Jacob Ilany

Hybrid Closed-Loop Insulin Delivery in Type 1 Diabetes During Supervised Outpatient Conditions

Background: Efficacy and safety of the Medtronic Hybrid Closed-Loop (HCL) system were tested in subjects with type 1 diabetes in a supervised outpatient setting. Methods: The HCL system is a prototype research platform that includes a sensor-augmented insulin pump in communication with a control algorithm housed on an Android-based cellular device. Nine subjects with type 1 diabetes (5 female, mean age 53.3 years, mean A1C 7.2%) underwent 9 studies totaling 571 hours of closed-loop control using either default or personalized parameters. The system required meal announcements with estimates of carbohydrate (CHO) intake that were based on metabolic kitchen quantification (MK), dietician estimates (D), or subject estimates (Control). Postprandial glycemia was compared for MK, D, and Control meals. Results: The overall sensor glucose mean was 145 ± 43, the overall percentage time in the range 70-180 mg/dL was 80%, the overall percentage time <70 mg/dL was 0.79%. Compared to intervals of default parameter use (225 hours), intervals of personalized parameter use (346 hours), sensor glucose mean was 158 ± 49 and 137 ± 37 mg/dL (P < .001), respectively, and included more time in range (87% vs 68%) and less time below range (0.54% vs 1.18%). Most subjects underestimated the CHO content of meals, but postprandial glycemia was not significantly different between MK and matched Control meals (P = .16) or between D and matched Control meals (P = .76). There were no episodes of severe hypoglycemia. Conclusions: The HCL system was efficacious and safe during this study. Personally adapted HCL parameters were associated with more time in range and less time below range than default parameters. Accurate estimates of meal CHO did not contribute to improved postprandial glycemia.

Comparison of Myocardial Reperfusion in Patients With Fasting Blood Glucose ≤100, 101 to 125, and >125 mg/dl and ST-Elevation Myocardial Infarction With Percutaneous Coronary Intervention

Diabetes and impaired fasting glucose (FG) were associated with worse outcomes in patients with acute myocardial infarction (MI). Because the underlying mechanism is not entirely clear, 376 consecutive patients with ST-elevation MI who underwent primary percutaneous coronary intervention (PPCI) were investigated. Patients were divided into 3 groups based on FG < or =100, FG of 101 to 125, and FG >125 mg/dl or previously diagnosed diabetes mellitus (DM) and studied for electrocardiographic signs of myocardial reperfusion (both spontaneous and after PPCI) and clinical outcomes. Clinical reperfusion was less likely with increasing FG: FG < or =100 mg/dl, 26%; FG of 101 to 125, 19%; and FG >125 and/or DM, 16% (p for trend = 0.03). Accordingly, angiographic TIMI grade 3 flow on initial angiography was 22% for FG < or =100 mg/dl, 13% for FG of 101 to 125, and 14% for FG >125 and/or DM (p for trend = 0.05). Despite similar TIMI flow after PPCI, early ST-segment resolution (> or =70%) was noted in 76%, 63%, and 60% in patients with FG < or =100 mg/dl, FG of 101 to 125, and FG >125 and/or DM, respectively (p for trend <0.01). Peak creatine phosphokinase (CPK) increased gradually, whereas left ventricular ejection fraction decreased with increased FG. Worse outcomes were observed with increasingly higher FG for heart failure (9%, 23%, and 26%; p for trend <0.01), cardiogenic shock (5%, 7%, and 13%; p for trend = 0.02), in-hospital mortality (1%, 2%, and 6%; p for trend = 0.01), and long-term mortality (2.5%, 4.5%, and 12%; p for trend <0.01) for patients with FG < or =100 mg/dl, FG of 101 to 125, and FG >125 and/or DM, respectively. In conclusion, increased FG and previously diagnosed DM were associated with less spontaneous reperfusion and less myocardial reperfusion after PPCI, resulting in worse clinical outcomes.

The effect of continuous subcutaneous recombinant PTH (1–34) infusion during pregnancy on calcium homeostasis – a case report

Abstract Objective: We describe calcium homeostasis during pregestation and gestation in a woman with iatrogenic hypoparathyroidism, treated with continuous subcutaneous recombinant parathyroid hormone (PTH) (1–34) infusion. Results: The requirement for PTH did not fluctuate much during pregnancy and was essential for maintaining normal calcium and phosphorus serum levels. Conclusions: This study documents the insufficiency of PTH-related protein (PTHrP) or other gestation-related hormones to compensate for PTH deficiency in hypoparathyroid women, and the successful utilization of continuous subcutaneous recombinant PTH (1–34) infusion to achieve normal calcium homeostasis during gestation. Clinical trials with PTH replacement in such circumstances are warranted.

Glucose homeostasis abnormalities assessed by an OGTT in coronary artery disease patients during admission and follow-up at ambulation.

BACKGROUND Most non diabetic patients admitted with acute coronary syndrome (ACS) demonstrate an abnormality in glucose homeostasis. It was claimed that an oral glucose tolerance test (OGTT) undertaken during the admission is a good indicator of the patients glycemic status. AIM The aim of this study was to examine the reproducibility of OGTT based dysglycemic diagnosis during the acute admission and during an ambulatory visit in patients with ischemic heart disease (IHD). METHODS We have repeated an OGTT on 29 patients with IHD who had been tested with OGTT during hospitalization for ACS. RESULTS In 20 of the 29 (69%) patients the OGTT results improved on the repeated ambulatory test. This improvement was evident in the post-prandial glucose level yet not in the fasting levels. There were no significant differences in beta-cell function or in insulin sensitivity between the OGTTs as assessed by HOMA calculations. However there was tendency for improvement in insulin sensitivity at 2 h when assessed by the SI120 formula. CONCLUSIONS In this pilot study we found that impaired post-prandial glucose control in patients with ACS improves when retested at ambulation. Therefore, it is probably better to perform the OGTT as an ambulatory test and not during the acute admission for defining abnormalities in glucose homeostasis of patients with ACS.

Effect of prandial treatment timing adjustment, based on continuous glucose monitoring, in patients with type 2 diabetes uncontrolled with once-daily basal insulin: A randomized, phase IV study

To evaluate the glycaemic control achieved by prandial once‐daily insulin glulisine injection timing adjustment, based on a continuous glucose monitoring sensor, in comparison to once‐daily insulin glulisine injection before breakfast in patients with type 2 diabetes who are uncontrolled with once‐daily basal insulin glargine.