Citations

In June 2016, Diabetes Technology Society convened a panel of US experts in inpatient diabetes management to discuss the current and potential role of continuous glucose monitoring (CGM) in the hospital. This discussion combined with a literature review was a follow-up to a meeting, which took place in May 2015. The panel reviewed evidence on use of CGM in 3 potential inpatient scenarios: (1) the intensive care unit (ICU), (2) non-ICU, and (3) transitioning outpatient CGM use into the hospital setting. Panel members agreed that data from limited studies and theoretical considerations suggested that use of CGM in the hospital had the potential to improve patient clinical outcomes, and in particular reduction of hypoglycemia. Panel members discussed barriers to widespread adoption of CGM, which patients would benefit most from use of this technology, and what type of outcome studies are needed to guide use of CGM in the inpatient setting.

Background: We propose a methodology to analyze complex real-life glucose data in insulin pump users. Methods: Patients with type 1 diabetes (T1D) on insulin pumps were recruited from an academic endocrinology practice. Glucose data, insulin bolus (IB) amounts, and self-reported alcohol consumption and exercise events were collected for 30 days. Rules were developed to retrospectively compare IB recommendations from the insulin pump bolus calculator (IPBC) against recommendations from a proposed decision aid (PDA) and for assessing the PDA’s recommendation for exercise and alcohol. Results: Data from 15 participants were analyzed. When considering instances where glucose was below target, the PDA recommended a smaller dose in 14%, but a larger dose in 13% and an equivalent IB in 73%. For glucose levels at target, the PDA suggested an equivalent IB in 58% compared to the subject’s IPBC, but higher doses in 20% and lower in 22%. In events where postprandial glucose was higher than target, the PDA suggested higher doses in 25%, lower doses in 13%, and equivalent doses in 62%. In 64% of all alcohol events the PDA would have provided appropriate advice. In 75% of exercise events, the PDA appropriately advised an IB, a carbohydrate snack, or neither. Conclusions: This study provides a methodology to systematically analyze real-life data generated by insulin pumps and allowed a preliminary analysis of the performance of the PDA for insulin dosing. Further testing of the methodological approach in a broader diabetes population and prospective testing of the PDA are needed.

101 Background: Diabetes mellitus (DM) has been associated with an increased risk of mortality among patients with many types of cancers. The aim of this case-control study was to determine the impact of DM on short-term overall survival in prostate cancer patients, and to examine the impact of prostate cancer on glycemic control in DM. Methods: 276 patients with newly diagnosed prostate cancer from 2007-2014 with DM were identified from the Institutional Cancer Registry and matched to 276 prostate cancer patients without DM according to age and year of prostate cancer diagnosis. The file was linked to the electronic medical record to obtain information on DM and cancer therapies, and laboratory results. Results: The mean age of the entire prostate cancer cohort was 72 years, most (93%) were white, the most common Gleason score (in 52%) was 7, and the majority (56%) were tumor stage 2. No differences in age, race/ethnicity, Gleason score, or tumor stage were detected between patients with and without DM, although DM patients had higher body mass index (P = .031). Among those with DM the mean hemoglobin A1c (HbA1c) was 6.7%. In Kaplan-Meier survival analysis (median follow-up time of 43.7 months), 5-year overall survival was estimated at 88% for DM patients versus 93% in non-DM patients. Hazard ratio (for matched pairs) was 1.64 (95% CI: 0.77-3.46, P = .20). Moreover, mean HbA1c and glucose values among DM cases did not significantly change over 1 year (P ≥ .13). Mean glucose among DM patients was significantly (p < 0.01) higher compared to non-DM patients. Conclusions: DM did not adversely impact survival in prostate cancer patients. In addition, prostate cancer or its treatment does not appear to affect glycemic control. Both patients and their providers can be reassured that the two concurrent diagnoses do not adversely interact to worsen short term outcomes.

Poly(GP) proteins are a promising pharmacodynamic marker for developing and testing therapeutics for treating C9ORF72 -associated amyotrophic lateral sclerosis.

