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Objective: Peripheral blood CD34(+) cells from diabetic patients demonstrate reduced vascular reparative function due to decreased proliferation and diminished migratory prowess, largely resulting from decreased nitric oxide (NO) bioavailability. The level of TGF-beta, a key factor that modulates stem cell quiescence, is increased in the serum of type 2 diabetic patients. We asked whether transient TGF-beta1 inhibition in CD34(+) cells would improve their reparative ability.Research Design and Methods: To inhibit TGF-beta1 protein expression, CD34(+) cells were treated ex vivo with antisense phosphorodiamidate morpholino oligomers (TGF-beta1-PMOs) and analyzed for cell surface CXCR4 expression, cell survival in the absence of added growth factors, SDF-1-induced migration, NO release, and in vivo retinal vascular reparative ability.Results: TGF-beta1-PMO treatment of diabetic CD34(+) cells resulted in increased expression of CXCR4, enhanced survival in the absence of growth factors, and increased migration and NO release as compared with cells treated with control PMO. Using a retinal ischemia reperfusion injury model in mice, we observed that recruitment of diabetic CD34(+) cells to injured acellular retinal capillaries was greater after TGF-beta1-PMO treatment compared with control PMO-treated cells.Conclusions: Transient inhibition of TGF-beta1 may represent a promising therapeutic strategy for restoring the reparative capacity of dysfunctional diabetic CD34(+) cells. [ABSTRACT FROM AUTHOR]

Hyperglycemia in hospitalized patients is associated with increased morbidity, mortality, and length of hospital stay. Insulin counteracts the damaging processes caused by hyperglycemia and is therefore a logical choice in treating inpatient hyperglycemia. This article emphasizes the importance of using a physiological (basal-bolus) insulin regimen for noncritically ill hospitalized patients, discusses protocols for initiating and titrating insulin doses and for transitioning from insulin infusion to a subcutaneous regimen, and recommends insulin teaching as part of discharge planning for patients who were not on insulin before admission. [ABSTRACT FROM AUTHOR]

BACKGROUND: Thiazolidinediones (TZD) have been reported to improve early stages of diabetic nephropathy independent of glycaemic control. Since blockade of the renin-angiotensin system (RAS) is known to reduce the risk of nephropathy, we hypothesised that the renal effect of TZDs might be related to a favourable effect on the intrarenal RAS. We aimed to determine if the TZD rosiglitazone could reduce RAS activation. METHODS: We studied adult type 2 diabetic patients and placed them on rosiglitazone for three months. We have previously used the renal haemodynamic response to angiotensin-converting enzyme (ACE) inhibition to demonstrate the state of RAS activation, and thus measured renal plasma flow (RPF) and glomerular filtration rate (GFR) before and after administration of captopril at 0 month and at three months. Plasma renin activity (PRA), active renin, aldosterone and natriuretic peptides were analysed. RESULTS: The RPF response to ACE inhibition was not altered. There was no change in GFR, PRA, active renin and aldosterone levels. Two patients developed oedema one had an elevated baseline active renin and another had an elevated baseline aldosterone level. CONCLUSION: The favourable effects of TZDs on diabetic nephropathy is likely not related to an influence on the RAS. [ABSTRACT FROM AUTHOR]

Objective: Hypoglycemia can be life-threatening for patients with diabetes. We aimed to 1) evaluate percentage of glucagon prescription in patients with hypoglycemia on continuous glucose monitoring (CGM) reports, and 2) determine incident glucagon prescription after an educational letter delivered to the providers., Research Design and Methods: The study had 2 components - retrospective chart review and a quality improvement (QI) component. Chart review was conducted from March to October 2023 on adult patients in a tertiary care health system with type 1 diabetes or type 2 diabetes on insulin, sulfonylurea, or meglitinide. Percentages of pre-existing and incident glucagon prescription were evaluated. For the QI, we contacted providers whose patients had hypoglycemia defined as time below range ≥ 4% on CGM reports without a glucagon prescription and shared the American Diabetes Association Standards of Care on hypoglycemia along with information about various forms of glucagon. Data on glucagon prescription were collected 4 weeks later., Results: Of the 1543 patients included, 170 had time below range ≥4%. Among them, 37% had pre-existing prescription and 14% incident glucagon prescription, compared with patients without hypoglycemia (P < .001). Pre-existing or incident glucagon prescription was seen in 28% without hypoglycemia, 38% with mild, 49% with moderate, and 63% with severe hypoglycemia (P < .001 mild vs severe; moderate vs no hypoglycemia; and severe vs no hypoglycemia). Among 70 patients whose providers received education, 27 (39%) prescribed glucagon. Glucagon emergency kit, glucagon autoinjector, and inhaled glucagon were top choices., Conclusion: Glucagon prescription remains suboptimal among patients with hypoglycemia on CGM reports. Provider engagement via QI can increase glucagon prescription., Competing Interests: Disclosure J.A. has no conflicts of interest. D.I. is a speaker and consultant for Abbott and Dexcom. M.C.L. has received research support from Abbott and Dexcom. J.R., H.X., J.B., and C.B. have no conflicts of interest., (Copyright © 2024 AACE. Published by Elsevier Inc. All rights reserved.)

Objective: This study examined the preoperative and postoperative variables associated with 1 year and long-term insulin independence following total pancreatectomy and islet autotransplantation (TPIAT)., Methods: 46 TPIAT patients from 2010 to 2022 in a single hospital system were retrospectively analyzed. Pre- and postoperative variables were compared between short-term (1 year) and long-term (last follow-up after year 1) insulin-independent versus -dependent patients., Results: Nine (20%) and seven (15%) patients achieved short- and long-term insulin independence, respectively. The patients were followed up for a median of 2.8 years (interquartile range [IQR] 1.0, 4.7). Short-term insulin independence was associated with higher median transplanted islet equivalents (IEQ) per kg (6981 vs 4493, P = .02), lower units of basal insulin on discharge (7 vs 12, P = .009), and lower rates of discharge with an insulin regimen (67% vs 100%, P = .006). Odds of short-term insulin independence increased by 80% for every 1000 increase in IEQ per kg (OR 1.80, CI 1.18-3.12, P = .005) and decreased by 32% for every additional basal unit of insulin on discharge (OR 0.68, CI 0.42-0.91, P = .003) on average. Long-term insulin independence was also associated with transplanted IEQ per kg. No patient on antihyperglycemic medication before surgery achieved insulin independence., Conclusion: Short- and long-term insulin independence after TPIAT is associated with higher transplanted IEQ per kg and immediate postoperative variables that can be used to inform the discussions clinicians have with their patients regarding glycemic prognosis following TPIAT., Competing Interests: Disclosure B.A.H. is a principal investigator for Tandem Diabetes Care, Inc. The other authors have no conflicts of interest to disclose., (Copyright © 2024 AACE. Published by Elsevier Inc. All rights reserved.)

