoglobin (HbA1c) levels, but its cost-effectiveness is seen as uncertain by reimbursement agencies. The aim of this study was to explore the impact of real-world, off-label, patient controlled CGM use in combination with continuous subcutaneous insulin infusion (CSII) on costs and effects in patients with type 1 diabetes in a Swedish clinic.Methods:A real-world, retrospective study with questionnaire on CGM use by adult patients with type 1 diabetes on CSII (Animas Vibe) were offered sensor augmented pump therapy (SAPT) (Dexcom G4) as part of hospital innovation funding program. Direct medical costs, HbA1c, and complications following switch from CSII with self-monitoring of blood glucose (SMBG) to SAPT were calculated.Results:Questionnaire data showed that CGM sensors were on average used 92% of the time for 22 days. One hundred and thirty-nine (95%) of 146 respondents used each sensor for longer than one week. Data analysis showed a statistically significant HbA1c decrease of 0.56% (6.1 mmol/mol) after change to SAPT. In patients using the sensor 100%, the decrease was 0.89% (9.8 mmol/mol). The analysis showed that SAPT led to higher costs (5500 USD/year) than CSII + SMBG (3680 USD/year), with incremental costs being 1815 USD per year to achieve an HbA1c decrease of 0.56% (6.1 mmol/mol). The incidence of all complications declined after switch to SAPT.Conclusion:The primary data analysis showed a decrease in HbA1c values following switch to SAPT, corresponding to previous cost-effectiveness studies, but at substantially lower costs due to longer sensor off-label use.     

Overweight and obese children with optimal control in the T1D Exchange Registry: How are they different from lean children with optimal control?

AimsIncreased adiposity is a risk factor for suboptimal diabetes control and cardiovascular disease (CVD) complications.Our goal was to identify modifiable behavioral characteristics of overweight and obese pediatric patients with type 1 diabetes mellitus (T1DM) who achieve optimal glycemic control and to evaluate their CVD risk compared to lean patients. Our hypothesis was that optimally controlled obese and overweight participants require more total daily insulin and are at higher CVD risk compared to optimally controlled lean participants.MethodsWe analyzed a cohort of 9263 participants with T1DM aged <21 years in the T1D Exchange Registry. Optimal diabetes control was defined as HbA1c ≤ 7.5% (58 mmol/mol). We compared factors that influence glycemic control in lean, overweight and obese participants with optimal vs. suboptimal control, using logistic regression.ResultsAge, race, overweight status, continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring (CGM) use were important variables influencing glycemic control. In the optimally controlled cohort, 27% of participants were overweight or obese versus 30% in the suboptimally controlled cohort (P < 0.001). Overweight and obese participants with optimal control were not significantly different from lean participants in terms of CSII use, total daily insulin dosage per kg of bodyweight, glucose checks per day, boluses with bedtime snack, use of CGM, but had higher LDL cholesterol and triglycerides, and lower HDL cholesterol (P < 0.05).ConclusionsThere were no differences in modifiable behavioral characteristics between the obese, overweight and lean optimally controlled participants. However, predictors of cardiovascular disease were higher in the overweight and obese group.     

Predictive Low Glucose Suspend Algorithm in Real Life: A Five-Year Follow-Up Retrospective Analysis