452 Background: CC pts with biliary stents or catheters often present with fever and/or jaundice requiring urgent treatment for which there is no uniform guideline. We aimed to develop an expert panel consensus on this topic using the modified RAND/UCLA Delphi process to rate treatment appropriateness. Methods: We recruited 13 physician experts from relevant specialty, geography, and practice settings. Patient scenarios were developed based on a literature review, and therapies were rated by the experts before and after a face-to-face discussion. The appropriateness of various therapies was rated on a 1-9 scale and classified as appropriate, inappropriate, or uncertain. Scenarios with > 2 ratings of 1-3 (inappropriate) and > 2 ratings of 7-9 (appropriate) were considered to have disagreement and were not assigned an appropriateness rating. Results: Panelists were from all US regions (92%) and the UK (8%); had practiced for a mean 16.5 years (4-33 years) and reported seeing an average of 120 unique CC patients a year (0-900 pts). Panelists rated 288 clinical scenarios. Experts decided that ongoing treatment with chemotherapy did not influence decision-making. Disagreement decreased from 37.5% before the meeting to 10.4% after. Consensus statements are summarized in table 1. Conclusions: The Delphi process produced consensus guidelines to fill an unmet need in urgent management of ascending cholangitis in pts with CC. Studies of the impact of these guidelines on cost of care and pt outcomes are warranted. (Support: The Cholangiocarcinoma Foundation)[Table: see text]

Background: Currently, glycemic management for individuals with diabetes mellitus involves monitoring glucose only, which is insufficient as glucose metabolism involves other biomarkers such as insulin. Monitoring additional biomarkers alongside glucose has been proposed to improve glycemic control. In this work, the development of a rapid and label-free insulin biosensor with high sensitivity and accuracy is presented. The insulin sensor prototype also serves as a prior study for a multimarker sensing platform technology that can further improve glycemic control in the future. Methods: Electrochemical impedance spectroscopy was used to identify an optimal frequency specific to insulin detection on a gold disk electrode with insulin antibody immobilized, which was accomplished by conjugating the primary amines of insulin antibody to the carboxylic bond of the self-assembling monolayer on the gold surface. After blocking with ethanolamine, the insulin physiological concentration gradient was tested. The imaginary impedance was correlated to insulin concentration and the results were compared with standard equivalent circuit analysis and correlation of charge transfer resistance to target concentration. Results: The optimal frequency of insulin is 810.5 Hz, which is characterized by having the highest sensitivity and sufficient specificity. The lower limit of detection was 2.26 ρ M which is comparable to a standard and better than traditional approaches. Conclusion: An insulin biosensor prototype capable of detecting insulin in physiological range without complex data normalization was developed. This prototype will be the ground works of a multimarker platform sensor technology for future all-in-one glycemic management sensors.

137 Background: Diabetes has been associated with an increased risk of mortality among patients with many types of cancers. Methods: We performed a case-control study of 109 breast cancer patients to determine the impact of diabetes on disease recurrence and survival. These 109 patients diagnosed with invasive breast cancer during 2007-2011 with diabetes were identified from the institutional Cancer Registry and matched to 109 breast cancer patients without diabetes according to age, race/ethnicity and year of diagnosis. Statistical tests included paired t-tests, McNemar’s tests, and stratified Cox regression. Results: The median ages of those with and without diabetes were 68 years, and 91% in both groups were white (both matched). Patients with and without diabetes were not significantly different in terms of tumor grade, cancer stage, estrogen or progesterone receptor status, HER2 neu status, marital and employment status, smoking use, use of adjuvant chemotherapy, and steroid treatment (all P >.4). Patients with diabetes reported less use of alcohol (50% vs 64%, P=.04), and had greater BMI (79% overweight/obese vs 58%, P= .002). Survival analysis demonstrated no differences in survival from initial breast cancer diagnosis (HR=1.25, 95% CI 0.49-3.17) with median follow-up of 2.2 years (range 0.1-4.9), and no differences in recurrence-free survival (HR=1.00, 95% CI 0.14-7.10) though very few deaths and recurrences were observed. Within the diabetes group, 96 (88%) had type 2 diabetes and 97/106 (92%, 3 unknown) had diabetes pre-existing to cancer diagnosis. Initial diabetes therapy included diet (33, 30%), oral therapy (48, 44%), insulin (21, 19%), or oral+insulin (6, 6%). 7 patients required a change in diabetes therapy within 1 year of cancer diagnosis with 3 patients starting insulin. 32/70 (46%) with available lab data had 1 or more A1C >/=7 within 1 year of cancer diagnosis. Conclusions: In this retrospective, carefully matched case-control study, we developed a comprehensive profile of the patient population with newly diagnosed breast cancer and diabetes. Diabetes did not appear to impact mortality or recurrence-free survival based on descriptive estimates in this small breast cancer cohort.