Objective: Cardiac surgery is associated with hyperglycemia, which in turn is associated with adverse postsurgical outcomes such as wound infections, acute renal failure, and mortality. This pilot study seeks to determine if Dexcom G6Pro continuous glucose monitor (Dexcom G6Pro CGM) is accurate during the postoperative cardiac surgery period when fluid shifts, systemic inflammatory response syndrome, and vasoactive medications are frequently encountered, compared to standard glucose monitoring techniques., Methods: This study received institutional review board approval. In this prospective study, correlation between clinical and Dexcom glucose readings was evaluated. Clinical glucose (blood gas, metabolic panel, and point of care) data set included 1428 readings from 29 patients, while the Dexcom G6Pro CGM data included 45 645 data points following placement to upper arm. Additionally, average clinical measurements of day and overnight temperatures and hemodynamics were evaluated. Clinical and Dexcom data were restricted to being at least 1 hour after prior clinical reading Matching Dexcom G6Pro CGM data were required within 5 minutes of clinical measure. Data included only if taken at least 2 hours after Dexcom G6Pro CGM insertion (warm-up time) and analyzed only following intensive care unit (ICU) admission. Finally, a data set excluding the first 24 hours after ICU admission was created to explore stability of the device. Patients remained on Dexcom G6Pro CGM until discharge or 10 days postoperatively., Results: The population was 71% male, 14% with known diabetes; 66% required intravenous insulin infusion. The Clarke error grid plot of all measures post-ICU admission showed 53.5% in zone A, 45.9% in zone B, and 0.6% (n = 5) in zones D or E. The restricted dataset that excluded the first 24 hours post-ICU admission showed 55.9% in zone A, 43.9% in zone B, and 0.2% in zone D. Mean absolute relative difference between clinical and Dexcom G6Pro CGM measures was 20.6% and 21.6% in the entire post-ICU admission data set, and the data set excluding the first 24 hours after ICU admission, respectively. In the subanalysis of the 12 patients who did not have more than a 5-minute tap in the operating room, a consensus error grid, demonstrated that after ICU admission, percentage in zone A was 53.9%, zone B 45.4%, and zone C 0.7%. Similar percentages were obtained removing the first 24 hours post-ICU admission. These numbers are very similar to the entire cohort. A consensus error grid created post-ICU admission demonstrated: (zone A) 54%, (zone B) 45%, (zone C) 0.9%, and the following for the dataset created excluding the first 24 hours: (zone A) 56%, (zone B) 44%, (zone C) 0.4%, which demonstrated very close agreement with the original Clarke error grid. No adverse events were reported., Conclusions: Almost 100% of Dexcom G6Pro CGM and clinical data matching points fell within areas considered as giving clinically correct decisions (zone A) and clinically uncritical decisions (zone B). However, the relatively high mean absolute relative difference precludes its use for both monitoring and treatment in the clinical context. As technology evolves, interstitial glucose monitoring may become an important tool to limit iatrogenic anemia and mitigate glycemic fluctuations., Competing Interests: Disclosure D.I. serves as a speaker and consultant for Abbott, Medtronic, Ascensia, and Dexcom., (Copyright © 2024 AACE. Published by Elsevier Inc. All rights reserved.)

Diabetes technology is evolving rapidly and is changing the way both patients and clinicians approach the management of diabetes. With more devices gaining US Food and Drug Administration approval and insurance coverage expanding, these new technologies are being widely adopted by people living with diabetes. We provide a summary of the commonly available devices in the market today that clinicians will likely encounter. This includes continuous glucose monitors (CGMs); connected insulin pens, caps, and buttons; and insulin pumps. Clinicians' awareness of and familiarity with this technology will enhance its accessibility for patients with diabetes., (Copyright © 2024 The Cleveland Clinic Foundation. All Rights Reserved.)

Diseases of the adrenal glands can lead to primary adrenal insufficiency, and suppression of the hypothalamic-pituitary-adrenal axis can cause secondary adrenal insufficiency (adrenal suppression). The most common cause of adrenal suppression is exogenous steroids, a condition recently termed glucocorticoid-induced adrenal insufficiency (GIAI). Similarly, weaning from high doses of glucocorticoids or giving insufficient glucocorticoid replacement after curative surgery for endogenous hypercortisolism (Cushing syndrome) can lead to glucocorticoid withdrawal syndrome, which overlaps with GIAI., (Copyright © 2024 The Cleveland Clinic Foundation. All Rights Reserved.)

Objective: The effects of diabetes medications on COVID-19 hospitalization outcomes have not been consistent. We sought to determine the effect of metformin, dipeptidyl peptidase-4 inhibitors (DPP-4i), and insulin on admission to the intensive care unit (ICU), need for assisted ventilation, development of renal insufficiency, and mortality in patients admitted with COVID-19 infection after controlling for clinical variables and other relevant diabetes-related medications in patients with type 2 diabetes mellitus (DM)., Methods: This was a retrospective study of patients hospitalized with COVID-19 from a single hospital system. Univariate and multivariate analyses were performed that included demographic data, glycated hemoglobin, kidney function, smoking status, insurance, Charlson comorbidity index, number of diabetes medications, and use of angiotensin-converting enzyme inhibitors and statin prior to admission and glucocorticoids during admission., Results: A total of 529 patients with type 2 DM were included in our final analysis. Neither metformin nor DPP4i prescription was associated with ICU admission, need for assisted ventilation, or mortality. Insulin prescription was associated with increased ICU admission but not with need for assisted ventilation or mortality. There was no association of any of these medications with development of renal insufficiency., Conclusions: In this population, limited to type 2 DM and controlled for multiple variables that have not been consistently studied (such as a measure of general health, glycated hemoglobin, and insurance status), insulin prescription was associated with increased ICU admission. Metformin and DPP4i prescriptions did not have an association with the outcomes., Competing Interests: Disclosure K.M.P. has the following disclosures: Speaker Bureau for AstraZeneca, Corcept Therapeutics, Merck, Novo Nordisk; Consultant for AstraZeneca, Bayer, Corcept Therapeutics, Diasome, Eli Lilly, Merck, Novo Nordisk, Sanofi, and Twinhealth; Research Support for Bayer, Novo Nordisk, Merck, Twinhealth. The other authors have no multiplicity of interest to disclose., (Copyright © 2023 AACE. Published by Elsevier Inc. All rights reserved.)