Aim:Sensor-augmented pumps with predictive low glucose suspend function (PLGS-SAP) help patients avoid hypoglycemia and improve quality of life: in this retrospective study, we investigated long-term effects of PLGS-SAP on metabolic outcomes, acute and chronic diabetic complications, in particular cardiovascular events.Materials and Methods:One hundred thirty-nine adults with type 1 diabetes (T1D) treated for more than 10 years with continuous subcutaneous insulin infusion (CSII) were followed for 5 years; 71 (Group 1) started to use PLGS-SAP, and 68 (Group 2) maintained on their non-PLGM insulin pump. Glucose control measures (hemoglobin A1c [HbA1c], acute diabetic complications), clinical outcomes (body mass index [BMI], arterial hypertension, dyslipidemia), chronic diabetes-related complications, and device utilization (continuous glucose monitoring utilization, use of temporary basal rates or special boluses, carbohydrate counting usage) were assessed.Results:The reduction of HbA1c was significant in Group 1 (from 7.5% ± 1.1% to 7.0% ± 1.0%, P = .02), while in Group 2 it did not reach statistical significance (from 7.5% ± 1.1% to 7.4% ± 0.9%, P = .853). BMI increased significantly in Group 2 (from 25.3 ± 2.8 to 25.7 ± 3.4, P < .001), but not in Group 1 (from 25.2 ± 3.5 to 25.2 ± 2.8, P = .887). There were no statistically significant differences in occurrence of acute diabetes complications, other clinical outcomes, prevalence of diabetes-related complications, or device utilization between the groups.Conclusions:In our five-year follow-up experience with T1D CSII users, PLGS-SAP has resulted efficient in improving metabolic control and maintaining the body weight.     

Diabetes Management According to Health Status in Older Adults with Type 2 Diabetes Staying in Geriatric Care Facilities

Background:About 25% of adults >70 years suffer from type 2 diabetes. Due to the heterogeneity of the geriatric population, guidelines emphasize the need to individualize glycemic goals and simplify treatment strategies with the main focus of avoiding hypoglycemia. The aim of this study was to assess glycemic control in patients with type 2 diabetes in geriatric care facilities based on their individual health status.Methods:170 medical records of older adults with type 2 diabetes in geriatric care facilities were retrospectively assessed (64.7% female, age 80 ± 9 years; glycated hemoglobin 6.8% ± 3.6% [51 ± 16 mmol/mol]; body mass index 27.9 ± 5.8 kg/m²). Based on the individual health status, patients were allocated to three groups (healthy n = 27, complex n = 86, and poor n = 57).Results:The overall blood glucose (BG) value was highest in the poor health group with 188 ± 47 mg/dL (poor) vs 167 ± 42 mg/dL (complex) vs 150 ± 34 mg/dL (healthy). BG values of 1.6% (poor) vs 2.8% (complex) vs 1.5% (healthy) of patients were below 90 mg/dL. 36.8% (poor) vs 23.4% (complex) vs 18.5% (healthy) of patients received insulin as the main diabetes therapy, but of these only 14.3% (poor) vs 20% (complex) vs 40% (healthy) were treated with basal insulin.Conclusions:Overall, BG values were higher in the poor and complex health group. There were a few low BG values in all groups. Although recommended by international guidelines, basal insulin therapy with its low complexity and low hypoglycemic risk is still underused, especially in the poor health group. Therefore, simplification of diabetes therapy should be considered further.     

A Pilot Study of Flat and Circadian Insulin Infusion Rates in Continuous Subcutaneous Insulin Infusion (CSII) in Adults with Type 1 Diabetes (FIRST1D)

Background:Initiation of continuous subcutaneous insulin therapy (CSII) in type 1 diabetes requires conversion of a basal insulin dose into a continuous infusion regimen. There are limited data to guide the optimal insulin profile to rapidly achieve target glucose and minimize healthcare professional input. The aim of this pilot study was to compare circadian and flat insulin infusion rates in CSII naïve adults with type 1 diabetes.Methods:Adults with type 1 diabetes commencing CSII were recruited. Participants were randomized to circadian or flat basal profile calculated from the total daily dose. Basal rate testing was undertaken on days 7, 14 and 28 and basal rates were adjusted. The primary outcome was the between-group difference in absolute change in insulin basal rate over 24 hours following three rounds of basal testing. Secondary outcomes included the number of basal rate changes and the time blocks.Results:Seventeen participants (mean age 33.3 (SD 8.6) years) were recruited. There was no significant difference in absolute change in insulin basal rates between groups (P = .85). The circadian group experienced significant variation in the number of changes made with the most changes in the morning and evening (P = .005). The circadian group received a greater reduction in total insulin (−14.1 (interquartile range (IQR) −22.5-12.95) units) than the flat group (−7.48 (IQR −11.90-1.23) units) (P = .021).Conclusion:The initial insulin profile does not impact on the magnitude of basal rate changes during optimization. The circadian profile requires changes at specific time points. Further development of the circadian profile may be the optimal strategy.     