Purpose Professional development (PD)—both for-credit continuing medical education (CME) and informal self-directed or point-of-care learning—is vital to all physicians. The authors sought to understand physicians’ PD perceptions and practices and how these vary by specialty and practice type. Method The authors administered an Internet and paper survey, from September 2015 to April 2016, to randomly sampled U.S. physicians. Survey items addressed perceived PD needs and barriers and how physicians identify knowledge/skills gaps. Results Of 4,648 invitees, 988 (21.6%) responded. Respondents believed that they already know what they need to learn (mean 5.8 [1 = strongly disagree; 7 = strongly agree]), can answer clinical questions using available resources (5.9), and want credit for learning during patient care (5.1). They did not strongly desire help identifying learning gaps (4.0) or indicate difficulty accumulating CME credits (3.1). Most PD was done during personal time (5.5). Competencies regarding medical knowledge/skills, wellness, informatics, and practice/systems improvement were rated the highest priority, while research, teaching, and professionalism were rated the lowest. The most important sources used to identify knowledge/skills gaps were immediate patient care needs (4.1 [1 = not important; 5 = extremely important]), personal awareness (3.8), and practice updates (3.7). The most important barriers were time (3.5) and cost (2.9). Differences by specialty and practice type were generally small and not statistically significant. Conclusions Physicians feel confident in identifying their own learning needs, perceive medical knowledge/skills as their highest-priority need, and desire more credit for learning during patient care.

Introduction: Extracorporeal membrane oxygenation (ECMO) has been extensively used for potentially reversible acute respiratory failure associated with severe influenza A (H1N1) pneumonia; however, it remains an expensive, resource-intensive therapy, with a high associated mortality. This systematic review and meta-analysis aims to summarize and pool outcomes data available in the published literature to guide clinical decision-making and further research. Methods: We conducted a systematic search of MEDLINE (1966 to April 15, 2015), EMBASE (1980 to April 15, 2015), CENTRAL, and Google Scholar for patients with severe H1N1 pneumonia and respiratory failure who received ECMO. The study validity was appraised by Newcastle–Ottawa Scale. The primary outcome was all-cause mortality. The secondary outcomes were duration of ECMO therapy, mechanical ventilation, and Intensive Care Unit (ICU) length of stay. Results: Of 698 abstracts screened and 142 full-text articles reviewed, we included 13 studies with a total of 494 patients receiving ECMO in our final review and meta-analysis. The study validity was satisfactory. The overall mortality was 37.1% (95% confidence interval: 30–45%) limited by underlying heterogeneity ( I 2 = 65%, P value of Q statistic = 0.006). The median duration for ECMO was 10 days, mechanical ventilation was 19 days, and ICU length of stay was 33 days. Exploratory meta-regression did not identify any statistically significant moderator of mortality ( P < 0.05), except for the duration of pre-ECMO mechanical ventilation in days (coefficient 0.19, standard error: 0.09, Z = 2.01, P < 0.04, R 2 = 0.16). The visual inspection of funnel plots did not suggest the presence of publication bias. Conclusions: ECMO therapy may be used as an adjunct or salvage therapy for severe H1N1 pneumonia with respiratory failure. It is associated with a prolonged duration of ventilator support, ICU length of stay, and high mortality. Initiating ECMO early once the patient has been instituted on mechanical ventilation may result in improved survival.