Janice L. Gilden

Pathways to Quality Inpatient Management of Hyperglycemia and Diabetes: A Call to Action

Currently patients with diabetes comprise up to 25–30% of the census of adult wards and critical care units in our hospitals. Although evidence suggests that avoidance of hyperglycemia (>180 mg/dL) and hypoglycemia (<70 mg/dL) is beneficial for positive outcomes in the hospitalized patient, much of this evidence remains controversial and at times somewhat contradictory. We have recently formed a consortium for Planning Research in Inpatient Diabetes (PRIDE) with the goal of promoting clinical research in the area of management of hyperglycemia and diabetes in the hospital. In this article, we outline eight aspects of inpatient glucose management in which randomized clinical trials are needed. We refer to four as system-based issues and four as patient-based issues. We urge further progress in the science of inpatient diabetes management. We hope this call to action is supported by the American Diabetes Association, The Endocrine Society, the American Association of Clinical Endocrinologists, the American Heart Association, the European Association for the Study of Diabetes, the International Diabetes Federation, and the Society of Hospital Medicine. Appropriate federal research funding in this area will help ensure high-quality investigations, the results of which will advance the field. Future clinical trials will allow practitioners to develop optimal approaches for the management of hyperglycemia in the hospitalized patient and lessen the economic and human burden of poor glycemic control and its associated complications and comorbidities in the inpatient setting.

Effects of Self-Monitoring of Blood Glucose on Quality of Life in Elderly Diabetic Patients

Self‐monitoring of blood glucose (SMBG) has been associated with improvement in diabetes knowledge and glycemic control in young and middle‐aged diabetic patients. This study investigated the influences of SMBG on the quality of life in 20 older diabetic individuals, aged 60 to 79 years with duration of diabetes 15.6 ± 2.3 (SD) years. Questionnaires (Cronbachs alpha reliability = .93) were administered regarding the impact of four aspects of diabetic self‐care—general factors, diet, medications, and monitoring blood or urine—on quality of life. Each category was scored separately. Data were analyzed comparing individuals using SMBG with those monitoring glycosuria. Older patients showed acceptance of SMBG with respect to performance, lack of time consumption, ease of record keeping, and less embarrassment. Individuals performing SMBG reported better medication compliance than those monitoring glycosuria. No differences were observed between the two groups for general factors, diet, or the overall perception of quality of life. Both groups of patients reported that diabetes and performing self‐care techniques did not significantly interfere with their lifestyle. In conclusion, this study demonstrates that self‐care techniques, such as SMBG, do not negatively influence the perception of quality of life in older people.

Round Table Discussion on Inpatient Use of Continuous Glucose Monitoring at the International Hospital Diabetes Meeting

In May 2015 the Diabetes Technology Society convened a panel of 27 experts in hospital medicine and endocrinology to discuss the current and potential future roles of continuous glucose monitoring (CGM) in delivering optimum health care to hospitalized patients in the United States. The panel focused on 3 potential settings for CGM in the hospital, including (1) the intensive care unit (ICU), (2) non-ICU, and (3) continuation of use of home CGM in the hospital. The group reviewed barriers to use and solutions to overcome the barriers. They concluded that CGM has the potential to improve the quality of patient care and can provide useful information to help health care providers learn more about glucose management. Widespread adoption of CGM by hospitals, however, has been limited by added costs and insufficient outcome data.In May 2015 the Diabetes Technology Society convened a panel of 27 experts in hospital medicine and endocrinology to discuss the current and potential future roles of continuous glucose monitoring (CGM) in delivering optimum health care to hospitalized patients in the United States. The panel focused on 3 potential settings for CGM in the hospital, including (1) the intensive care unit (ICU), (2) non-ICU, and (3) continuation of use of home CGM in the hospital. The group reviewed barriers to use and solutions to overcome the barriers. They concluded that CGM has the potential to improve the quality of patient care and can provide useful information to help health care providers learn more about glucose management. Widespread adoption of CGM by hospitals, however, has been limited by added costs and insufficient outcome data.

The most accurate autonomic function test: the medical history

‘‘Data! Data! Data! I can’t make bricks without clay’’ stated the famous detective Sherlock Holmes, a fictional character of the British writer, Sir Arthur Conan Doyle. It is true that data are needed to draw a proper conclusion. In patients with autonomic dysfunction, every symptom is a ‘‘clue’’ or ‘‘piece of data’’, that must be precisely evaluated and interpreted by a well-trained eye. This is required in order to arrive at the correct solution of the case. Thus, the second paper of the series on Autonomic Function Tests by Goldstein and Cheshire, published in this issue of Clinical Autonomic Research, highlights the importance of the medical history, the most accurate autonomic function test [1, 2]. They also emphasize the need to rule out other disorders and to be certain that the patient truly has autonomic dysfunction. Autonomic medicine is a relatively new and rapidly evolving field, and it has been under-recognized by the medical community. Therefore, it is crucial to educate multidisciplinary providers, as well as to support further research in this area. Hence, this paper is quite timely. The authors summarize the relevant and important steps required to perform a comprehensive autonomic medical history, which—let me reiterate—is the most important autonomic test [2]. It is crucial to query the patient’s account of daily activities and the chronology relating to the autonomic nervous system (ANS), and then to recognize that these symptoms may also fluctuate from day to day. The medical history should focus upon various aspects of autonomic disorders with regard to: Chief Complaint (the description by the patient for the reason of this evaluation); History of the Present Illness (history of the condition with chronology and patterns of autonomic symptoms, prior evaluations, including review of medical records, family observations); Past Medical History (past medical issues, including toxic exposures, chemotherapy, or Lyme disease); Family History (medical conditions of family members, especially those related to the patient’s current medical problems, such as neurologic, cardiac, endocrine, or genetic disorders (e.g., inherited synucleinopathies), and hyperflexibility syndromes, which are sometimes present in patients diagnosed with postural tachycardia syndrome (POTS); Current Medications, Dietary Supplements, and Herbal Remedies; Personal and Social History (living situation, daily functioning, disability, smoking, alcohol, substance abuse, past traumas and physical abuse, car accidents, stresses); and Review of Systems (with focus on specific components of the ANS). Goldstein and Cheshire also include less commonly recognized symptoms, such as: ‘‘water bottle sign’’, ‘‘coat hanger pain’’, shifting weight back and forth while standing, leg fidgeting while seated, physical deconditioning, and pretzel legs [2]. Olfactory dysfunction, visual hallucinations (a feature of dementia with Lewy bodies) and dream enactment behavior (rapid eye movement behavior disorder), visceral hypersensitivity or ‘‘somatic hypervigilance’’, as described by Khurana [3], may point to specific disorders. The authors also highlight the importance of having an appropriately trained and experienced clinician who is knowledgeable in asking the correct questions and interpreting the subjective answers, with the ability to & Janice L. Gilden Janice.gilden@rosalindfranklin.edu

Response to Comment on: Draznin et al. Pathways to Quality Inpatient Management of Hyperglycemia and Diabetes: A Call to Action. Diabetes Care 2013;36:1807–1814

We are pleased to hear from our British colleagues who agreed with our call to action to engage in more clinical research in order to generate data supporting the benefit of glycemic control in hospitalized patients with diabetes (1,2 …

Balancing Service and Education: An AAIM Consensus Statement

AAIM is the largest academically focused specialty organization representing departments of internal medicine at medical schools and teaching hospitals in the United States and Canada. As a consortium of five organizations, AAIM represents department chairs and chiefs; clerkship, residency, and fellowship program directors; division chiefs; and academic and business administrators as well as other faculty and staff in departments of internal medicine and their divisions.