Pediatric Medicaid Patients With Type 1 Diabetes Benefit From Continuous Glucose Monitor Technology

Background:We determined the uptake rate of continuous glucose monitors (CGMs) and examined associations of clinical and demographic characteristics with CGM use among patients with type 1 diabetes covered by Colorado Medicaid during the first two years of CGM coverage with no out-of-pocket cost.Method:We retrospectively reviewed data from 892 patients with type 1 diabetes insured by Colorado Medicaid (Colorado Health Program [CHP] and CHP+, Colorado Medicaid expansion). Demographics, insulin pump usage, CGM usage, and hemoglobin A1c (A1c) were extracted from the medical record. Data downloaded into CGM software at clinic appointments were reviewed to determine 30-day use prior to appointments. Subjects with some exposure to CGM were compared to subjects never exposed to CGM, and we examined the effect of CGM use on glycemic control.Results:Twenty percent of subjects had some exposure to CGM with a median of 22 [interquartile range 8, 29] days wear. Sixty one percent of CGM users had >85% sensor wear. Subjects using CGM were more likely to be younger (P < .001), have shorter diabetes duration (P < .001), and be non-Hispanic White (P < .001) than nonusers. After adjusting for age and diabetes duration, combined pump and CGM users had a lower A1c than those using neither technology (P = .006). Lower A1c was associated with greater CGM use (P = .002) and increased percent time in range (P < .001).Conclusion:Pediatric Medicaid patients successfully utilized CGM. Expansion of Medicaid coverage for CGM may help improve glycemic control and lessen disparities in clinical outcomes within this population.     

Electronic Diabetes Management System Replaces Paper Insulin Chart: Improved Quality in Diabetes Inpatient Care Processes Due to Digitalization

Background:GlucoTab, an electronic diabetes management system (eDMS), supports healthcare professionals (HCPs) in inpatient blood glucose (BG) management at point-of-care and was implemented for the first time under routine conditions in a regional hospital to replace the paper insulin chart.Method:To investigate quality of the eDMS for inpatients with type 2 diabetes mellitus a monocentric retrospective before-after evaluation was conducted. We compared documentation possibilities by assessing a blank paper chart vs the eDMS user interface. Further quality aspects were compared by assessing filled-in paper charts (n = 106) vs filled-in eDMS documentation (n = 241). HCPs (n = 59) were interviewed regarding eDMS satisfaction.Results:The eDMS represented an improvement of documentation possibilities by offering a more structured and comprehensive user interface compared to the blank paper chart. The number of good diabetes days averaged to a median value of four days in both groups (paper chart: 4.38 [0-7] vs eDMS: 4.38 [0-7] days). Median daily BG was 170 (117-297) mg/dL vs 168 (86-286) mg/dL and median fasting BG was 152 (95-285) mg/dL vs 145 (69-333) mg/dL, and 0.1% vs 0.4% BG values <54 mg/dL were documented. Diabetes documentation quality improved when using eDMS, for example, documentation of ordered BG measurement frequency (1% vs 100%) and ordered BG targets (0% vs 100%). HCPs stated that by using eDMS errors could be prevented (74%), and digital support of work processes was completed (77%). Time saving was noted by 8 out of 11 HCPs and estimated at 10-15 minutes per patient day by two HCPs.Conclusions:The eDMS completely replaced the paper chart, showed comparable glycemic control, was positively accepted by HCPs, and is suitable for inpatient diabetes management.     

