Glucose(monitoring): from bench to real world experiences

Glucose monitoring systems emerged as an option to measure glucose concentrations in the interstitial fluid using a sensor. Main findings of this thesis are:• To achieve a glucose measurement with the smallest measurement uncertainty when diagnosing (gestational) diabetes, measurements should be performed using a FC-Mix blood collection tube instead of the standard NaF-EDTA or NaF-oxalate blood collection tube.• When using the FreeStyle Libre Flash Glucose Monitoring System (FSL-FGM) in daily life, it should be taken in account that readings in the lower range are likely to be lower than the actual glucose reading. Furthermore, after ingestion of a meal, FSL-FGM measured glucose lag behind the blood measured glucose. As a result, there is a risk of underestimating the effect of a meal on the glucose response• One-year use of FSL-FGM in people with diabetes resulted in improved well-being and decreased disease burden, as well as improvement of glycemic control, especially at those users with initially the poorest metabolic control. From a user perspective, the beneficial influence on the frequency and severity of hypoglycemia’s was also of great importance.• In a considerable percentage of people with diabetes, HbA1c levels reported by themselves are not accurate enough to be useful in research.• In case the glucose outcome derived from a glucose monitoring system does not match with the expected outcome by the user, a capillary glucose measurement should be performed. This is of particular importance during exercise

Identiteit door de lens van de liturgie : een onderzoek naar de bijdrage van de theologische ethiek van Stanley Hauerwasmet het oog op de identiteitsbeleving en -vorming van christenen in Nederland

Masterthesis Practices (Ethiek

The mixed and multi model line balancing problem : a comparison

The balancing problem deals with the assignment of tasks to work stations. We can distinguish two approaches in the literature on the mixed model line balancing problem, that both transform this problem into a single model line balancing problem. These approaches use combined precedence diagrams and adjusted task processing times, respectively. An experiment was carried out to compare several heuristics based on the combined precedence diagram. A new optimisation method has been developed. The results indicate that the position of common tasks in the precedence diagram of the different models has a significant effect on both the CPU time and the unequal distribution of the total work content of single models among work stations. Moreover, good solutions with respect to the number of required stations go together with long CPU times. For several instances, we decreased the CPU times considerably without deteriorating the performance of the methods, by using a reversed combined precedence diagram

Experience with FreeStyle Libre Flash glucose monitoring system in management of refractory dumping syndrome in pregnancy shortly after bariatric surgery

Bariatric surgery is an effective therapy for obesity but is associated with long-term complications such as dumping syndromes and nutritional deficiencies. We report a case of a 26-year-old caucasian female, with history of morbid obesity and gestational diabetes (GDM), who became pregnant 4 months after Roux-en-Y bypass surgery. She developed GDM during subsequent pregnancy, which was initially managed with metformin and insulin. Nocturnal hypoglycaemia causing sleep disturbance and daytime somnolence occured at 19 weeks of pregnancy (19/40). Treatment with rapid-acting carbohydrates precipitated further hypoglycaemia. Laboratory investigations confirmed hypoglycaemia at 2.2 mmol/L with appropriately low insulin and C-peptide, intact HPA axis and negative IgG insulin antibodies. The patient was seen regularly by the bariatric dietetic team but concerns about compliance persisted. A FreeStyle Libre system was used from 21/40 enabling the patient a real-time feedback of changes in interstitial glucose following high or low GI index food intake. The patient declined a trial of acarbose but consented to an intraveneous dextrose infusion overnight resulting in improvement but not complete abolishment of nocturnal hypoglycaemia. Hypoglycaemias subsided at 34/40 and metformin and insulin had to be re-introduced due to high post-prandial blood glucose readings. An emergency C-section was indicated at 35 + 1/40 and a small-for-gestational-age female was delivered. There have been no further episodes of hypoglycaemia following delivery. This case illustrates challenges in the management of pregnancy following bariatric surgery. To our knowledge, this is the first use of FreeStyle Libre in dumping syndrome in pregnancy following bariatric surgery with troublesome nocturnal hypoglycaemia. Learning points: Bariatric surgery represents the most effective treatment modality in cases of severe obesity. With increasing prevalence of obesity, more people are likely to undergo bariatric procedures, many of which are women of childbearing age. Fertility generally improves after bariatric surgery due to weight reduction, but pregnancy is not recommended for at least 12-24 months after surgery. If pregnancy occurs, there are currently little evidence-based guidelines available on how to manage complications such as dumping syndromes or gestational diabetes (GDM) in women with history of bariatric surgery. Diagnosis of GDM relies on the use of a 75 g oral glucose tolerance test (OGTT). The use of this test in pregnant women is not recommended due to its potential to precipitate dumping syndrome. Capillary glucose monitoring profiles or continuous glucose monitoring (CGM) is being currently discussed as alternative testing modalities. As the CGM technology becomes more available, including the recently introduced FreeStyle Libre Flash glucose monitoring system, more pregnant women, including those after bariatric surgery, will have access to this technology. We suggest urgent development of guidelines regarding the use of CGM and flash glucose monitoring tools in these circumstances and in the interim recommend careful consideration of their use on a case-to-case basis