Background: A composite metric for the quality of glycemia from continuous glucose monitor (CGM) tracings could be useful for assisting with basic clinical interpretation of CGM data., Methods: We assembled a data set of 14-day CGM tracings from 225 insulin-treated adults with diabetes. Using a balanced incomplete block design, 330 clinicians who were highly experienced with CGM analysis and interpretation ranked the CGM tracings from best to worst quality of glycemia. We used principal component analysis and multiple regressions to develop a model to predict the clinician ranking based on seven standard metrics in an Ambulatory Glucose Profile: very low-glucose and low-glucose hypoglycemia; very high-glucose and high-glucose hyperglycemia; time in range; mean glucose; and coefficient of variation., Results: The analysis showed that clinician rankings depend on two components, one related to hypoglycemia that gives more weight to very low-glucose than to low-glucose and the other related to hyperglycemia that likewise gives greater weight to very high-glucose than to high-glucose. These two components should be calculated and displayed separately, but they can also be combined into a single Glycemia Risk Index (GRI) that corresponds closely to the clinician rankings of the overall quality of glycemia (r = 0.95). The GRI can be displayed graphically on a GRI Grid with the hypoglycemia component on the horizontal axis and the hyperglycemia component on the vertical axis. Diagonal lines divide the graph into five zones (quintiles) corresponding to the best (0th to 20th percentile) to worst (81st to 100th percentile) overall quality of glycemia. The GRI Grid enables users to track sequential changes within an individual over time and compare groups of individuals., Conclusion: The GRI is a single-number summary of the quality of glycemia. Its hypoglycemia and hyperglycemia components provide actionable scores and a graphical display (the GRI Grid) that can be used by clinicians and researchers to determine the glycemic effects of prescribed and investigational treatments.

Objective: To assess the attitudes, behaviors, and barriers with diabetes technology use in the general medicine hospital wards. Research Design and Methods: The authors developed a nonincentivized web-based anonymous survey that captured demographic and practice data regarding continuous subcutaneous insulin infusion (CSII) and continuous glucose monitor (CGM) use in the hospital. Setting: Four large hospital systems in the United States. Results: Among 128 survey respondents, 76%, 10%, and 6% were hospitalists, advanced practice providers, and primary care physicians, respectively. The majority of respondents rated the treatment of inpatient hyperglycemia (96%) and the continuation of CSII during the hospital stay (93%) "important." While most respondents (64%) acknowledged knowing the existence of their institution's policies for CSII use, only 84% of those respondents felt somewhat to very familiar with the policy. The most common barrier to CSII use in the inpatient setting was lack of practitioner (70%) and nursing (67%) knowledge of using the device. With regard to CGM use in the hospital, a minority (28%) of respondents were aware of their institution's CGM policies. Less than half of the providers, 43.8%, stated that, when admitting a patient, they reviewed CGM data to guide insulin dosing. Conclusions: In this US multicenter survey, we found that most inpatient practitioners valued glycemic control, but many were not familiar with institutional policies, had lack of knowledge with CSII, and were not reviewing CGM data.

The annual Virtual Hospital Diabetes Meeting was hosted by Diabetes Technology Society on April 1 and April 2, 2022. This meeting brought together experts in diabetes technology to discuss various new developments in the field of managing diabetes in hospitalized patients. Meeting topics included (1) digital health and the hospital, (2) blood glucose targets, (3) software for inpatient diabetes, (4) surgery, (5) transitions, (6) coronavirus disease and diabetes in the hospital, (7) drugs for diabetes, (8) continuous glucose monitoring, (9) quality improvement, (10) diabetes care and educatinon, and (11) uniting people, process, and technology to achieve optimal glycemic management. This meeting covered new technology that will enable better care of people with diabetes if they are hospitalized.

Bariatric and metabolic surgery is an effective treatment for patients with severe obesity and obesity-related diseases. In patients with type 2 diabetes, it provides marked improvement in glycemic control and even remission of diabetes. In patients with type 1 diabetes, bariatric surgery may offer improvement in insulin sensitivity and other cardiometabolic risk factors, as well as amelioration of the mechanical complications of obesity. Because of these positive outcomes, there are increasing numbers of patients with diabetes who undergo bariatric surgical procedures each year. Prior to surgery, efforts should be made to optimize glycemic control. However, there is no need to delay or withhold bariatric surgery until a specific glycosylated hemoglobin target is reached. Instead, treatment should focus on avoidance of early postoperative hyperglycemia. In general, oral glucose-lowering medications and noninsulin injectables are not favored to control hyperglycemia in the inpatient setting. Hyperglycemia in the hospital is managed with insulin, aiming for perioperative blood glucose concentrations between 80 and 180 mg/dL. Following surgery, substantial changes of the antidiabetic medication regimens are common. Patients should have a clear understanding of the modifications made to their treatment and should be followed closely thereafter. In this review article, we describe practical recommendations for the perioperative management of diabetes in patients with type 2 or type 1 diabetes undergoing bariatric surgery. Specific recommendations are delineated based on the different treatments that are currently available for glycemic control, including oral glucose-lowering medications, noninsulin injectables, and a variety of insulin regimens., (Copyright © 2022 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Cystic fibrosis (CF) is an autosomal recessive disorder, with a prevalence of 1 in 2,500 live births. It is caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. With the significant advancement in CFTR-directed therapies, life expectancy of CF patients has steadily increased. With improved survival, CF related co-morbidities have become more apparent. The most common endocrine complication includes Cystic fibrosis related diabetes (CFRD). Impaired glucose tolerance and insulin deficiency in CFRD leads to a decline in pulmonary function in CF patients. Here we review the underlying mechanisms involved in the pathogenesis of CFRD, focusing on the role of CFTR in the regulation of insulin secretion from the β-cell. We then discuss CFTR modulators and their effect on impaired glucose tolerance and CFRD., (© 2022 The Author(s).)

Objective: The Alertgy noninvasive continuous glucose monitor (ANICGM) is a novel wristband device that reports glucose levels without entailing skin puncture. This study evaluated the performance of the ANICGM compared to a Food and Drug Administration-approved glucose meter in patients with type 2 diabetes., Methods: The ANICGM device measures changes in the electromagnetic field generated by its sensor to produce a dielectric spectrum. The data contained within this spectrum are used in tandem with machine learning algorithms to estimate blood glucose levels. Values from the ANICGM were collected, sent to the Alertgy lab, formatted, and compared with fingerstick blood glucose levels, which were measured using the Accuchek Inform II glucometer. Fifteen patients completed three 120-minute sessions. The mean absolute relative difference (MARD) was calculated., Results: MARD values were compared between study days 2 and 3. The MARD for day 2 was 18.5% (95% CI, 12.8-42.2%), and the MARD for day 3 was 15.3% (95% CI, 12.3-18.4%). The difference in the MARD between days 2 and 3 was not statistically significant (P = .210)., Conclusion: The resulting MARDs suggest that further investigation into the use of dielectric spectroscopy for glucose monitoring should be explored., (Copyright © 2021 AACE. Published by Elsevier Inc. All rights reserved.)

