Hyperglycaemia in patients with no history of diabetes presenting to Internal Medicine Departments.

AIMS: Stress hyperglycaemia during hospitalisation may be the first sign of diabetes mellitus (DM). Most hospitals routinely measure blood glucose, which may enable early diagnosis. This study measured the prevalence of hyperglycaemia in hospitalised adults with no history of diabetes, and whether the discharge summary recommended work-up. METHODS: Files with at least one random blood glucose (RBG) sample were included and reviewed for specific discharge recommendations concerning elevated blood glucose. Hyperglycaemia was defined as serum glucose > 200 mg/dl. Length of stay, in-hospital mortality and 3-year mortality were examined. RESULTS: Among 5274 discharged patients, 1479 had DM. They were older and had a higher incidence of cerebrovascular risk factors. Among 3714 patients without known DM, 211 (5.7%) had at least one RBG > 200 mg/dl. Of these patients, 31 died and 24 left against medical advice. Of the remaining 156, 25(16%) files included instructions to the family physician. These patients were younger, more overweight and less frequently diagnosed with dementia or other mental illness. Patients with RBG > 200 mg/dl had prolonged hospital stay (6.5 ± 5.3 vs. 4.0 ± 4.8; p < 0.001). In-hospital mortality and 3-year mortality were increased by 5.1 and 1.89, respectively (p < 0.001 for both parameters) compared to those without RBG ≤ 200 mg/dl. RBG > 200 mg/dl emerged as a significant, independent predictor of prolonged hospital stay and death. CONCLUSIONS: Random blood glucose > 200 mg/dl is common in medical departments and is associated with increased in-hospital and 3-year out-hospital mortality.

The use of continuous glucose monitoring systems in a pediatric population with type 1 diabetes mellitus in real-life settings: the AWeSoMe Study Group experience.

AIMS: The aim of the study was (a) to compare annual glycemic control in pediatric patients with type 1 diabetes mellitus (T1DM) who used a healthcare-funded continuous glucose monitoring system (RT-CGMS) to that of those who performed self-monitoring blood glucose (SMBG) only, in a real-life setting, and (b) to define parameters associated with compliance and glycemic control. METHODS: A total of 149 youth with T1DM (52.3 % females), mean age 11.8 ± 3.6 years, and 83 in the CGMS group were followed prospectively for 12 months. Glycemic control parameters and compliance to RT-CGMS were assessed periodically. RESULTS: Glycemic parameters did not differ significantly between the groups during follow-up periods. The time spent with RT-CGMS decreased and only 38 % used it for more than 75 % of the time during the 12 months (consistent users). Mean HbA1c decreased by 0.27 % in consistent users and increased by 0.21 % among intermittent users (used RT-CGMS less than 75 % of time), p = 0.013. Consistent users were younger 10. 6 ± 4.2 vs. 12.5 ± 3.6, p = 0.07, and had higher frequency of SMBG at baseline, 10.6 ± 4.9 vs. 6.3 ± 2.8, p = 0.011. CONCLUSIONS: The adoption of RT-CGMS was low, even in a healthcare system that funds its use. Caregivers should consider patient characteristics when recommending RT-CGMS use.

Inpatient hyperglycaemia improvement quality program.

BACKGROUND: Poorly controlled hyperglycaemia is associated with increased morbidity and mortality in hospitalised patients. Based on the view that hospitalisation provides a window of opportunity to improve patient quality of care and health status, a comprehensive program for treating hospitalised diabetic patients was initiated. This study assessed the effectiveness of the Inpatient Hyperglycaemia Improvement Quality Program (IHIQP) over a 4-year period. METHODS: Pre-test post-test design. In the pre-intervention period (August-December 2007), an institution-wide blood glucose monitoring system was introduced in August 2007. The remaining program components were introduced in January 2008, including implementing a hospital care protocol based on the 2007 American Diabetes Association Standards, a multidisciplinary team that participates in patient care and arranges continuing care after discharge and comprehensive patient education prior to discharge. Program results from January 2008 through October 2011 were evaluated. RESULTS: During follow-up, more than 600,000 blood glucose tests were performed. Blood glucose values declined from 196.4 ± 98.4 mg/dl pre-IHIQP (August-December 2007) to 174.5 ± 82.0 mg/dl post-IHIQP (January-October 2011) (p < 0.0001). Prevalence of glucose values lower than 60 mg/dl declined from 2% to 1.3% (p < 0.004). Prevalence of glucose values ≥ 300 mg/dl declined from 13.6% to 8.4% (p < 0.0001). Concomitantly, the proportion of in-target values of 80-180 mg/dl increased from 47.7% to 58.1% (p < 0.0001). CONCLUSION: This in-patient hyperglycaemia quality improvement program led to improvements in-patient glycaemic control, which continued over time. The effect of this improvement on in-patient mortality and morbidity needs additional follow-up.