Improved well-being and decreased disease burden after 1-year use of flash glucose monitoring (FLARE-NL4)

Introduction: The FreeStyle Libre is a flash glucose monitoring (FSL-FGM) system. Compared with finger-prick based self-monitoring of blood glucose, FSL-FGM may provide benefits in terms of improved glycemic control and decreased disease burden. Methods: Prospective nationwide registry. Participants with diabetes mellitus (DM) used the FSL-FGM system for a period of 12 months. End points included changes in HbA1c, hypoglycemia, health-related quality of life (12-Item Short Form Health Surveyv2 (SF-12v2) and 3-level version of EuroQol 5D (EQ-5D-3L)), a specifically developed patient-reported outcome measures (PROMs) questionnaire, diabetes-related hospital admission rate and work absenteeism. Measurements were performed at baseline, and after 6 months and 12 months. Results: 1365 persons (55% male) were included. Mean age was 46 (16) years, 77% of participants had type 1 DM, 16% type 2 DM and 7% other forms. HbA1c decreased from 64 (95%CI 63 to 65) mmol/mol to 60 (95%CI 60 to 61) mmol/mol with a difference of -4 (95% CI -6 to 3) mmol/mol. Persons with a baseline HbA1c >70 mmol/mol had the most profound HbA1c decrease: -9 (95% CI -12 to to 5) mmol/mol. EQ-5D tariff (0.03 (95%CI 0.01 to 0.05)), EQ-VAS (4.4 (95%CI 2.1 to 6.7)) and SF-12v2 mental component score (3.3 (95%CI 2.1 to 4.4)) improved. For most, PROMs improved. Work absenteeism rate (/6 months) and diabetes-related hospital admission rate (/year) decreased significantly, from 18.5% to 7.7% and 13.7% to 2.3%, respectively. Conclusions: Real world data demonstrate that use of FSL-FGM results in improved well-being and decreased disease burden, as well as improvement of glycemic control

Comparison of Accu Chek Inform II point-of-care test blood glucose meter with Hexokinase Plasma method for a diabetes mellitus population during surgery under general anesthesia

Purpose Blood glucose (BG) concentrations of patients with diabetes mellitus (DM) are monitored during surgery to prevent hypo- and hyperglycemia. Access to point-of-care test (POCT) glucose meters at an operating room will usually provide monitoring at shorter intervals and may improve glycemic control. However, these meters are not validated for patients under general anesthesia. Methods This cross-sectional study included 75 arterial BG measurements from 75 patients (71 with DM, mostly insulin dependent) who underwent elective non-cardiac surgery under general anesthesia. Arterial blood samples were taken at least 60 minutes after induction. One drop of blood was used for Accu Chek Inform II (ACI II) POCT BG meter and the residual blood was sent to the clinical laboratory for a Hexokinase Plasma reference method. A Bland-Altman plot was used to visualize the differences between both methods, and correlation was assessed using the intra-class correlation coefficient (ICC). Results The results showed an estimated mean difference of 0.8 mmol/L between ACI II and the reference method, with limits of agreement equal to -0.6 and 2.2 mmol/L. In general, the reference method produced higher values than ACI II. ICC was 0.955 (95% CI 0.634-0.986), P &lt; 0.001, and concordance correlation coefficient (CCC) was 0.955 (95% CI 0.933-0.970). Conclusion Arterial BG measurements during surgery in patients with DM under general anesthesia using POCT BG meter are in general lower than laboratory measurements, but the ICC and CCC show a clinically acceptable correlation. We conclude that POCT measurements conducted on arterial specimens using the ACI II provide sufficiently accurate results for glucose measurement during surgery under general anesthesia.</p

Performance of continuous glucose monitoring devices during intensive exercise conditions in people with diabetes:the Mont Blanc experience

With increasing use of both flash glucose monitoring and real-time continuous glucose monitoring and the reliance of users on these readings, accuracy is important, in particular during intensive exercise. We investigated the performance of the FreeStyle Libre 1 flash glucose monitor and the Guardian Connect EnliteTM real-time continuous glucose monitor by comparing readings with self-monitored blood glucose values during intensive exercise.</p