Continuous Glucose Monitoring for the Detection of Hypoglycemia in Patients With Diabetes of the Exocrine Pancreas

Background:Detailed evaluations of hypoglycemia and associated indices based on continuous glucose monitoring (CGM) are limited in patients with diabetes of the exocrine pancreas. Our study sought to evaluate the frequency and pattern of hypoglycemic events and to investigate hypoglycemia-specific indices in this population.Methods:This was a cross-sectional study comprising 83 participants with diabetes of the exocrine pancreas. CGM and self-monitoring of blood glucose (SMBG) were performed on all participants for a minimum period of 72 hours. The frequency and pattern of hypoglycemic events, as well as hypoglycemia-related indices, were evaluated.Results:Hypoglycemia was detected in 90.4% of patients using CGM and 38.5% of patients using SMBG. Nocturnal hypoglycemic events were more frequent (1.9 episodes/patient) and prolonged (142 minutes) compared with day-time events (1.1 episodes/patient; 82.8 minutes, P < 0.05). The mean low blood glucose index was 2.1, and glycemic risk assessment diabetes equation hypoglycemia was 9.1%. The mean time spent below (TSB) <70 mg/dL was 9.2%, and TSB <54 mg/dL was 3.7%. The mean area under curve (AUC) <70 mg/dL was 1.7 ± 2.5 mg/dL/hour and AUC <54 mg/dL was 0.6 ± 1.3 mg/dL/hour. All of the CGM-derived hypoglycemic indices were significantly more deranged at night compared with during the day (P < 0.05).Conclusion:Patients with diabetes of the exocrine pancreas have a high frequency of hypoglycemic episodes that are predominantly nocturnal. CGM is superior to SMBG in the detection of nocturnal and asymptomatic hypoglycemic episodes. CGM-derived hypoglycemic indices are beneficial in estimating the risk of hypoglycemia.     

Prediction of Individual Basal Rate Profiles From Patient Characteristics in Type 1 Diabetes on Insulin Pump Therapy

Background:Basal rate profiles in patients with type 1 diabetes on insulin pump therapy are subject to enormous inter-individual heterogeneity. Tools to predict basal rates based on clinical characteristics may facilitate insulin pump therapy.Methods:Data from 339 consecutive in-patients with adult type 1 diabetes on insulin pump therapy were collected. Basal rate tests were performed over 24 hours. A mathematical algorithm to predict individual basal rate profiles was generated by relating the individual insulin demand to selected clinical characteristics in an exploratory cohort of 170 patients. The predicted insulin pump profiles were validated in a confirmatory cohort of 169 patients.Findings:Basal rates (0.27 ± 0.01 IU.d^−1.kg⁻¹) showed circadian variations with peaks corresponding to the “dawn” and “dusk” phenomena. Age, gender, duration of pump treatment, body-mass-index, HbA_1c, and triacylglycerol concentrations largely predicted the individual basal insulin demand per day (IU/d; exploratory vs prospective cohorts: r² = 0.518, P < .0001). Model-predicted and actual basal insulin rates were not different (exploratory cohort: Δ 0.1 (95% CI −0.9; 1.0 U/d; P = .95; prospective cohort: Δ −0.5 (95% CI −1.5; 0.6 IU/d; P = .46). Similarly, precise predictions were possible for each hour of the day. Actual and predicted “dawn” index correlated significantly in the exploratory but not in the confirmatory cohort.Interpretation:Clinical characteristics predict 52% of the variation in individual basal rate profiles, including their diurnal fluctuations. The multivariate regression model can be used to initiate or optimize insulin pump treatment in patients with type 1 diabetes.     

