Inpatient Glycemic Control on the Vascular Surgery Service

ObjectiveTo describe a structured inpatient insulin management protocol and order set for glycemic control on a vascular surgery service.MethodsPatients admitted to the vascular surgery service with underlying diabetes were enrolled in a study of use of a preprinted basal-bolus insulin order set based on a total daily dose of 0.5 U/kg (0.25 U/kg of insulin glargine and 0.25 U/kg of insulin aspart divided into 3 equal mealtime doses). Outcomes included the mean glycemic control at each of 5 established time intervals, the percentage of blood glucose measurements within the target range of 70 to 180 mg/dL, the incidence of hypoglycemia, and the insulin dosages. Historical control patients with diabetes from the same hospital service were used for comparison.ResultsBoth the study group and the control group consisted of 26 patients. The number of finger-stick blood glucose measurements performed was 871 in the control group and 896 in the intervention group. The mean blood glucose level (± SD) for the intervention group was 149.4 ± 50.7 mg/dL, in comparison with 165.2 ± 64.4 mg/dL for the control group. The incidence of hypoglycemia decreased 50% in the intervention group—from 32 (4% of the finger-stick assessments in the control group) to 19 (2% of the finger-stick blood glucose measurements in the study group). The blood glucose target range of 70 to 180 mg/dL was achieved in 75% of the measurements in the study group versus 61% in the control group. The basal insulin dose was unchanged in 65% of the patients, and of the 9 patients requiring a change in the dose, 5 had the dose decreased by 10% and 4 had the dose increased by 10%.ConclusionThe use of a standardized basal-bolus weight-based insulin regimen was successful at achieving improved glycemic control as well as reducing the incidence of hypoglycemia in an inpatient population with diabetes. (Endocr Pract. 2008;14:185-192)     

Benchmarking Glycemic Control In U.S. Hospitals

ObjectiveReport data on glucose control from 635 U.S. hospitals.MethodsPoint-of-care blood glucose (POC-BG) test data from January through December 2012 from 635 facilities were extracted. Glucose control was evaluated using patient-day–weighted mean POC-BG values. We calculated hypoglycemia and hyperglycemia rates, stratified by presence or absence of intensive care unit (ICU) admission, and we evaluated the relationship between glycemic control and hospital characteristics.ResultsIn total, 51,375,764 POC-BG measurements (non-ICU, 39,197,762; ICU, 12,178,002) from 2,612,966 patients (non-ICU, 2,415,209; ICU, 575,084) were analyzed. The mean POC-BG was 167 mg/dL for non-ICU patients and 170 mg/dL for ICU patients. The prevalence of hyperglycemia (defined as glucose value > 180 mg/dL) was 32.3 and 28.2% in non-ICU and ICU patients, respectively. The prevalence of hypoglycemia (defined as glucose value < 70 mg/dL) was 6.1 and 5.6% in non-ICU and ICU patients, respectively. In non-ICU and ICU settings, the patient-day–weighted mean glucose was highest in the smallest hospitals, in rural hospitals, and in hospitals located in the Northeast (all P < .01). For non-ICU patients, we observed a significant difference in the percentage of patient days with hypoglycemia by geographic region only (P < .001). In ICU patients, the prevalence of hypoglycemia varied significantly by hospital type (P < .03) and geographic region (P < .01).ConclusionIn this largest POC-BG data set analysis conducted to date, glycemic control varied according to hospital characteristics. Our findings remain consistent with previous reports. Among other variables, national benchmarking of inpatient glucose data will need to consider differences in hospital characteristics. (Endocr Pract. 2014;20:876-883)     

Factors Associated with Glycemic Control in Patients with Type 2 Diabetes Mellitus in Rural Areas of the United States