Opinion and knowledge among hospital medical staff regarding diagnosis of diabetes and proper usage of a specific test tube for glucose analysis.

BACKGROUND: Accuracy of blood sugar values, as examined by glucose analysis, has significant importance on the diagnosis of diabetes and follow up of diabetes treatment. Usage of a designated test tube significantly improves the accuracy of measurement. Knowledge of the medical staff is a major determinant in the current usage of such a technology. The aim of the study was to assess the level of knowledge exhibited by medical staff in the diabetes field and specifically for the usage of a designated tube to test blood glucose level. METHODS: A prospective study. The staff of the internal and surgical departments and outpatient clinics at the Wolfson Medical Center completed a questionnaire that assessed the level of knowledge about the designated glucose test tube, other randomly used test tubes, the parameters that influence the blood glucose values in a non-designated tube and the diagnosis of diabetes. RESULTS: A number of 160 questionnaires (50% from internal departments, 36% from surgical departments and 14% from outpatient clinics) were analysed. The majority of the staff members (65%) knew that diabetes is diagnosed by glucose levels in blood. Of the 35% that did not know, 91% were nurses. The majority (75%) knew that diabetes is diagnosed during fasting conditions; however, most of the staff indicated that 12 h is needed. Only 25% knew of the designated test tube, and most of the staff indicated that a regular chemistry tube was the tube of choice for them. The staff exhibited poor level of knowledge regarding the parameters that influence the quality of the test. CONCLUSIONS: Staff members are not aware of the various aspects of diabetes diagnosis and the designated test tube for glucose measurements, and most of them use a tube that gives inaccurate measurements, therefore there is an urgent need to improve diabetes knowledge among staff members.

Parental sleep quality and continuous glucose monitoring system use in children with type 1 diabetes.

To compare sleep quality and sleep-wake patterns in parents of children with type 1 diabetes before routine use of the continuous glucose monitoring system (CGMS) and while using it. Thirteen parents completed the Pittsburg Sleep Quality Index (PSQI), a 7-day sleep diary, and wore an actigraph (a wristwatch-size motion detector) during the night for 1 week before pediatric use of CGMS and 4-8 weeks after initiating routine use of the CGMS. Mean age of parents (ten mothers, three fathers) was 39 (range 32-47) years; mean age of children was 9.3 years (range 5.5-16.5 years); mean disease duration was 3.4 (range 0.6-11.2) years. PSQI total score demonstrated similar quality of sleep with and without use of the CGMS (4.6 and 4.9, respectively, p = 0.45). Six of the 13 parents reported severe sleep problems (PSQI ≥ 5) with and without the CGMS. The sleep diary indicated a greater number of awakening episodes during CGMS use than without the CGMS (1.6 and 1, respectively, p = 0.03), and actigraphy documented an increase in the number of wake bouts (22.9 and 19.7, p = 0.03) as well as in total wake time (48.3 and 42.2 min, p = 0.03) during CGMS use as compared with the period prior to CGMS use. Although self-perception of sleep quality remained unchanged, CGMS use appeared to affect actual parental sleep continuity somewhat negatively. This should be made clear to parents who may hold expectations of improvement in sleep quality following initiation of CGMS use.

Jewish New Year associated with decreased point of care glucose in hospitalised patient population.

