Cost-Effectiveness of Inpatient Continuous Glucose Monitoring.

Introduction Our department conducted a retrospective cohort study to compare the efficacy of continuous glucose monitoring devices versus capillary blood glucose in the glycemic control of inpatient type 2 diabetes on intensive insulin therapy in a Portuguese hospital. The use of continuous glucose monitoring devices was associated with improved glycemic control, including an increased number of glucose readings within target range and reduced hyperglycemic events, being safe concerning hypoglycemias. This is the cost-effectiveness analysis associated with these results. Aim The primary objective was to compare the cost-effectiveness of achieving glycemic control, defined as the number of patients within glycemic goals, between groups. Secondary endpoints included cost-effectiveness analyses of each time in range goal, and each percentual increment in time in range. Methods We defined each glycemic goal as: "readings within range (70-180 mg/dL) >70%", "readings below range (below 70 mg/dL) <4%", "severe hypoglycemia (below 54 mg/dL) <1%", "readings above range (above 180 mg/dL) <25%", "very high glycemic readings (above 250 mg/dL) <5%". Results Continuous glucose monitoring showed lower median cost per effect for the primary outcome (€11.1 vs. €34.9/patient), with lower cost for readings in range (€7.8 vs. €11.6/patient) and for both readings above range goals ("above 180mg/dL": €7.4 vs. €9.9/patient, and "above 250mg/dL": €6.9 vs. €17.4/patient). Conclusions There are no published data regarding the cost-effectiveness of continuous glucose monitoring devices in inpatient settings. Our results show that continuous glucose monitoring devices were associated with an improved glycemic control, at a lower cost, and endorse the feasibility of incorporating these devices into hospital settings, presenting a favorable cost-effective option compared to capillary blood glucose.

Continuous Glucose Monitoring vs. Capillary Blood Glucose in Hospitalized Type 2 Diabetes Patients.

INTRODUCTION: The emergence of continuous glucose monitoring devices revolutionized the monitoring of diabetes, allowing real-time measurement of interstitial glucose levels. These devices are especially important for people with diabetes treated with insulin therapy and have been extensively studied in outpatient settings. In hospitalized patients, studies using continuous glucose monitoring have focused mainly on evaluating its accuracy and feasibility, but the results were unclear on whether continuous glucose monitoring was superior to capillary blood glucose in improving glycemic control and further research is needed to support the use of these devices in hospitalized patients with diabetes. OBJECTIVE: The primary endpoint of this study was to assess the increase in time-in-range (glycemic readings between 100-180 mg/dL) in hospitalized patients with continuous glucose monitoring, compared to capillary blood glucose. The secondary endpoints included the assessment of reductions in hypoglycemia incidence, mean glucose levels, and glucose coefficient of variation. Additionally, we assessed the intervention's impact on reducing the length of hospital stay, mortality rates, and incidence of inpatient infections. RESEARCH DESIGN AND METHODS: This was a retrospective, cohort study of 60 hospitalized patients with type 2 diabetes, divided into two groups of 30 individuals each: an intervention group monitored through continuous glucose monitoring and a control group using capillary blood glucose. RESULTS: Both groups were comparable in terms of demographic and clinical characteristics. Continuous glucose monitoring users had a higher number of readings per day (six vs. four, p < 0.001), in-range readings (53.5% vs. 35%, p = 0.027), fewer above-range readings (25.5% vs. 56.5%, p = 0.003), particularly above 250 mg/dL (5% vs. 27.5%, p = 0.001), with no difference in the percentage of hypoglycemia occurence (1% vs. 0%, p = 0.107). Lower mean glucose (161.9 mg/dL vs. 206.5 mg/dL, p < 0.001) was also observed in this group. No difference was observed in mortality, length of stay, or in infection rate (p = 1.000, p = 0.455, and p = 0.606, respectively). CONCLUSIONS: This retrospective study supports the use of continuous glucose monitoring in optimizing glycemic control in hospitalized patients with type 2 diabetes on intensive insulin therapy. These findings suggest that continuous glucose monitoring can improve time-in-range and prevent hyperglycemia.

Challenges in Management of Concomitant Primary Aldosteronism and Pheochromocytoma.

