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.     

Amalgamating Oncolytic Viruses to Enhance Their Safety,Consolidate Their Killing Mechanisms,and Accelerate Their Spread

Oncolytic viruses are structurally and biologically diverse, spreading through tumors and killing them by various mechanisms and with different kinetics. Here, we created a hybrid vesicular stomatitis/measles virus (VSV/MV) that harnesses the safety of oncolytic MV, the speed of VSV, and the tumor killing mechanisms of both viruses. Oncolytic MV targets CD46 and kills by forcing infected cells to fuse with uninfected neighbors, but propagates slowly. VSV spreads rapidly, directly lysing tumor cells, but is neurotoxic and loses oncolytic potency when neuroattenuated by conventional approaches. The hybrid VSV/MV lacks neurotoxicity, replicates rapidly with VSV kinetics, and selectively targets CD46 on tumor cells. Its in vivo performance in a myeloma xenograft model was substantially superior to either MV or widely used recombinant oncolytic VSV-M51.     

Real-Time Improvement of Continuous Glucose Monitoring Accuracy: The smart sensor concept

OBJECTIVE

Reliability of continuous glucose monitoring (CGM) sensors is key in several applications. In this work we demonstrate that real-time algorithms can render CGM sensors smarter by reducing their uncertainty and inaccuracy and improving their ability to alert for hypo- and hyperglycemic events.

RESEARCH DESIGN AND METHODS

The smart CGM (sCGM) sensor concept consists of a commercial CGM sensor whose output enters three software modules, able to work in real time, for denoising, enhancement, and prediction. These three software modules were recently presented in the CGM literature, and here we apply them to the Dexcom SEVEN Plus continuous glucose monitor. We assessed the performance of the sCGM on data collected in two trials, each containing 12 patients with type 1 diabetes.

RESULTS

The denoising module improves the smoothness of the CGM time series by an average of ∼57%, the enhancement module reduces the mean absolute relative difference from 15.1 to 10.3%, increases by 12.6% the pairs of values falling in the A-zone of the Clarke error grid, and finally, the prediction module forecasts hypo- and hyperglycemic events an average of 14 min ahead of time.

CONCLUSIONS

We have introduced and implemented the sCGM sensor concept. Analysis of data from 24 patients demonstrates that incorporation of suitable real-time signal processing algorithms for denoising, enhancement, and prediction can significantly improve the performance of CGM applications. This can be of great clinical impact for hypo- and hyperglycemic alert generation as well in artificial pancreas devices.Continuous glucose monitoring (CGM) technology has significantly modified the way glucose levels are monitored in patients with type 1 diabetes, allowing an increase in the number of readings from, for example, 3 to 4 spot measurements per day to a continuous glucose signal (1,2). In the beginning, CGM was used retrospectively to analyze glycemic profiles and to better understand glucose variability (3). Then, thanks to advances in technology, CGM systems turned into real-time devices, and their benefit in improved glycemic control and reduced risks of hypo- and hyperglycemia became evident (4–6).The large amount of data obtained by CGM sensors stimulated the development of several applications. The most straightforward application is to combine CGM with a system for real-time generation of alerts when the measured glucose value crosses hypoglycemic (e.g., 70 mg/dL) or hyperglycemic (e.g., 180 mg/dL) thresholds (7). Another possible use is within systems that combine a CGM and a continuous subcutaneous insulin infusion pump in a single unit, the so-called sensor-augmented pump, whose use can produce a reduction of hyperglycemia and an improvement in glycemic control (8–10). Among all, the most ambitious is probably the artificial pancreas (AP), a system for delivering insulin steered by a closed-loop control algorithm in which the uncertainty and accuracy of the CGM sensor play a crucial role because the CGM measurements feed the control algorithm (11).Even if the reliability of CGM outcome in accuracy is key, CGM performance is still suboptimal because of three main issues (12,13) that are related more to the way in which the stream of data given in output by the sensor is processed rather than on the electrochemical processes occurring within the sensor. The first issue is related to the uncertainty of CGM data, because glucose readings are corrupted by random noise that complicates their interpretation and use (14,15). For instance, noise may result in spurious spikes and oscillations that could trigger false hypo- or hyperglycemic alerts. Some denoising algorithms have recently been developed to deal with this problem (14–17).The second issue concerns accuracy. In fact, compared with gold standard blood glucose (BG) references measured by laboratory instruments, the CGM time series present delays, which are mainly due to the blood-to-interstitium glucose transport and the sensor processing time (18), and often systematic under- or overestimations due to calibration problems (19–21). For instance, when actual glucose is in the hypoglycemic range, systematic overestimation of glucose levels due to lack of calibration can expose the patient to critical situations. To compensate for the inaccuracy and to enhance CGM data, several strategies have been proposed in the last few years (20–25).Finally, because CGM sensors report glucose value with a delay with respect to BG, there is the necessity of generating hypo- and hyperglycemic prealerts by applying short-term glucose prediction strategies (26–32). Generation of prealerts can allow the patient to take prompt countermeasures before a forthcoming (e.g., hypoglycemic) event, increasing the possibility of mitigating or even avoiding, it.So far, these mentioned methods have always been tested in the literature as stand-alone applications, and a quantification of the improvement in CGM performance that can be achieved by their combination has never been assessed. Therefore, we propose the concept of a smart CGM (sCGM) sensor consisting of a cascade of a commercial CGM sensor and three software modules for denoising, enhancement, and prediction, able to work in real time.     

