Continuous glucose monitoring (CGM) technology has emerged as an important diabetes management tool. Use of CGM with real-time glucose data can improve glycemic control with reduction in HbA1c and reduced time spent in hypoglycemia in both children and adults with type 1 diabetes. The magnitude of clinical benefit is related to duration of use. 1 Despite the advantages of CGM, it has not been widely integrated into routine management of type 1 diabetes. T1D exchange data demonstrates that CGM technology is being used by only 6.5% of people with type 1 diabetes in United States and that among individuals who have used CGM, twothirds stopped using it. 2 One of the major challenges facing widespread adoption of CGM technology is reduced accuracy and reliability of CGM systems, with a subsequent negative impact on adherence and effectiveness. 3 We present a case of deliberate insulin overdose in a person with type 1 diabetes wearing blinded CGM, highlighting the issue of accuracy of existing CGM systems in the hypoglycemic range. CaseA 25-year-old man with poorly controlled type 1 diabetes which had been diagnosed at the age of 10 years. His complications include laser-treated preproliferative retinopathy, microalbuminuria, and recurrent diabetic ketoacidosis. He has a personality disorder with multiple previous presentations with deliberate self-harm including insulin overdose. A Medtronic iPro2 blinded CGM system using an Enlite sensor (Medtronic, Northridge, CA) was arranged for 7 days to guide intensification of insulin therapy. On day six of monitoring, he presented to the emergency department with a deliberate overdose of 300 units of insulin aspart (Novorapid, Novo Nordisk, Copenhagen, Denmark). His venous blood glucose was 1.6 mmol/L (28 mg/dL) and serum insulin level was 452.3 mu/L (fasting reference range 3-15 mu/L) at admission.He was treated with dextrose infusion, glucagon injection, and 40% glucose gel over 9 hours with in-patient monitoring for 36 hours. At the end of day 7, the sensor was removed and data were downloaded. ResultSevere hypoglycemia was managed appropriately with parenteral and enteral glucose, and glucagon. Analysis of CGM data (Figure 1) showed failure of the sensor to detect hypoglycemia with the reported sensor glucose ranging between 5 and 6 mmol/L (90-108 mg/dL). While the mean absolute relative difference (MARD%) for the whole 7 days of CGM was 17.7%, it was 52% in the first 9 hours post-insulin overdose. DiscussionDespite clinical benefits of CGM and data suggesting continuous knowledge of glucose is a research priority, uptake is lower than may be expected. 2 This in part due to reimbursement challenges, discomfort, complexity, the need for calibration and the limited life span of sensors, but also reflects alarm fatigue related to sensor inaccuracy, particularly in the hypoglycemic range. For people who persevere with CGM despite these limitations, an increase in 579691D STXXX10.1177/1932296815579691Journal of Diabetes Science and TechnologyEl-Laboudi et al research-article2015
Summary Thromboembolic disease remains the leading cause of maternal death in the UK. Recent literature has proposed that folate status is a strong predictor for venous thrombosis. Using thrombelastography (TEG®), we tested the hypothesis that folic acid supplementation is associated with a reduction in whole blood coagulability. Blood samples and questionnaire data were obtained at a mean gestation of 13·6 weeks (SD: 3·8, range: 6–38 weeks) from unselected consecutive women attending for their antenatal booking scan. Of 588 patients, 439 (74·7%) took folic acid. All TEG® parameters were less hypercoagulable in women that had taken folic acid compared with those that had not: mean maximum amplitude (MA) 60·3 versus 62·1; mean difference 1·8; 95% confidence interval 0·8, 2·8; P = 0·0001; mean coagulation index (CI) 0·54 versus 0·85; mean difference 0·31; 95% confidence interval 0·11, 0·5; P = 0·002. There was no difference in the incidence of the homozygous MTHFR mutation in patients taking folic acid (5·53%) compared with those that were not (4·08%). This study suggests that benefit may be derived from longer‐term treatment, although large multicentre studies are required to determine whether the relative hypocoagulability is associated with a reduction in risk of venous thrombosis.
COVID-19 can present with respiratory symptoms ranging from mild cough to viral pneumonia and ARDS. Lung ultrasonography has emerged as a promising imaging modality during the pandemic, but there is still a paucity of systematic analysis of lung ultrasound findings. In this retrospective observational study, 12 Zone ultrasound scans of COVID-19 positive patients were systematically analysed for pleural irregularities, subpleural consolidations, B lines, deep consolidations and effusions. Lung abnormalities were analysed according to overall frequency, frequency distribution in coronal and sagittal lung planes and were also correlated to clinical severity groups as determined by oxygenation deficit. Our results show that lung zones with abnormalities can occur juxtaposed to normal lung. Irregular pleural and small subpleural consolidations appear ubiquitously distributed throughout both lungs and occur early in the disease process. Wide B-lines are a predominant feature in COVID-19 infection. B-lines are found in a variety of patterns with number and width correlated to disease severity. In our analysis we also describe a previously unrecognised finding of small peri-pleural effusions in 8.7% of scans occurring in all areas of the lung. The current results form the basis for a more thorough understanding of the lung changes occurring in COVID-19 and the incorporation of lung ultrasound in the setting of COVID-19 infection including triage, diagnosis, treatment approach and prognosis.
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