Comparison of CGM-Derived Measures of Glycemic Variability Between Pancreatogenic Diabetes and Type 2 Diabetes Mellitus

Background:To compare glycemic variability (GV) indices between patients with fibrocalculous pancreatic diabetes (FCPD) and type 2 diabetes mellitus (T2D) using continuous glucose monitoring (CGM).Methods:We measured GV indices using CGM (iPro™2 Professional CGM, Medtronic, USA) data in 61 patients each with FCPD and T2D who were matched for glycated hemoglobin A1c (HbA1c) and duration of diabetes. GlyCulator2 software was used to estimate the CGM-derived measures of GV (SD, mean amplitude of glycemic excursion [MAGE], continuous overall net glycemic action [CONGA], absolute means of daily differences [MODD], M value, and coefficient of variance [%CV]), hypoglycemia (time spent below 70 mg/dL, AUC below 70 mg/dL, glycemic risk assessment diabetes equation hypoglycemia, Low Blood Glucose Index), and hyperglycemia (time spent above 180 mg/dL at night [TSA > 180], AUC above 180 mg/dL [AUC > 180], glycemic risk assessment diabetes equation hyperglycemia, High Blood Glucose Index [HBGI], and J index). The correlation of GV indices with HbA1c, duration of diabetes, and demographic and biochemical parameters were also assessed.Results:All the CGM-derived measures of GV (SD, MAGE, CONGA, MODD, and %CV), except M value, were significantly higher in the FCPD group than in the T2D group (P < 0.05). Measures of hyperglycemia (TSA >180, AUC >180, HBGI, and J index) were significantly higher in the FCPD group than in the T2D group (P < 0.05). The measures of hypoglycemia were not significantly different between the two groups. All the hyperglycemia indices showed a positive correlation with HbA1c in both groups.Conclusions:FCPD is associated with higher GV than is T2D. The findings of higher postprandial glycemic excursions in patients with FCPD could have potential therapeutic implications.     

Real-time continuous glucose monitoring improves glycemic control and reduces hypoglycemia: Real-world data

AimTo study the effect of real time continuous glucose monitor (RT-CGM) use on glycemic parameters in patients with diabetes mellitus (DM) in real world practice.MethodsWe retrospectively studied 91 adult subjects with DM who had been using Dexcom? RT-CGM. Two consecutive hemoglobin A1c (HbA1c), both prior to and after at least 3 months of RT-CGM initiation, were collected. A total of 31 subjects completed a 5–14 day user blinded CGM using a Freestyle Libre? prior to RT-CGM initiation. The first two week period following at least 3 months use of RT-CGM was analyzed for CGM metrics.ResultsA total of 51.6 % of subjects had T1DM, 34.1 % used continuous subcutaneous insulin infusion (CSII), and 62.6 % had DM for > 10 years. Both HbA1c obtained following RT-CGM initiation decreased significantly compared to baseline (8.11 + 1.47% vs 7.69 + 1.25 %; P = 0.002 & 8.16 + 1.51 % vs 7.62 + 1.06 %; P = 0.001). Subjects with baseline HbA1c > 7.0 % showed even more robust reduction in both HbA1c after RT-CGM initiation (8.74 + 1.24 % vs 7.99 + 1.22 %; P = 0.000 & 8.74 + 1.32 % vs 7.85 + 1.07 %; P = 0.001). On comparison of CGM metrics, there was a significant reduction in time spent in hypoglycemia (sugars < 70 mg/dl) including severe hypoglycemia (sugars < 54 mg/dl) after initiation of the RT-CGM (9.16 + 8.68 % vs 1.29 + 2.21 %; P = <0.001 & 4.58 + 5.43 % vs 0.28 + 0.58 %; P = <0.001). CoV of glucose was also decreased significantly (39.61 + 9.36 % vs 31.06 + 6.74 %; P = <0.001) with RT- CGM use.ConclusionRT-CGM use for at least 3 months in patients with DM results in meaningful HbA1c reductions with stable glycemic control without increasing the risk of hypoglycemia.     