BACKGROUND: In individuals with diabetes, glycaemic control has been shown to be disrupted during the winter holiday period. OBJECTIVES: The aim of this study was to examine whether blood glucose levels are influenced by the Jewish New Year period in hospitalised individuals with diabetes. METHODS: At E. Wolfson Medical Center, Holon, Israel, blood glucose values from individuals hospitalised in internal medicine units were collected and analysed during the period surrounding Rosh Hashanah, the Jewish New Year, 2010. Values obtained from 4 to 7 September 2010 were categorised as preholiday values; values from 8 to 11 September 2010 were classed as holiday values; and values from 12 to 15 September 2010 were labelled postholiday values. All values were collected at point of care (POC) using an automated, institutional glucometer located in each department, the data from which is downloaded to a central database. RESULTS: A total of 3403 POC glucose values were recorded during the observation period. POC glucose values were significantly lower during the Rosh Hashanah holiday than the pre holiday or postholiday periods: 176.8 ± 81.3 mg/dl vs. 181.4 ± 78.8 mg/dl or 184.9 ± 83.02 mg/dl, p = 0.03. During the Rosh Hashanah holiday, mean patient age was significantly older than the preholiday or postholiday period: 77.4 ± 10.9 years vs. 74.9 ± 12.0 years or 75.3 ± 11.8 years, p < 0.0001; however, age predicted less than 1% of the variability in POC glucose: r = 0.02, p = 0.23. Significantly more women were hospitalised during the preholiday than during the holiday or postholiday periods. In a linear regression model, holiday period remained a significant independent predictor of POC glucose even after controlling for age and gender. CONCLUSIONS: Point of care glucose was significantly lower during the Rosh Hashanah period relative to preholiday and postholiday values. This may reflect a shift in the composition of the hospitalised patient population during the holidays towards older individuals with more restricted dietary intake.

Palmitate induced lipoapoptosis of exocrine pancreas AR42J cells.

Chronic surplus of dietary consumption, typical to obesity, results in overflow of fat to non-adipose tissues. Intracellular accumulation of fat in non-adipose tissues is associated with cellular dysfunction and cell death and ultimately contributes to the pathogenesis of chronic diseases. The influence of fat overflow on the exocrine pancreas is not known. The purpose of this research was to study the lipotoxic and lipoapoptotic effect of prolonged (72 h) long chain saturated palmitic fatty acid (0.1 mM) on the survival of exocrine pancreas AR42J cells. We demonstrate that chronic exposure of AR42J cells to palmitic acid results in significant increase in triglycerides accumulation (up to 25% of cells area), compared to untreated cultures. Lipid accumulation prompted a typical apoptotic process, demonstrated by both DNA fragmentation and condensed chromatin appearance (DAPI staining). Quantitative real-time PCR studies demonstrated that prolonged palmitic acid supplementation induced down-regulation of the anti-apoptotic Bcl2 mRNA levels (22%) and up-regulation of the pro-apoptotic Bax mRNA levels (300%), leading to disruption of the pro/anti apoptotic balance (Bax/Bcl2=3). No major change was detected in iNOS mRNA expression. In conclusion, prolonged exposure to saturated palmitic acid induces lipoapoptosis in exocrine pancreatic AR42J cells, through disturbance of the Bax/Bcl-2 balance.

Clinical characteristics of the West Nile fever outbreak, Israel, 2000.

West Nile (WN) virus is endemic in Israel. The last reported outbreak had occurred in 1981. From August to October 2000, a large-scale epidemic of WN fever occurred in Israel; 417 cases were confirmed, with 326 hospitalizations. The main clinical presentations were encephalitis (57.9%), febrile disease (24.4%), and meningitis (15.9%). Within the study group, 33 (14.1%) hospitalized patients died. Mortality was higher among patients >70 years (29.3%). On multivariate regressional analysis, independent predictors of death were age >70 years (odds ratio [OR] 7.7), change in level of consciousness (OR 9.0), and anemia (OR 2.7). In contrast to prior reports, WN fever appears to be a severe illness with high rate of central nervous system involvement and a particularly grim outcome in the elderly.

Heparin-like inhibitory activity to fibroblast growth factor-2 in wound fluids of patients with chronic skin ulcers and its modulation during wound healing.

Fibroblast growth factors are potent mitogens and angiogenic factors which play a critical role in wound healing. Fibroblast growth factors require heparan sulfates as cofactors in order to activate their cognate receptors and exert their cellular and biological effects. Heparan sulfates were extracted from wound fluids of 5 patients with chronic diabetic foot ulcers or chronic venous stasis ulcers and tested for their capacity to modulate fibroblast growth factor-receptor binding, during the course of the ulcers' resolution, until complete healing (3-8 months). Total heparan sulfates concentration measured as iduronic acid equivalents, decreased in wound fluids from 1.1 +/-0.3 microg/ml to 0.26 +/-0.1 microg/ml as wound healing progressed. These heparan sulfates exhibited a predominant inhibitory effect on fibroblast growth factor-2 binding to fibroblast growth factor receptor-1, when tested in cells deficient in cell surface heparan sulfates. During wound healing, there was a marked decrease in the relative inhibitory activity of the extracted heparan sulfates on fibroblast growth factor-2-receptor binding. Heparan sulfates extracted from chronic skin ulcers of different etiologies such as diabetic foot or chronic venous stasis ulcers showed the same pattern of alternating balance in heparan sulfates mediated activity. The presence of fibroblast growth factor inhibitory factors which possess heparin-like activity in fluids of chronic skin ulcers and their ability to modulate fibroblast growth factor-receptor activity throughout the process of wound healing, may significantly contribute to the mechanism of chronicity. Treatments to counter this inhibition may offer new possibilities for healing chronic wounds.