Objective: Hyperglycemia often occurs after the transition from intravenous insulin infusion (IVII) to subcutaneous insulin. Weight-based basal insulin initiated earlier in the course of IVII in the medical intensive care unit (MICU), and a weight-based basal-bolus regimen after IVII, can potentially improve post-IVII glycemic control by 48 hours., Methods: This prospective study included 69 patients in MICU who were on IVII for ≥24 hours. Exclusions were end-stage renal disease, type 1 diabetes mellitus, and the active use of vasopressors. The intervention group received weight-based basal insulin (0.2-0.25 units/kg) with IVII and weight-based bolus insulin after IVII. The control group received current care. The primary end points were glucose levels at specific time intervals up to 48 hours after IVII., Results: There were 25 patients in the intervention group and 44 in the control group. The mean age of the patients was 59 ± 15 years, 32 (47%) were men, and 52 (78%) had prior diabetes mellitus. The 2 groups were not different (acute kidney injury/chronic kidney disease, pre-existing diabetes mellitus, illness severity, or nothing by mouth status after IVII), except for the steroid use, which was higher in the control group than in the intervention group (34% vs 12%, respectively). Glucose levels were not lower until 36 to 48 hours after IVII (166.8 ± 39.1 mg/dL vs 220.0 ± 82.9 mg/dL, P < .001). When controlling for body mass index, nutritional status, hemoglobin A1C, and steroid use, glucose level was lower starting at 12 to 24 hours out (166.87 mg/dL vs 207.50 mg/dL, P = .015). The frequency of hypoglycemia was similar between the 2 groups (5.0% vs 7.1%). The study did not reach target enrollment., Conclusion: The addition of weight-based basal insulin during, and basal-bolus insulin immediately after, IVII in MICU results in better glycemic control at 24 hours after IVII with no increased hypoglycemia., (Copyright © 2021 AACE. Published by Elsevier Inc. All rights reserved.)

Context: Though posttransplant diabetes mellitus (PTDM, occurring > 45 days after transplantation) and its complications are well described, early post-renal transplant hyperglycemia (EPTH) (< 45 days) similarly puts kidney transplant recipients at risk of infections, rehospitalizations, and graft failure and is not emphasized much in the literature. Proactive screening and management of EPTH is required given these consequences., Objective: The aim of this article is to promote recognition of early post-renal transplant hyperglycemia, and to summarize available information on its pathophysiology, adverse effects, and management., Methods: A PubMed search was conducted for "early post-renal transplant hyperglycemia," "immediate posttransplant hyperglycemia," "post-renal transplant diabetes," "renal transplant," "diabetes," and combinations of these terms. EPTH is associated with significant complications including acute graft failure, rehospitalizations, cardiovascular events, PTDM, and infections., Conclusion: Patients with diabetes experience better glycemic control in end-stage renal disease (ESRD), with resurgence of hyperglycemia after kidney transplant. Patients with and without known diabetes are at risk of EPTH. Risk factors include elevated pretransplant fasting glucose, diabetes, glucocorticoids, chronic infections, and posttransplant infections. We find that EPTH increases risk of re-hospitalizations from infections (cytomegalovirus, possibly COVID-19), acute graft rejections, cardiovascular events, and PTDM. It is essential, therefore, to provide diabetes education to patients before discharge. Insulin remains the standard of care while inpatient. Close follow-up after discharge is recommended for insulin adjustment. Some agents like dipeptidyl peptidase-4 inhibitors and glucagon-like peptide-1 receptor agonists have shown promise. The tenuous kidney function in the early posttransplant period and lack of data limit the use of sodium-glucose cotransporter 2 inhibitors. There is a need for studies assessing noninsulin agents for EPTH to decrease risk of hypoglycemia associated with insulin and long-term complications of EPTH., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Endocrine Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: The transition of diabetes care from home to hospital, within the hospital, and upon discharge is fraught with gaps that can adversely affect patient safety and length of stay. We aimed to highlight the variability in care during these transitions and point out areas where research is needed., Methods: A PubMed search was performed with a combination of search terms that pertained to diabetes, hyperglycemia, hospitalization, locations in the hospital, discharge to home or a nursing facility, and diabetes medications. Studies with at least 50 patients that were written in the English language were included., Results: With the exception of transitioning from intravenous insulin infusion to subcutaneous insulin and perhaps admission to the regular floors, few studies pointedly focused on transitions of care, leading us to extrapolate recommendations based on data from disparate areas of care in the hospital. There is evidence at every stage of care, starting from the entry into the hospital and ending with discharge home or to a facility, that patients benefit from having protocols in place guiding overall care., Conclusion: Pockets of care exist in hospitals where methods of effective diabetes management have been studied and implemented. However, there is no sustained continuum of care. Protocols and care teams that follow patients from one physical location to the other may result in improved clinical outcomes during and following a hospital stay., (Copyright © 2021 AACE. Published by Elsevier Inc. All rights reserved.)

Hyperglycaemia in people with and without diabetes admitted to the hospital is associated with a substantial increase in morbidity, mortality, and health-care costs. Professional societies have recommended insulin therapy as the cornerstone of inpatient pharmacological management. Intravenous insulin therapy is the treatment of choice in the critical care setting. In non-intensive care settings, several insulin protocols have been proposed to manage patients with hyperglycaemia; however, meta-analyses comparing different treatment regimens have not clearly endorsed the benefits of any particular strategy. Clinical guidelines recommend stopping oral antidiabetes drugs during hospitalisation; however, in some countries continuation of oral antidiabetes drugs is commonplace in some patients with type 2 diabetes admitted to hospital, and findings from clinical trials have suggested that non-insulin drugs, alone or in combination with basal insulin, can be used to achieve appropriate glycaemic control in selected populations. Advances in diabetes technology are revolutionising day-to-day diabetes care and work is ongoing to implement these technologies (ie, continuous glucose monitoring, automated insulin delivery) for inpatient care. Additionally, transformations in care have occurred during the COVID-19 pandemic, including the use of remote inpatient diabetes management-research is needed to assess the effects of such adaptations., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Thyroid uptake and scan (TUS) is a clinical tool used for differentiation of thyrotoxicosis etiologies. Although guidelines recommend ordering a TUS for evaluation of low TSH levels, no specific value is defined. This study aimed to determine a TSH cutoff at which TUSs yield a greater likelihood of successful determination of etiology to avoid unnecessary testing., Methods: This was a retrospective study on 137 patients seen by an endocrinologist who underwent TUS for evaluation of low TSH (<0.4 μU/mL). A receiver operating curve analysis was performed to determine the TSH cutoff with maximal sensitivity and specificity for prediction of diagnostic utility., Results: Ninety percent of TUSs (n = 123) led to a diagnosis, while 10% (n = 14) were inconclusive or normal. Diagnoses included Graves' diseases (52%), toxic multinodular goiter (19%), thyroiditis (12%), and solitary toxic adenoma (7%). The median TSH value was 0.008 μU/mL (IQR 0.005, 0.011), and the median free T4 value was 1.7 μU/mL (IQR 1.3, 2.8). The ROC analysis produced an area under the curve of 0.86. The optimal TSH cutoff value was 0.02 μU/mL (sensitivity 80%, specificity 93%) for prediction of diagnostic yield., Conclusion: This study demonstrates that TSH is a useful predictor of the utility of TUS in yielding an etiology of thyrotoxicosis. Our analysis showed that TUS had a greater likelihood of determining an etiology when TSH was ≤0.02 μU/mL. This information can help clinicians avoid unnecessary cost and patient time burden when TUS is unlikely to aid in determining the etiology of thyrotoxicosis.

