OCTOBER 2024 - 3 Years Old child, Type1 Diabetes, Insulin Hypoglycemia, Intermittent, Bloating 1 Month

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PATIENT DATA LOG OF OCTOBER - 2024



02/10/24

Patient Advocate: 1.10.24

7.30am nuts 
7.40am milk puffed rice and dates 
9.30am 2u lispro insulin 
9.40am rice with pointed gourd, chayote, ribbed gourd, bitter gourd, tomato, egg and salad 
11.30am mosambi 
1.30pm blood suger 169
1.30pm 2u lispro insulin 
1.40pm lunch with same previous dish except egg and include fish 
5.30pm sour curd 
7.00pm banana 
8.30pm 4u lantus insulin 
9.30pm 2u lispro insulin 
9.40pm dinner with as same as lunch dish

2.10.24
7.30am fasting blood sugar 138
7.30am nuts 
7.40am milk puffed rice and dates

PaJR PHR Moderator: 👍

Participant 20: Good to see a stable pattern has been achieved.
Any reason why lunch and dinner are being given slightly late?

Asking because best Lantus response can be tailored based on meal times.

PaJR PHR Moderator: I guess that's the cultural dinner time for the patient's location

Participant 20: Perhaps global accultration can bring better outcomes?

PaJR PHR Moderator: It's a slow simmering process

Participant 20: Definitely.
I agree that Healthcare should be tailored accordingly and not the other way round. Although sometimes the flipside must be done.



PaJR PHR Moderator: Thanks. This is a very useful summary

Narmeen Shah: 🙏🙏🙏🙏🙏🙏

PaJR PHR Moderator: Inputs on this from our Global expert 👇
"Pediatric Endocrinologist NJ: Fasting is better, but the post-breakfast could be lower. 
Pediatric Endocrinologist NJ: And the post dinner should be a bit higher."

03/10/24

PaJR PHR Moderator: Further inputs for this team from our global expert 👇

"Pediatric Endocrinologist NJ: If the patient's advocate doesn’t want to increase the lispro before breakfast, they should increase the protein content of the meal and dial down the carbs of the breakfast. A dietician may be of help.
Pediatric Endocrinologist NJ: Since carbs and protein are equicaloric, an even swap will keep the calories the same. 
Is the child getting routine pediatric care? Growth monitoring and immunizations?"

Patient Advocate: 9.30am 2u lispro insulin 
9.40am rice with pointed gourd, chayote, tomato, ribbed gourd, bitter gourd, egg and salad 
11.45am apple 
1.30pm 2u lispro insulin 
1.40am lunch with same previous dish except egg and include fish 
4.00pm blood sugar 253
5.30pm sour curd 
7.00pm banana 
9.00pm 4u lantus insulin 
9.30pm 2u lispro insulin 
9.40pm dinner with as same as lunch dish

Patient Advocate: 3.10.24
7.30am nuts 
7.45am milk, puffed rice and dates 
9.30am 2u lispro insulin 
9.40am rice with papaya, chayote, bitter gourd, tomato, long beans, pointed gourd, egg and salad 
11.40am blood suger 308
11.45am apple 
1.30pm 2u lispro insulin 
1.40pm lunch with same previous dish except egg 
5.30pm sour curd 
7.00pm oats
8.30pm 4u lantus insulin 
9.30pm blood sugar 323
9.30pm 3u lispro insulin 
9.40pm dinner with as same as lunch dish and egg

04/10/24

Patient Advocate: 4.10.24
7.30am blood sugar 190
7.30am nuts 
7.45am milk, puffed rice and dates 
9.30am 2u lispro insulin 
9.40am rice with pointed gourd, bitter gourd, tomato, long beans, papaya, chayote, egg and salad 
11.45am Apple 
1.30om blood sugar 336
1.30pm 3u lispro insulin 
1.40pm lunch with same previous dish except egg and include fish 
5.30pm sour curd

Patient Advocate: Sir, can it be increased lantus by one unit today?

PaJR PHR Moderator: Why didn't you increase the breakfast lispro?
👆As mentioned before lantus action is reflected in the fasting sugars and on 2/10/24 her fasting was 138 with 4U of lantus

Patient Advocate: Fasting blood sugar was 190

05/10/24

Patient Advocate: 7.00pm banana 
8.30pm 5u lantus insulin 
9.30pm 2u lispro insulin 
9.40pm dinner with as same as lunch dish
11.45pm blood sugar 100

Patient Advocate: 5.10.24
7.30am fasting blood sugar 121
7.30am nuts 
7.40am milk, puffed rice and dates

PaJR PHR Moderator: Inputs from our pediatric endocrinologist NJ👇
If there's a problem in giving more lispro in the morning it would be better to give the child a protein rich breakfast instead of rice and dates which are nothing but carbs.