BACKGROUND Primary aldosteronism and pheochromocytoma are endocrine causes of secondary arterial hypertension. The association of primary aldosteronism and pheochromocytoma is rare and the involved mechanisms are poorly understood. Either there is a coexistence of both diseases or the pheochromocytoma stimulates the production of aldosterone. Since management approaches may differ significantly, it is important to properly diagnose the 2 conditions. We describe concomitant pheochromocytoma and primary aldosteronism in a patient with resistant hypertension, which demanded a challenging and individualized approach. CASE REPORT A 64-year-old man was sent for observation in our department for type 2 diabetes and resistant hypertension. Laboratory work-up suggested a primary aldosteronism and a pheochromocytoma. The abdominal CT (before and after intravenous contrast, with portal and delayed phase acquisitions) revealed an indeterminate right adrenal lesion and 3 nodules in the left adrenal gland: 1 indeterminate and 2 compatible with adenomas. A 18F-FDOPA PET-CT showed increased uptake in the right adrenal gland. The patient underwent a right adrenalectomy and a pheochromocytoma was confirmed. An improvement in glycemic control was observed after surgery but the patient remained hypertensive. A captopril test confirmed the persistence of primary aldosteronism, and he was started on eplerenone, achieving blood pressure control. CONCLUSIONS This case highlights the challenges in diagnosing and treating the simultaneous occurrence of pheochromocytoma and primary aldosteronism. Our main goal was surgical removal of the pheochromocytoma due to the risk of an adrenergic crisis.

Congenital adrenal hyperplasia with a CYP21A2 deletion overlapping the tenascin-X gene: an atypical presentation.

OBJECTIVES: Congenital Adrenal Hyperplasia (CAH) is a group of genetic diseases characterized by impaired cortisol biosynthesis. 95% of CAH cases result from mutation in the CYP21A2 gene encoding 21-hydroxilase. TNX-B gene partially overlaps CYP21A2 and encodes a matrix protein called Tenascin-X (TNX). Complete tenascin deficiency causes Enlers-Danlos syndrome (EDS). A mono allelic variant called CAH-X CH-1 was recently described, resulting from a CYP21A2 complete deletion that extends into the TNXB. This haploinsufficiency of TNX may be associated with a mild hypermobility form of EDS, as well as other connective tissue comorbidities such as hernia, cardiac defects and chronic arthralgia. CASE PRESENTATION: We report four patients heterozygous for a CAH-X CH-1 allele that do not present clinical manifestations of the EDS. CONCLUSIONS: All CAH patients, carriers of these TNXA/TNXB chimeras, should be evaluated for clinical manifestations related to connective tissue hypermobility, cardiac abnormalities and other EDS features, allowing for better clinical surveillance management.

Thyrotropin and body mass index, are they related?

OBJECTIVES: It is well recognized that overt thyroid dysfunction is associated with changes in body mass index (BMI). However, there is ongoing debate regarding the influence of thyroid stimulating hormone (TSH) on BMI, in euthyroid subjects. The aim of this study is to examine the association of TSH with BMI in an outpatient population without evidence of thyroid disease. METHODS: Cross-sectional study conducted in an Endocrinology Department. We identified the latest TSH and BMI measurements in 923 patients from the reference euthyroid population. All patients with positive thyroid autoimmunity and nodules were excluded. We performed a linear regression analysis using SPSSv.025. RESULTS: 923 adult patients were evaluated. 79.4% were males, with a mean age of 67.6 years old. Mean TSH level was 1.78 mIU/L and mean BMI was 29.2 kg/m2. A significant negative correlation between serum TSH concentration and BMI was evident (p=0.04; r=-0.067). Statistical significance was lost when performing subgroup analysis, for males and females (p=0.19 and p=0.075), elderly (≥65 years) and non-elderly (p=0.55 and p=0.32) and also obese (BMI ≥30 kg/m2) and non-obese (p=0.39 and p=0.13). CONCLUSIONS: The relationship between BMI and TSH is not consensual in the literature. This study included a large cohort sample of euthyroid patients, majority men and with negative autoimmunity. Our results support the hypothesis that variation in thyroid status within the normal range, could have a negative effect on BMI, contrary to most published studies.