Sodium-glucose cotransporter-2 (SGLT-2) inhibitors are an exceptionally versatile class of medication, and their glycemic and nonglycemic benefits could help millions of patients with type 2 diabetes. Of note, they have been shown to improve cardiac and renal outcomes, much-needed benefits in patients with type 2 diabetes, who are at a higher risk for developing cardiac and renal dysfunction than those who do not have diabetes. The indications for SGLT-2 inhibitors may continue to expand as ongoing clinical trials provide more insight into these drugs., (Copyright © 2021 The Cleveland Clinic Foundation. All Rights Reserved.)

Introduction: Insulin pumps are increasingly being used as a method of insulin delivery in patients with type 1 diabetes mellitus (T1DM). Diabetic ketoacidosis (DKA) is a serious complication of T1DM. This study aims to identify the causes of DKA in patients with T1DM on continuous subcutaneous insulin infusion (CSII) and to compare these with patients with T1DM on multiple daily insulin injections (MDIIs)., Research Design and Methods: This is a prospective observational study between January and June 2019 at the Cleveland Clinic Fairview Hospital. Demographic, clinical, and biochemical data were obtained from chart review. A questionnaire to explore additional clinical data relating to DKA was administered, with additional items for patients on the insulin pump., Results: Seventy-four patients were admitted with a diagnosis of DKA between the period of January and June 2019. Of these, 45 met the inclusion criteria and 43 consented. These were divided into two groups: group 1 included patients on MDII and group 2 included CSII. Overall, the most common precipitating factor for developing DKA was insulin non-adherence, seen in 51.2% of the cases. The most common cause of DKA in group 2 was pump/tubing related to 55% of the cases., Conclusion: Despite non-adherence being common in both CSII and MDII, a combination of social factors, education and insulin pump malfunction, such as pump/tubing problems, might be playing a pivotal role in DKA etiology in young adults with T1DM, especially in CSII users. Continued education on pump use may reduce the rate of DKA in pump users., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Medical tourism, a form of patient mobility across international borders to seek medical services, has gained significant momentum. We aimed to assess the outcomes of medical tourism consultations on chronic diseases, more specifically diabetes mellitus, amongst a cohort of international patients, originating from different healthcare systems, and referred to the United States for medical care., Methods: We identified international adults with established diabetes mellitus, referred globally from 6 countries to the United States between 2010 and 2016 for medical care, and were seen at the Cleveland Clinic Foundation (CCF). Group 1 included adults seen by an endocrinology provider during their CCF medical stay, whilst group 2 included those not seen by an endocrinology provider. To assess the impact of our consultations, changes in hemoglobin A1c (HbA1c) were assessed between visit(s)., Results: Our study included 1,108 subjects (771 in group 1, 337 in group 2), with a mean age (± SD) of 61.3±12.7 years, 62% male, and a median medical stay of 136 days (interquartile range: 57, 660). Compared to group 2, group 1 had a higher baseline mean HbA1c (8.0 ± 1.8% &lsqb;63.9 mmol/mol] vs. 7.1 ± 1.4% &lsqb;54.1 mmol/mol]; P<.001). After 1 visit with endocrinology, there was a significant decrease in mean HbA1c from 8.44 ± 1.98% (68.3 mmol/mol) to 7.51 ± 1.57% (58.5 mmol/mol) (P<.001). Greatest reductions in mean HbA1c were -1.47% (95% CI: -2.21, -0.74) and -1.27% (95% CI: -1.89, -0.66) after 3 and 4 visits, respectively (P<.001)., Conclusion: Short-term diabetes mellitus consultations, in the context of medical tourism, are effective., (© 2020 American Association of Clinical Endocrinologists. Published by Elsevier, Inc. All rights reserved.)

It has been well established that patients with diabetes who have COVID-19 have a more severe disease course and higher mortality. Providing adequate care for these patients has required hospitals to adapt protocols for monitoring blood glucose and administering therapy to protect both patient and caregiver safety. Inpatient use of continuous glucose monitoring systems or home-use glucose monitoring systems has provided options for reduced contact glucose monitoring. For therapy, protocols for managing hyperglycemia and diabetes ketoacidosis have been designed with less frequent monitoring and medication administration. Finally, telemedicine has allowed for consultative care in a manner not requiring physical proximity., (Copyright © 2020 The Cleveland Clinic Foundation. All Rights Reserved.)

Objective: The role of U300 glargine insulin for the inpatient management of type 2 diabetes (T2D) has not been determined. We compared the safety and efficacy of glargine U300 versus glargine U100 in noncritically ill patients with T2D., Research Design and Methods: This prospective, open-label, randomized clinical trial included 176 patients with poorly controlled T2D (admission blood glucose [BG] 228 ± 82 mg/dL and HbA 1c 9.5 ± 2.2%), treated with oral agents or insulin before admission. Patients were treated with a basal-bolus regimen with glargine U300 ( n = 92) or glargine U100 ( n = 84) and glulisine before meals. We adjusted insulin daily to a target BG of 70-180 mg/dL. The primary end point was noninferiority in the mean difference in daily BG between groups. The major safety outcome was the occurrence of hypoglycemia., Results: There were no differences between glargine U300 and U100 in mean daily BG (186 ± 40 vs. 184 ± 46 mg/dL, P = 0.62), percentage of readings within target BG of 70-180 mg/dL (50 ± 27% vs. 55 ± 29%, P = 0.3), length of stay (median [IQR] 6.0 [4.0, 8.0] vs. 4.0 [3.0, 7.0] days, P = 0.06), hospital complications (6.5% vs. 11%, P = 0.42), or insulin total daily dose (0.43 ± 0.21 vs. 0.42 ± 0.20 units/kg/day, P = 0.74). There were no differences in the proportion of patients with BG <70 mg/dL (8.7% vs. 9.5%, P > 0.99), but glargine U300 resulted in significantly lower rates of clinically significant hypoglycemia (<54 mg/dL) compared with glargine U100 (0% vs. 6.0%, P = 0.023)., Conclusions: Hospital treatment with glargine U300 resulted in similar glycemic control compared with glargine U100 and may be associated with a lower incidence of clinically significant hypoglycemia., (© 2020 by the American Diabetes Association.)