Topical hyperbaric oxygen and low energy laser therapy for chronic diabetic foot ulcers resistant to conventional treatment.

Chronic foot ulcers are common in long-standing diabetes, may herald severe complications and are often resistant to therapy. To evaluate the effects of adjunctive topical hyperbaric oxygen treatment (THBO) and low energy laser (LEL) irradiation on ulcer healing, a 100 consecutive patients with chronic diabetic foot ulcers (DFU) refractory to 4.5 +/- 1.2 months of comprehensive treatment, were enrolled in a prospective open study. While conventional treatment was continued as necessary, THBO was administered by pumping 100 percent oxygen into a disposable sealed polythylene hyperbaric chamber (150 min x 2 to 3/wk at up to 1.04 atm). Helium-neon LEL irradiation was given concurrently using a Unilaser Scan Unit at 4 J/cm2 for 20 min. Some patients continued THBO at home or their treatment was confined to THBO at home. Patients were monitored every two weeks revealing 81 percent cure after 25 +/- 13 treatments over 3.2 +/- 1.7 months. On follow-up (median 18 months), only 3/81 (4 percent) had reulceration, which responded to THBO/LEL retreatment. Nonresponders had significantly lower ankle brachial indices (ABI) than patients whose ulcers were healed (0.55 vs. 0.78, p < 0.01) and ultimately required amputation. Patient compliance was full and no adverse events occurred. In conclusion, although the study was open and uncontrolled, an 81 percent healing of DFU in patients who previously did not respond to a comprehensive treatment program, constitutes an intriguing preliminary result. Thus, THBO/LEL therapy may be a safe, simple, and inexpensive early adjunctive treatment for patients with chronic diabetic foot ulcers. Our findings should prompt its evaluation by large randomized controlled trials.

Chronic brucellosis in workers in a meat-packing plant.

We report an outbreak of brucellosis among 9 patients in a meat-packing plant. All patients developed chronic brucellosis characterized by severe chronic musculoskeletal pains, diffuse arthralgia, myalgia and recurrent bouts of fever, which we suggest may be related to a delay in antibiotic treatment. All the patients had a prolonged recovery requiring rehabilitation therapy.

Mediterranean spotted fever in pregnancy.

Mediterranean spotted fever has rarely been reported in pregnancy. We report a case occurring in a young pregnant woman, which responded well to treatment with a combination of erythromycin and rifampicin. The treatment of spotted fevers in pregnancy is discussed in detail.

Topical hyperbaric oxygen and low energy laser for the treatment of diabetic foot ulcers.

Fifty patients with chronic diabetic foot ulcers in whom conventional therapy had failed were treated with topical hyperbaric oxygen alone (15 patients) or in combination with a low energy laser (35 patients). Eleven of these patients were treated on an ambulatory basis with topical hyperbaric oxygen. The mean time the ulcer was present before therapy was 9+/-6.6 months. The mean number of treatments was 25+/-13, and the mean duration of therapy was 3+/-1.8 months. Forty-three of the 50 patients were cured. No adverse reactions were noted. Our impression is that topical hyperbaric oxygen alone or in combination with a low power laser are valuable adjuvants to conventional therapy for diabetic foot ulcers.

Triple anti-TNF-alpha therapy in early sepsis: a preliminary report.

Ten of 26 patients with sepsis were given a combination of dexamethasone (0.15 mg/kg, intravenously, once on admission), colchicine (0.5 mg, orally, daily, for 3 days) and pentoxifylline (DCP) (400 mg, orally, daily, for 3 days), together with best medical therapy. Serum tumour necrosis factor-alpha (TNF-alpha) levels were undetectable at 24 h compared with about 4 IU/ml (mean) in 16 similar control patients who were not given DCP (P < 0.06). Although the clinical course in the two groups was not significantly different, this simple, well-tolerated and inexpensive regimen should be further evaluated as a possible means of preventing the deleterious effects of TNF-alpha in sepsis.

Acute cholecystitis caused by Campylobacter jejuni.

An 83-year-old man with acute cholecystitis caused by Campylobacter jejuni is described. The patient was cured after undergoing cholecystectomy and intravenous ofloxacin therapy.