Type 1 diabetes mellitus – Population characterization and metabolic control outcomes in a Portuguese patient sample

AimsTo characterize a cohort of T1D patients and to compare diabetes control between patients using different regimen of insulin therapy and glucose monitoring.MethodsWere included all T1D patients followed at the Pediatric Endocrinology Unit, between April 1st and June 30th, 2021. Several clinical and demographic variables were analyzed.ResultsOur sample included 208 patients, 56.7 % males, mean age of 12.7 ± 4.6 years. The median HbA1c was 7.3 %. Most patients, 78.8% were treated with continuous subcutaneous insulin infusion (CSII) and 81.3 % used continuous glucose monitoring (CGM). CSII had a lower HbAc compared with multiple daily injections (MDI) users (7.1vs 8.1 %, p < 0.01). In the CSII group, those who used CGM had a lower HbAc (7.1 vs 7.5 %,p = 0.02). Analyzing the data of the ambulatory glucose report, the CSII users had a lower glucose management indicator, (7.2 % vs 7.6 %, p < 0.01), more time in range (58.0 % vs 52.4 %;p < 0.01) and less time above range > 250 mg/dL (12.4 % vs 20.5 %;p < 0.01) than MDI users.ConclusionsThe median HbA1c was 7.3% very close to the recommended target. In Portugal, pediatric patients can access a CSII provided by the national health service and a CGM system due to an elevated reimbursement of their cost. This healthy policy allows us to achieve better goals without the risk of hypoglycemia.     

Continuous glucose monitoring reduces both hypoglycaemia and HbA1c in hypoglycaemia-prone type 1 diabetic patients treated with a portable pump

AimThis study aimed to assess the effectiveness of continuous glucose monitoring (CGM) for glucose control in type 1 diabetic patients treated by continuous subcutaneous insulin infusion (CSII) and presenting with frequent hypoglycaemic episodes.MethodsThirteen patients with type 1 diabetes (diabetes duration: 25 ± 15 years; CSII duration: 5.5 ± 7.0 years), with more than six recorded capillary blood glucose (CBG) values < 60 mg/dL, according to their metres for the past 14 days, were offered the permanent use of a CGM device (Guardian RT^®, Medtronic) plus ongoing self-monitoring of blood glucose (SMBG) for 12 weeks, followed by a 12-week crossover period of SMBG only, or vice versa. Glucose control, determined by recorded 14-day CBG values < 60 mg/dL and HbA_1c levels, and quality of life according to the Diabetes Quality of Life (DQOL) questionnaire, were assessed at baseline, and after 12- and 24-week follow-ups.ResultsFour patients withdrew from the study during the first period (of whom three were using CGM). In the nine study completers, the number of low CBG values decreased significantly from 13.9 ± 9.2 to 7.6 ± 6.8 (P = 0.011) when patients used CGM, in either the initial or final trial period, while a decrease in HbA_1c from 8.3 ± 0.7 to 7.7 ± 0.6% (P = 0.049) was also observed, in contrast to the absence of any significant differences during the SMBG-only period. DQOL scores were also essentially unaffected.ConclusionThis pilot observational study supports the hypothesis that CGM use can significantly improve overall glucose control while reducing hypoglycaemic episodes in hypoglycaemia-prone type 1 diabetic patients treated by CSII.     

Monitoring the Impact of Aggressive Glycemic Intervention during Critical Care after Cardiac Surgery with a Glycemic Expert System for Nurse-Implemented Euglycemia: The MAGIC GENIE Project

A novel, multi-dimensional protocol named GENIE has been in use for intensive insulin therapy (IIT, target glucose <140 mg/dL) in the surgical intensive care unit (SICU) after open heart surgery (OHS) at VA Pittsburgh since 2005. Despite concerns over increased mortality from IIT after the publication of the NICE-SUGAR Trial, it remains in use, with ongoing monitoring under the MAGIC GENIE Project showing that GENIE performance over 12 years (2005-2016) aligns with the current consensus that IIT with target blood glucose (BG) <140 mg/dL is advisable only if it does not provoke severe hypoglycemia (SH). Two studies have been conducted to monitor glucometrics and outcomes during GENIE use in the SICU. One compares GENIE (n = 382) with a traditional IIT protocol (FORMULA, n = 289) during four years of contemporaneous use (2005-2008). The other compares GENIE’s impact overall (n = 1404) with a cohort of patients who maintained euglycemia after OHS (euglycemic no-insulin [ENo-I], n = 111) extending across 12 years (2005-2016). GENIE performed significantly better than FORMULA during contemporaneous use, maintaining lower time-averaged glucose, provoking less frequent, severe, prolonged, or repetitive hypoglycemia, and achieving 50% lower one-year mortality, with no deaths from mediastinitis (0 of 8 cases vs 4 of 9 on FORMULA). Those benefits were sustained over the subsequent eight years of exclusive use in OHS patients, with an overall one-year mortality rate (4.2%) equivalent to the ENo-I cohort (4.5%). The results of the MAGIC GENIE Project show that GENIE can maintain tight glycemic control without provoking SH in patients undergoing OHS, and may be associated with a durable survival benefit. The results, however, await confirmation in a randomized control trial.     