Objective: To determine predictors of prolonged length of stay (LOS), 30-day readmission, and 30-day mortality in a multihospital health system. Methods: We performed a retrospective review of 531 adults admitted with diabetic ketoacidosis (DKA) to a multihospital health system between November 2015 and December 2016. Demographic and clinical data were collected. Linear regression was used to calculate odds ratios (ORs) for predictors and their association with prolonged LOS (3.2 days), 30-day readmission, and 30-day mortality. Results: Significant predictors for prolonged LOS included: intensive care unit (ICU) admission (OR, 2.12; 95% confidence interval [CI], 1.38 to 3.27), disease duration (nonlinear) (OR, 1.28; 95% CI, 1.10 to 1.49), non-white race (OR, 1.73; 95% CI, 1.15 to 2.60), age at admission (OR, 1.03; 95% CI, 1.01 to 1.04), and Elixhauser index (EI) (OR, 1.21; 95% CI, 1.13 to 1.29). Shorter time to consult after admission (median [Q1, Q3] of 11.3 [3.9, 20.7] vs. 14.8 [7.4, 37.3] hours, P <.001) was associated with a shorter LOS. Significant 30-day readmission predictors included: Medicare insurance (OR, 2.35; 95% CI, 1.13 to 4.86) and EI (OR, 1.31; 95% CI, 1.21 to 1.41). Endocrine consultation was associated with reduced 30-day readmission (OR, 0.51; 95% CI, 0.28 to 0.92). A predictive model for mortality was not generated because of low event rates. Conclusion: EI, non-white race, disease duration, age, Medicare, and ICU admission were associated with adverse outcomes. Endocrinology consultation was associated with lower 30-day readmission, and earlier consultation resulted in a shorter LOS. Abbreviations: CI = confidence interval; DKA = diabetic ketoacidosis; EI = Elixhauser index; HbA1c = hemoglobin A1c; ICD = International Classification of Diseases; ICU = intensive care unit; LOS = length of stay; OR = odds ratio; Q = quartile.

Objective: Basal/basal-bolus insulin with discontinuation of home oral antidiabetes medications (OADs) is the preferred method to achieve glycemic control in many hospitalized patients. We hypothesized that a subset of patients with type 2 diabetes mellitus (T2DM) can achieve an acceptable level of blood sugar control without cessation of their OADs when hospitalized. Methods: A retrospective chart review was conducted on patients with T2DM who were only on OADs at home, admitted to Fairview Hospital, a community hospital in the Cleveland Clinic Health System. We divided patients into those whose OADs were continued (group 1) and those whose OADs were discontinued (group 2), with or without the addition of insulin in the hospital. Blood glucose (BG) levels and patient characteristics were compared. Results: There were 175 patients, 73 in group 1 and 102 in group 2. The percentage of patients achieving all BG values within 100 to 180 mg/dL was the same between group 1 (21.9%) and group 2 (23.8%) ( P = .78). Mean BG was similar between group 1 and group 2 (146.1 ± 41.4 mg/dL versus 152.1 ± 38.9 mg/dL; P = .33), with no significant difference in terms of percentage of patients with hyperglycemia or hypoglycemia. A greater proportion of patients in group 1 had an uninterrupted feeding status, nonintensive care unit admission and no contrast dye exposure, and a shorter length of stay. Conclusion: Our study shows that patients with certain characteristics could achieve an acceptable level of glycemic control without cessation of their home OADs. Abbreviations: BG = blood glucose; DPP-4 = dipeptidyl dipeptidase 4; GFR = glomerular filtration rate; HbA1c = hemoglobin A1c; ICU = intensive care unit; LOS = length of stay; NPO = nil per os; OAD = oral antidiabetes medication; POC = point of care; T2DM = type 2 diabetes mellitus.

Diabetes management is a tailored affair. Patients live with the disease for decades and need increasingly complicated treatment regimens to attain glycemic goals. But other goals such as cardiovascular risk reduction, weight control, and avoidance of hypoglycemia also need consideration., (Copyright © 2019 Cleveland Clinic.)

