Journal of diabetes science and technology
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J Diabetes Sci Technol · May 2011
ReviewReview of electronic decision-support tools for diabetes care: a viable option for low- and middle-income countries?
Diabetes care is complex, requiring motivated patients, providers, and systems that enable guideline-based preventative care processes, intensive risk-factor control, and positive lifestyle choices. However, care delivery in low- and middle-income countries (LMIC) is hindered by a compendium of systemic and personal factors. While electronic medical records (EMR) and computerized clinical decision-support systems (CDSS) have held great promise as interventions that will overcome system-level challenges to improving evidence-based health care delivery, evaluation of these quality improvement interventions for diabetes care in LMICs is lacking. OBJECTIVE AND DATA SOURCES: We reviewed the published medical literature (systematic search of MEDLINE database supplemented by manual searches) to assess the quantifiable and qualitative impacts of combined EMR-CDSS tools on physician performance and patient outcomes and their applicability in LMICs. ⋯ This narrative review supports EMR-CDSS tools as innovative conduits for structuring and standardizing care processes but also highlights setting and selection limitations of the evidence reviewed. In the context of limited resources, individual economic hardships, and lack of structured systems or trained human capital, this review reinforces the need for well-designed investigations evaluating the role and feasibility of technological interventions (customized to each LMIC's locality) in clinical decision making for diabetes care.
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J Diabetes Sci Technol · May 2011
Review Meta AnalysisIntensive insulin therapy in critically ill hospitalized patients: making it safe and effective.
Intensive insulin therapy (IIT) for hyperglycemia in critically ill patients has become a standard practice. Target levels for glycemia have fluctuated since 2000, as evidence initially indicated that tight glycemic control to so-called normoglycemia (80-110 mg/dl) leads to the lowest morbidity and mortality without hypoglycemic complications. Subsequent studies have demonstrated minimal clinical benefit combined with greater hypoglycemic morbidity and mortality with tight glycemic control in this population. ⋯ Three questions must be answered to understand the role of IIT for defined populations of critically ill patients: (1) How safe is IIT, with various glycemic targets, from the risk of hypoglycemia? (2) How tightly must BG be controlled for this approach to be effective? (3) What role does the accuracy of BG measurements play in affecting the safety of this method? For each state of impaired glucose regulation seen in the hospital, such as hyperglycemia, hypoglycemia, or glucose variability, the benefits, risks, and goals of treatment, including IIT, might differ. With improved accuracy of BG monitors, IIT might be rendered even more intensive than at present, because patients will be less likely to receive inadvertent overdosages of insulin. Greater doses of insulin, but with dosing based on more accurate glucose levels, might result in less hypoglycemia, less hyperglycemia, and less glycemic variability.
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Telemedicine is a technology-based alternative to traditional health care delivery. However, poor security measures in telemedicine services can have an adverse impact on the quality of care provided, regardless of the chronic condition being studied. We undertook a systematic review of 58 journal articles pertaining to telemedicine security. ⋯ Prior research indicates inadequate reporting of methodology in telemedicine research. We found that to be true for security research as well. We also identified other issues such as using outdated security standards.
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J Diabetes Sci Technol · May 2011
Effect of diabetes mellitus on outcomes of hyperglycemia in a mixed medical surgical intensive care unit.
Intensive insulin therapy and degree of glycemic control in critically ill patients remains controversial, particularly in patients with diabetes mellitus. We hypothesized that diabetic patients who achieved tight glucose control with continuous insulin therapy would have less morbidity and lower mortality than diabetic patients with uncontrolled blood glucose. ⋯ The results showed that a diagnosis of diabetes was not an independent predictor of mortality, and that diabetic patients who were uncontrolled did not have worse outcomes. Diabetic nonsurvivors were associated with a greater amount of hypoglycemic episodes, suggesting these patients may benefit from a more lenient blood glucose protocol.
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J Diabetes Sci Technol · May 2011
Use of a novel fluorescent glucose sensor in volunteer subjects with type 1 diabetes mellitus.
Stress hyperglycemia in the critically ill has been found to be associated with increased morbidity and mortality. Studies have found significant improvements in morbidity and mortality in postsurgical patients whose glucose levels were closely maintained in the euglycemic range. However, subsequent studies, in particular the Normoglycemia in Intensive Care Evaluation and Survival Using Glucose Algorithm Regulation (NICE-SUGAR) study, found no improvement in subjects with tight glycemic control. In addition to differences in protocol design, patients in the tight glycemic control arm of the NICE-SUGAR study experienced high rates of hypoglycemia compared with other studies. One interpretation of the NICE-SUGAR study results is that it is difficult to achieve normal glycemia in critically ill patients with existing glucose monitoring technology. The purpose of the study reported here was to evaluate the safety and performance of a continuous intravascular glucose sensor that could be used in the future in critically ill patients. ⋯ This pilot study was the first use in human subjects of a prototype of the GluCath Intravascular Continuous Glucose Monitoring System (GluCath System). The GluCath System is based on a novel fluorescent sensor chemistry. The study found the GluCath System had a high level of accuracy as compared with a laboratory reference analyzer.