Background: According to the US Department of Health and Human Services, an estimated 18.2 million Americans, or 6.3% of the population, has diabetes mellitus (DM). Approximately 90% of these individuals have type 2 DM. The most widely used clinical test for defining glycemic control is measurement of blood glycosylated hemoglobin (AIC).Objective: The goal of this study was to estimate the proportion of diabetic patients who achieved the AIC goal of _<7.0% in a rural western Pennsylvania practice and to determine the factors that influence the achievement of the AIC goal.Methods: This was an observational study conducted in a rural family medicine office in Clarksburg, Pennsylvania. To be included in the study, patients had to have been diagnosed with type 2 DM >2 years prior, had to be aged >18 years, and had to be adhering to a medical nutrition therapy diet. Both univariate analysis and logistic regressions were used to identify the factors that were associated with the outcome.Results: A total of 136 diabetic patients were included in the study (70 men, 66 women; mean [SD] age, 59.7 [15.2] years). AIC of <7.0% was attained in 75.0% (n = 102) of the patients. Although the majority of patients were obese (69.1% [n = 94] with a body mass index >30 kg/m2), weight was not a factor in reaching AIC goal. The data showed that those patients who were older (62.3 vs 51.9 years; P = 0.004), using oral antidiabetic medication (96.1% vs 87.9%; P = 0.100), and not using insulin (86.3% vs 69.7%; P = 0.030) were more likely to achieve AIC goal. The proportion of patients achieving AIC goal levels decreased as the number of oral medications used increased.Conclusions: In this rural area of western Pennsylvania, the majority of our type 2 DM patients achieved glycemic control (ie, AIC <7.0%). The primary care physician, along with a DM care team, should address the issues of diet, exercise, weight management, and other comorbid illnesses to properly manage patients with type 2 DM. (Insulin. 2007;2:134-141)     

Encephalitis Hospitalization Rates and Inpatient Mortality in the United States, 2000-2010

Background

Encephalitis rates by etiology and acute-phase outcomes for encephalitis in the 21^st century are largely unknown. We sought to evaluate cause-specific rates of encephalitis hospitalizations and predictors of inpatient mortality in the United States.

Methods

Using the Nationwide Inpatient Sample (NIS) from 2000 to 2010, a retrospective observational study of 238,567 patients (mean [SD] age, 44.8 [24.0] years) hospitalized within non-federal, acute care hospitals in the U.S. with a diagnosis of encephalitis was conducted. Hospitalization rates were calculated using population-level estimates of disease from the NIS and population estimates from the United States Census Bureau. Adjusted odds of mortality were calculated for patients included in the study.

Results

In the U.S. from 2000–2010, there were 7.3±0.2 encephalitis hospitalizations per 100,000 population (95% CI: 7.1–7.6). Encephalitis hospitalization rates were highest among females (7.6±0.2 per 100,000) and those <1 year and >65 years of age with rates of 13.5±0.9 and 14.1±0.4 per 100,000, respectively. Etiology was unknown for approximately 50% of cases. Among patients with identified etiology, viral causes were most common (48.2%), followed by Other Specified causes (32.5%), which included predominantly autoimmune conditions. The most common infectious agents were herpes simplex virus, toxoplasma, and West Nile virus. Comorbid HIV infection was present in 7.7% of hospitalizations. Average length of stay was 11.2 days with mortality of 5.6%. In regression analysis, patients with comorbid HIV/AIDS or cancer had increased odds of mortality (odds ratio [OR]  = 1.70; 95% CI: 1.30–2.22 and OR = 2.26; 95% CI: 1.88–2.71, respectively). Enteroviral, postinfectious, toxic, and Other Specified causes were associated with lower odds vs. herpes simplex encephalitis.

Conclusions

While encephalitis and encephalitis-related mortality impose a considerable burden in the U.S. in the 21^st Century, the reported demographics of hospitalized encephalitis patients may be changing.     

Inpatient Hypoglycemic Events in a Comparative Effectiveness Trial for Glycemic Control in a High-Risk Population