Background: Literature directly looking at post-bariatric surgery hypoglycemia consists mostly of small case series. The rate, severity, and outcomes of treatment in a large bariatric population are less characterized., Objective: To determine the rate of post-bariatric surgery hypoglycemia, its clinical features and management outcomes over a 13-year period at our institution., Setting: An academic center in the United States., Methods: Patients who underwent bariatric surgery at a single academic center between 2002 and 2015 and had a postdischarge glucose level of ≤70 mg/dL were studied., Results: Of 6024 patients who underwent bariatric procedure, 118 patients (2.0%) had a postoperative glucose level ≤70 mg/dL. Eighty-three patients (1.4%) had symptomatic hypoglycemia. The known underlying causes of symptomatic hypoglycemia included postprandial hyperinsulinemic hypoglycemia (n = 32, 38%), infection (n = 8, 10%), diabetic medications (n = 8, 10%), and poor oral intake (n = 8, 10%). Overall, 9 patients required intervention for nutritional supplementation including enteral (n = 9) and intermittent parenteral (n = 2) nutrition. No patients required reversal of their bariatric surgeries or pancreatic resection for management of hypoglycemia. The majority of the symptomatic patients had resolution of their symptoms (n = 76, 92%). Thirty-two patients had postprandial hypoglycemia with a median onset of hypoglycemia after bariatric surgery of 790 days (interquartile range 388-1334). All 32 patients with postprandial hypoglycemia had dietary adjustment and 53% received pharmacotherapy, which resulted in complete resolution of hypoglycemia (n = 29, 91%) and resolution with minimal disability (n = 3, 9%)., Conclusion: The rate of symptomatic hypoglycemia and postprandial hypoglycemia after bariatric surgery were 1.4% and .5%. The majority of patients were successfully managed with dietary counseling, nutritional intervention, and occasionally pharmacotherapy. No surgical reversal or pancreatic procedures were performed., (Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: There is a paucity of studies on transitions from IV insulin infusion (IVII) to subcutaneous (SC) insulin in the medical ICU (MICU)., Methods: We conducted a retrospective study of patients admitted to the Cleveland Clinic MICU from June 2013 to January 2014 who received IVII. We compared blood glucose (BG) control between 3 cohorts based on timing of basal insulin dose: (1) NB (no basal), (2) IB (incorrect basal), (3) CB (correct basal) at 5 time points post-IVII discontinuation (1, 4, 8, 12, and 24h). Insulin doses used for transitioning were compared with 80% of estimated 24h IVII total. Analysis was done using chi-square, ANOVA and t-tests., Results: There were 269 patients (NB 166, IB 45, CB 58), 55% male with a mean age 58±16years. 103 patients (38%) had a transition attempted (IB 21%, CB 17%). The NB cohort had better BG than the IB cohort at all time points (p<0.001) but also lower HbA1c, prior DM diagnosis and home insulin use (p<0.001). IB and CB did not have significantly different BG with mean BG>180mg/dL at 4/5 time intervals. However, the dose of basal insulin used was less than 80% of estimated 24h IVII total (IB 21.4 vs 49.6U, CB 25vs 57.1U). Despite this, 15% of patients in the IB cohort and 24% of patients in the CB had hypoglycemic events., Conclusion: The low rates of IV to SC insulin transitions raises the question of challenges to transitions., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objective: Though insulin dose reduction months after surgery is a well-studied outcome, there are limited data on immediate postoperative changes. The goals of the present study were to ( 1) To determine peri-operative glycemic control in patients with type 2 diabetes mellitus (DM) on insulin who have undergone Roux-en-Y gastric bypass (RYGB) and ( 2) to compare pre- and postoperative insulin regimens and dosages in these patients., Methods: A retrospective chart review was conducted on patients with type 2 DM on insulin who underwent RYGB surgery. Blood glucose (BG) levels and insulin doses were compared prior to surgery, on the day of surgery (DOS), and postoperative days (POD) 1 and 2. Subgroup analysis was performed to see if insulin dose was related to glucose control., Results: There were 114 subjects with a mean (SD) age of 52.8 ± 9.8 years, body mass index (BMI) 46.2 ± 8.0 kg/m 2 , glycated hemoglobin A1c (HbA1c) 8.3% (67 mmol/mol) ± 1.7%, and 66% on insulin plus noninsulin medications and 34% on insulin only. Mean blood glucose (BG) significantly decreased from the DOS (185 ± 43 mg/dL) through POD2 (160 ± 36, P<.0001). The median daily insulin dose significantly decreased from before surgery on usual diet (75 units [36, 116 interquartile range (IQR)]) through POD2 (6 [2, 15 IQR]), P<.0001). The median insulin dose per body weight decreased significantly from before surgery on usual diet (0.58 units/kg [0.35, 0.84 IQR]) through POD2 (0.04 [0.02, 0.11 IQR]), P<.0001). The subgroup with relatively good control experienced a larger percentage reduction in insulin requirements versus subjects with poor control., Conclusion: An 87.5% reduction in total daily insulin dose was seen by POD2. This will assist in developing algorithms for insulin titration postbariatric surgery., Abbreviations: BG = blood glucose DM = diabetes mellitus DOS = day of surgery HbA1c = glycated hemoglobin IQR = interquartile range IV = intravenous NPH = neutral protamine Hagedorn POD = postoperative day RYGB = Roux-en-Y gastric bypass SSRI = sliding scale regular insulin.

Evidence of a neurophysiologic mechanism that involves hormones from adipocytes, pancreatic islet cells, and the gastrointestinal tract implicated in both obesity and diabetes has led to a search for drugs that not only either target obesity and diabetes or reduce hemoglobin A1c, but also have weight loss as a potential side effect. The authors review medications approved for the treatment of type 2 diabetes mellitus (including pramlintide, also approved for type 1 diabetes) that also have weight loss as a side effect. Drugs discussed include glucagon-like peptide-1 (GLP-1) receptor agonists, sodium-glucose cotransporter-2 (SGLT-2) inhibitors, neuroendocrine peptide hormones, alpha-glucosidase inhibitors, and metformin. Where appropriate, the authors comment on the cardiovascular effects of these drugs., (Copyright © 2017 Cleveland Clinic.)

For individuals who are overweight or obese, weight loss is effective in preventing and improving the management of type 2 diabetes. Together with other lifestyle factors like exercise and behavior modification, diet plays a central role in achieving weight loss. Diets vary based on the type and amount of carbohydrate, fat, and protein consumed to meet daily caloric intake goals. A number of popular diets are reviewed as well as studies evaluating the effect of various diets on weight loss, diabetes, and cardiovascular risk factors. Current trends favor the low-carbohydrate, low-glycemic index, Mediterranean, and very-low-calorie diets. However, no optimal dietary strategy exists for patients with obesity and diabetes, and more research is needed. Given the wide range of dietary choices, the best diet is one that achieves the best adherence based on the patient's dietary preferences, energy needs, and health status., (Copyright © 2017 Cleveland Clinic.)

Objective: Endocrinologists are faced with a growing elderly patient population with diabetes mellitus (DM), some of whom are in skilled nursing facilities (SNFs). Efforts at managing their DM is hampered by concerns for hypoglycemia. This study aimed to determine the frequency of hypo- and hyperglycemia in SNFs, and associated factors., Methods: We reviewed medical records of 200 consecutive residents admitted to two SNFs in the Cleveland area in 2014 with documented DM, aged ≥65 years. Data collected included blood glucose (BG) levels and DM regimens. Frequency of hyper- and hypoglycemic events was noted. Since patients had different frequencies of BG checks, event-days were calculated., Results: Mean age, BG, and glycated hemoglobin (±SD) were as follows: 80.2 ± 8.2 years, 172.4 ± 40.3 mg/dL, and 7.5 ± 1.9% (59 mmol/mol), respectively. Seventy-one percent were on insulin alone, 15.5% on insulin and oral diabetes agents, and 13.5% on oral diabetes agent on admission. Patients with at least one event were as follows: 38% hypoglycemia, 3.5% severe hypoglycemia, 90.5% hyperglycemia, and 15% severe hyperglycemia. Event-days were: 3.4% hypoglycemia and 52.4% hyperglycemia. Risk of hypoglycemia was highest with concomitant sulfonylurea and prandial or sliding-scale insulin. Hyperglycemia risk was high in basal insulin-containing regimens., Conclusion: Hypoglycemia was seen in one-third of patients, and hyperglycemia was common despite insulin use. Concomitant use of sulfonylurea and prandial or sliding-scale insulin is best avoided in this fragile population with hypo- and hyperglycemia., Abbreviations: ADA = American Diabetes Association BG = blood glucose DM = diabetes mellitus GLP-1 = glucagon-like peptide 1 HBA1c = glycated hemoglobin LOS = length of stay NPH = neutral protamine Hagedorn SNF = skilled nursing facility SSI = sliding-scale insulin.