The impact of atrial mechanical function on age‐dependent presentation of neurocardiogenic syncope

BackgroundThe contribution of atrial and ventricular function in neurocardiogenic syncope (NCS) pathophysiology is elusive.HypothesisWe assessed the influence of echocardiographic properties to the age of presentation and NCS recurrences.MethodsWe assigned 124 patients with symptoms suggesting NCS, to those with syncope initiation at age <35 (group A, n = 56) and >35 years (group B, n = 68). Echocardiographic indices were measured before head‐up tilt test (HUTT).ResultsA total of 55 had positive HUTT (44%) with a trend favoring group A (p = .08). Group A exhibited lower left atrial (LA) volume index (17 ± 6 vs. 22 ± 11 ml/m², p = .015), higher LA ejection fraction (69 ± 10 vs. 63 ± 11%, p = .008), LA peak strain (reservoir phase 41 ± 13 vs. 31 ± 14%, p = .001, contraction phase 27 ± 11 vs. 15 ± 10%, p < .001) and LA peak strain rate (reservoir phase 1.83 ± 1.04 vs. 1.36 ± 0.96 1/s, p = .012, conduit phase 2.36 ± 1.25 vs. 1.36 ± 0.78 1/s, p = .001). Group A showed smaller minimum right atrial (RA) volume, better RA systolic function, superior left ventricular diastolic indices, and lower filling pressures. Group A patients were more likely to have >3 recurrences (82.0% vs. 50.1%, p < .05).ConclusionsPatients with younger age of NCS onset and more syncopal recurrences manifest smaller LA and RA dimensions with distinct patterns of systolic and diastolic function and better LA reservoir and contraction properties. These findings may indicate an increased susceptibility to preload reduction, thereby triggering the NCS mechanism.     

Impact of regionalizing ST‐elevation myocardial infarction care on sex differences in reperfusion times and clinical outcomes

BackgroundWomen with ST‐elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention historically experience worse in‐hospital outcomes compared to men.HypothesisImplementation of a regional STEMI system will reduce care gaps in reperfusion times and in‐hospital outcomes between women and men.Methods1928 patients (413 women, 21.4%) presented with an acute STEMI between June 2007 and March 2016. The population was divided into an early cohort (n = 728 patients, 2007‐May 2011), and a late cohort (n = 1200 patients, June 2011–2016). The primary endpoints evaluated were reperfusion times and in‐hospital outcomes.ResultsCompared to men, women experienced significant delays in first medical contact (FMC) to arrival at the emergency room (26.0 vs. 22.0 min, p < 0.001) and FMC‐to‐device (109 vs. 101 min p = 0.001). Women had higher incidences of post‐PCI heart failure and death compared to men (p < 0.05). Following multivariable adjustment, no mortality difference was observed for women versus men (adjusted OR; 0.82; 95% confidence interval [CI], 0.51–1.34; p = 0.433) or for early versus late cohorts (adjusted OR; 1.04; 95% CI, 0.68–1.60; p = 0.856).ConclusionFollowing STEMI regionalization, women continued to experience significantly longer reperfusion times, although there was no difference in adjusted mortality. These results highlight the ongoing disparity of STEMI care between women and men, and suggest that regionalization alone is insufficient to close sex‐based care gaps.