Objective: Inpatient hypoglycemia (glucose ≤70 mg/dL) is a limitation of intensive control with insulin. Causes of hypoglycemia were evaluated in a randomized controlled trial examining intensive glycemic control (IG, target 140 mg/dL) versus moderate glycemic control (MG, target 180 mg/dL) on post–liver transplant outcomes.Methods: Hypoglycemic episodes were reviewed by a multidisciplinary team to calculate and identify contributing pathophysiologic and operational factors. A subsequent subgroup case control (1:1) analysis (with/without) hypoglycemia was completed to further delineate factors. A total of 164 participants were enrolled, and 155 patients were examined in depth.Results: Overall, insulin-related hypoglycemia was experienced in 24 of 82 patients in IG (episodes: 20 drip, 36 subcutaneous [SQ]) and 4 of 82 in MG (episodes: 2 drip, 2 SQ). Most episodes occurred at night (41 of 60), with high insulin amounts (44 of 60), and during a protocol deviation (51 of 60). Compared to those without hypoglycemia (n = 127 vs. n = 28), hypoglycemic patients had significantly longer hospital stays (13.6 ± 12.6 days vs. 7.4 ± 6.1 days; P = .002), higher peak insulin drip rates (17.4 ± 10.3 U/h vs. 13.1 ± 9.9 U/h; P = .044), and higher peak insulin glargine doses (36.8 ± 21.4 U vs. 26.2 ± 24.3 U; P = .035). In the case-matched analysis (24 cases, 24 controls), those with insulin-related hypoglycemia had higher median peak insulin drip rates (17 U/h vs. 11 U/h; P = .04) and protocol deviations (92% vs. 50%; P = .004).Conclusion: Peak insulin requirements and protocol deviations were correlated with hypoglycemia.Abbreviations:DM = diabetes mellitusICU = intensive care unitIG = intensive glycemic controlMELD = Model for End-stage Liver DiseaseMG = moderate glycemic controlSQ = subcutaneous     

Breastfeeding in the United States

The breastfeeding of US infants born in 1974-76 is analyzed using data form the 1976 National Survey of Family Growth. Life table estimates of the proportion of children breastfed by duration since birth and mean breastfeeding durations are presented. The life tables reported are constructed by standard cohort table methods. To compare life tables for children of mothers in various attribute categories, generalised Wilcoxon tests are used, together with multiple classification analysis for continuation at select durations. Variables considered include mother's age at the birth, ethnicity, educational level, education by ethnicity, region of residence and the child's birth order. Findings are restricted to infants remaining with their mothers for at least 2 months following delivery and surviving as of the survey date in January-September 1976. It is found that the proportion of infants breastfed was increasing rapidly, with the highest rates found among white (39%), college-educated (56%), western (56%) mothers and lowest rates among black mothers (17%) mothers with less than a high school education (19%) and mothers living in the south (24%). By age, the highest proportions are mothers at ages 25-29 (44%), followed closely by the mothers under 25 (29%). The proportions breastfeeding were also found to be higher in urban than in rural areas (38% vs. 28%) and higher at parities 1-2 (29%). A multiple classification analysis of the factors most strongly influencing breastfeeding in 1975 shows educational level to be the strongest single predictor of breastfeeding, followed by western residence and white ethnicity. Age effects were found to correlate strongly with education. Reviewing 1971-1981 changes, the proportion of mothers with less than a college education who breastfed their children increased from 19% to 51% over the decade, while the proportion among college-educated mothers rose from 42% to 74%. For children who were breastfed, the median duration was about 4.5 months. The mean was 5.5 months, with a range from about 3.0 months among black mothers with less than a high school education, to 6.0 months among college-educated white women. The nationwide changes in breastfeeding patterns and duration may confer modest health benefits on current generations of youngsters, although not benefits that are easily measured, since human milk substitutes are routinely subjected to rigourous testing for nutritional adequacy.     

Breastfeeding in the United States

Abstract

The breastfeeding of U.S. infants born in 1974–76 is analyzed using data from the 1976 National Survey of Family Growth. It is found that the proportion of infants breastfed was increasing rapidly, with the highest rates found among white, college‐educated, western mothers and lowest rates among black mothers and mothers with less than a high‐school education. For children who were breastfed, the median duration was about 4.5 months and the mean 5.5 months, also with marked differences by ethnicity, education, and region. Data from other sources confirm these differences and quantify subsequent increases in breastfeeding.     

Necropsy rates in the United Birmingham Hospitals.

The necropsy rate in the United Birmingham Hospital has fallen from 74-4% in 1958 to 46-0% in 1972. In the Birmingham region as a whole the rate is 27-3%, approximately equal to the national rate. Most clinicians in the group who replied to a standard questionary considered that the necropsy still has an important part to play in their own practice and in undergraduate training, and they viewed the declining rate as a matter for concern. Some measure of disagreement was found between the ante-mortem and post-mortem diagnoses of patients in the two largest hospitals in the group. This suggests that the necropsy has a role to play in medical audit and that attempts to reverse the declining trend should be encouraged.