Background and Objective: The purpose of this study was to identify whether endocrinologists and primary care physicians (PCP) adequately screen for ophthalmic symptoms/signs within office visits and provide timely ophthalmology referrals in patients with diabetes., Patients and Methods: Patients between the ages of 18 years and 80 years with diabetes who underwent an office visit with an endocrinologist or a PCP between January 1, 2014, and December 31, 2014, were identified. Demographics, ophthalmic assessments, and referral information were collected., Results: A total of 1,250 patient records were reviewed. Providers asked about ophthalmic symptoms/signs in 95.5% and 71% of endocrinology and primary care office encounters, respectively (P < .0001). Past and/or future ophthalmology appointments were verified in 86.1% and 49.7% of patients during endocrinology and PCP visits, respectively (P < .0001)., Conclusions: Ophthalmic complications from diabetes are not adequately screened, especially within the primary care setting, and further quality improvement measures may improve adherence to recommended screening protocols. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:930-934.]., (Copyright 2016, SLACK Incorporated.)

Purpose: To evaluate the effect of systemic factors on best-corrected visual acuity (BCVA) achieved with ranibizumab (Lucentis; Genentech, Inc, South San Francisco, CA) for treatment of diabetic macular edema (DME) in the RIDE and RISE phase 3 studies., Design: Exploratory, post hoc analysis of 2 randomized, double-masked, sham-injection controlled studies., Participants: Adults with DME, BCVA of 20/40 to 20/320 Snellen equivalent, and central foveal thickness of 275 μm or more., Methods: Analysis of RIDE (clinicaltrials.gov identifier, NCT00473382) and RISE (clinicaltrials.gov identifier, NCT00473330) pooled ranibizumab data through month 24. Change in BCVA was assessed for association with the following covariates: age, body mass index (BMI), blood pressure, serum glucose, glycosylated hemoglobin (HbA1c), blood urea nitrogen, serum creatinine, estimated glomerular filtration rate, and blood chemistry variables. Change in BCVA at month 24 was assessed according to the following categories of diabetes medication use history: insulin only (n = 193), insulin plus other medications (n = 221), or other noninsulin medications (n = 331)., Main Outcome Measures: Change in BCVA from baseline assessed by randomized treatment group in pooled 0.3- and 0.5-mg monthly ranibizumab groups., Results: In patients with DME, vision improvement with ranibizumab was not influenced by systemic factors such as diabetes medication history, serum glucose, HbA1c, renal function, BMI, and blood pressure. Patients taking insulin with or without other medications at baseline had longer diabetes disease duration (mean, 17.4 and 20.9 years, respectively) compared with those taking other noninsulin medications (mean, 11.9 years). At month 24, among ranibizumab-treated patients, the mean BCVA change from baseline (Early Treatment Diabetic Retinopathy Study letters ± standard deviation) was not different between patients taking only insulin (12.6±11.2 letters), insulin plus other medications (12.2±12.4 letters), or other noninsulin medications (14.0±13.7 letters). Mean BCVA change also was comparable among patients taking thiazolidinediones (12.9±9.7 letters) and those not taking thiazolidinediones (13.2±13.3 letters)., Conclusions: There were no associations between systemic factors (baseline values or change from baseline) and mean change of BCVA at month 24. These results suggest that visual response to ranibizumab therapy in DME was not influenced by nonocular factors related to systemic management of diabetes in the RIDE and RISE studies., (Copyright © 2016 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Inpatient hyperglycemia is common and is associated with an increased risk of hospital complications, higher healthcare resource utilization, and higher in-hospital mortality rates. Appropriate glycemic control strategies can reduce these risks, although hypoglycemia is a concern. In critically ill patients, intravenous (IV) insulin is most appropriate, with a starting threshold no higher than 180 mg/dL. Once IV insulin is started, the glucose level should be maintained between 140 and 180 mg/dL. In noncritically ill patients, basal-bolus regimens with basal, prandial, and correction components are preferred for those with good nutritional intake. In contrast, a single dose of long-acting insulin plus correction insulin is preferred for patients with poor or no oral intake. Measuring hemoglobin A1c at admission is important to assess glycemic control and to tailor the treatment regimen at discharge., (Copyright © 2016 Cleveland Clinic.)

The use of intra-articular (IA) glucocorticoids for reducing pain and inflammation in patients with osteoarthritis, rheumatoid arthritis, and other inflammatory arthropathies is widespread among primary care physicians, specialists, and non-specialists in the United States. Injectable glucocorticoids have anti-inflammatory and analgesic properties which can be effective in improving clinical parameters such as pain, range of motion, and quality of life. After injection into the IA space, glucocorticoids may be systemically absorbed; the degree of absorption can depend on the size of the joint injected, the injectable glucocorticoid preparation used, the dosage, and the frequency of the injection. The adverse effects of intra-articular glucocorticoid injections (IAGC) can often be overlooked by both the patient and physicians who administer them, in particular the potential deleterious effect on the hypothalamic-pituitary-adrenal (HPA)-axis which can result in adrenal suppression and/or iatrogenic Cushing syndrome. In this paper we provide an overview on the often under-recognized effects of IAGC on HPA-axis function.

Objective: U-500 is a potent insulin used in patients with severe insulin resistance. This study aimed to describe the inpatient insulin requirements, insulin regimens, and glycemic control of hospitalized patients using U-500., Methods: A retrospective chart review of adult patients using U-500 insulin at home who were admitted to Cleveland Clinic hospitals between 2001 and 2011 was performed. Two groups were compared: those who were given U-500 while hospitalized (Group A) and those who were switched to a different insulin regimen (Group B). The percentages of hypoglycemia days and hyperglycemia days were calculated as the number of days with the respective event divided by the length of stay (LOS) in days for each patient., Results: There were 61 patients, 59% of which were male, with a median body mass index (BMI) 38.4, age 60.8 years, hemoglobin A1c 8.9% or 74 mmol/mol, and LOS 5.0 days. The majority (66%) remained on a U-500-based insulin regimen, while the rest were switched to a combination of long-, intermediate-, short- and/or fast-acting insulin. The endocrinology service was consulted for 61% of patients. Glucose levels were not significantly different between the 2 groups. Group B was given less insulin in the hospital compared to their home regimen. Group A had more frequent hypoglycemia days (mean ± SD: 15.3 ± 21.3 vs. 2.8 ± 6.4%) and more frequent severe hyperglycemia days (16.8 ± 21.8 % vs. 6.3 ± 9.8%) than Group B., Conclusion: This study suggests that there is a subset of patients on U-500 at home who might be managed on conventional insulin in the hospital. Patients who remain on U-500 in the hospital tend to continue with a high insulin dose requirement, which might predispose them to more frequent hypoglycemia.