Blastomycosis of the lumbar spine: case report and review of the literature, with emphasis on diagnostic laboratory tools and management

We report on the conservative and surgical management of a patient with blastomycosis of the lumbar spine, causing severe and crippling deformity. The diagnosis was made through biopsy. Curative removal, reconstruction and realignment of the spine were achieved. Imaging modalities were highlighted, with a detailed discussion of the histology and conservative and surgical management. We emphasize the importance of early, aggressive treatment of blastomycosis to prevent deformity and disability, and to enable identification of the best management of a destructive lesion with deformity. This case demonstrates that empirical treatment should not be used in cases of unusual sinus and abscess locations. Specific diagnosis and early treatment are indicated to prevent dreadful complications and spinal deformity resulting from blastomycosis. Aggressive antifungal therapy can cure the disease but does not control complications related to deformity. The latter can only be addressed by surgical reconstruction. We review the literature of surgical treatment, focusing on abscess drainage, bone fusion and posterior instrumentation in the absence of addressing the deformity component. Received: 19 November 1997 Revised: 6 February 1998 Accepted: 16 April 1998     

Basic anatomical investigation of semitendinosus and the long head of biceps femoris muscle for their possible use in electrically stimulated neosphincter formation

Anal neosphincter formation with electrically stimulated gracilis muscle is used increasingly for the surgical treatment of fecal incontinence. An alternative to gracilis might be of interest if this muscle is not available. 30 semitendinosus muscles and 15 long heads of biceps femoris were investigated on human cadavers. In particular, the nerve and vascular supply of these muscles was studied, both representing basic factors for muscle transposition. The long head of biceps femoris m. was found to receive its dominant vascular supply from the first and second perforating artery and its nerve supply from one motor branch out of the sciatic nerve, both as described in literature. The examination of semitendinosus m., however, revealed new anatomical aspects in its vascular supply. In all cases semitendinosus m. was found to receive dominant vascular pedicles from the medial circumflex femoral artery close to the ischial tuberosity and the second perforating artery. The nerve supply consisted of two motor branches out of the sciatic nerve. Both muscles fulfilled several basic criterias for transposition to the anus. However, regarding these requirements, semitendinosus offered distinct advantages in comparison with the long head of biceps femoris. Due to its vascular and nerve topography, semitendinosus seems suitable to serve as an alternative to gracilis.     

Enlarged pupillary membranes

Pupillary membranes are very commonly found on routine microscopic examination of the anterior segment and are usually of no clinical significance. We describe a 4-year-old child with grossly enlarged pupillary membranes that formed a mesh-like arc over the entire pupillary aperture in both eyes. Although these membranous strands were very prominent, the child had normal visual acuity.     

Comparative evaluation of the diffusion of tobramycin and cefotaxime out of antibiotic-impregnated polymethylmethacrylate beads

Both tobramycin and cefotaxime diffuse from antibiotic-impregnated polymethylmethacrylate (PMMA) beads in quantities sufficient to inhibit the growth of bacteria on agar lawns or in broth cultures over a 28-day period. Extraction of antibiotic from tobramycin or cefotaxime-impregnated PMMA beads revealed that substantial amounts of both antibiotics remained within the beads despite 28 days of diffusion. Diffusion of antibiotic from the PMMA beads during the initial 3-5 days is much greater than occurs for the remainder of the 4-week period. The results of the study suggest that perhaps tobramycin of cefotaxime-impregnated PMMA beads would produce local levels of antibiotic high enough to sterilize a given dead space for a period of 28 days.