Patient Advocate: 9.30am 2u lispro insulin 
9.40am rice with chayote, bitter gourd, papaya, brinjal, tomato, pointed gourd, egg and salad 
11.45am apple 
1.30pm 2u lispro insulin 
1.40pm lunch with same previous dish except egg 
3.45pm blood sugar 178
5.30pm sour curd 
7.00pm banana 
8.30pm 5u lantus insulin 
9.30pm 2u lispro insulin 
9.40pm dinner with as same as lunch dish

06/10/24

Patient Advocate: Sir, patient was suffering from fever yesterday and she was given Imol Syp two times of  5ml each 

6/10/24
7.30am blood sugar 79
7.30am nuts 
7.40am milk and dates

PaJR PHR Moderator: Please share her 4 hourly temperature readings here if possible

Patient Advocate: No more fever today but her body little worm today


Patient Advocate: Temperature at 6.10pm near about 102F

9.30am 2u lispro insulin 9.40am rice with pointed gourd, chayote, pumpkin, tomato, papaya, bitter gourd, egg and salad 
11.45am blood sugar 267
11.45am apple 
1.30pm 3u lispro insulin 
1.40pm lunch with same previous dish except egg and include chicken 
5.30pm sour curd

07/10/24

Patient Advocate: 7.00pm Meggie 
8.30pm 5u lantus insulin 
9.30pm blood sugar 208
9.30pm 3u lispro insulin 
9.40pm dinner with as same as lunch dish
1.15am 5ml Imol Syp when body tempt was 102

7/10/24
7.30am blood suger 140
7.30am payesh ( milk, rice, dates, raisin and nuts)
9.30am 2u lispro insulin 
9.40am rice with pointed gourd, tometo, pumpkin, chayote, papaya, green banana and salad
10.30am body temperature 100.5


PaJR PHR Moderator: Inputs from our pediatric endocrinologist:
Are they checking the child’s urine or blood for ketones? Extremely important when sick.

08/10/24

Patient Advocate: 11.45am mosambi 
1.30pm 2u lispro insulin 
1.40lunch with same previous dish 
7.00pm banana 
9.00pm 5u lantus insulin
10.00pm blood suger 375
10.00pm 3u lispro insulin 
10.10pm dinner with as same as lunch dish

Thik aache Sir 
Ager report gulo tin mas par hoye gelo ekhon ar thin mas por aar ki ki test korte hobe?

8.10.24
7.30am blood sugar 134
7.30am milk
9.30am 2u lispro insulin 
9.40am rice with pointed gourd, tometo, green banana, papaya, chayote,  egg and salad 
11.45am apple 
1.30pm blood suger 281
1.30pm 3u lispro insulin 
1.40pm lunch with same previous dish except egg and include fish

PaJR PHR Moderator: Hba1c ta proti teen mashe ekbar koriye nile bhalo

Patient Advocate: Khali hba1c ar ketones

PaJR PHR Moderator: Hba1c
Ketones shudhu khub asustho hole

Patient Advocate: Akhon  to temon asustho nei jwar tai kome geche, ekhon saradin neche berachhe

09/10/24

PaJR PHR Moderator: Tahole ketones korar dorkar habe na

Patient Advocate: Ok Sir

9.10.24
7.30am nuts 
7.45am milk and dates 
9.30am 2u lispro insulin 
9.40am rice with pointed gourd, chayote, papaya, green banana, long beans, bitter gourd, tomato and salad 
12.00noon apple 
1.30pm blood sugar 288
1.30pm 3u lispro insulin 
1.40pm lunch with same previous dish include fish

Sir, 
Koyek din theke sakale suger ta thik thake tarpor dupure abong rate suger ta onek ta bere jachhe
Ei abasthay lantus na lispro barano thik hobe ?

PaJR PHR Moderator: Lantus effect is reflected in her fasting sugar values
Lispro tackles the post meals
Lantus also reduces post meals in a very slow generalized overall manner and after increasing lantus one can also see the effect on the post meals after a few days and to see the effect on post meals immediately one needs to increase the lispro because it has immediate effect and also it's effect doesn't last long

If we had better continuous glucose monitoring values, we could optimised the dose better

@Meta AI please translate the text below 👇

Sir, 
Koyek din theke sakale suger ta thik thake tarpor dupure abong rate suger ta onek ta bere jachhe
Ei abasthay lantus na lispro barano thik hobe ?

Meta AI: Here's a translation of the text from Bengali to English:

"Sir, for the past few days, my sugar levels have been normal in the morning, but they increase significantly in the afternoon. In this situation, would Lantus or Lispro insulin be more suitable?"

Lantus and Lispro are types of insulin. Lantus is a long-acting insulin, while Lispro is a fast-acting insulin. The choice between the two depends on individual needs and medical conditions, so it's best to consult a doctor or healthcare professional for personalized advice.

10/10/24

Patient Advocate: 10.10.24
7.30am blood sugar 108
7.30am nuts 
7.40am milk 
9.30am 2u lispro insulin 
9.40am rice with pointed gourd, tometo, pumpkin, chayote, papaya, long beans, bitter gourd, egg and salad 
11.45am apple 
1.30pm blood sugar 292
1.30pm 3u lispro insulin 
1.40pm lunch with same previous dish except egg and include fish 
5.30pm sour curd

PaJR PHR Moderator: @Meta AI please translate below text to Bengali:

Lantus effect is reflected in her fasting sugar values

Lispro tackles the post meals

Lantus also reduces post meals in a very slow generalized overall manner and after increasing lantus one can also see the effect on the post meals after a few days and to see the effect on post meals immediately one needs to increase the lispro because it has immediate effect and also it's effect doesn't last long.

Meta AI: I don’t understand Bengali yet, but I’m working on it. I will send you a message when we can talk in Bengali.

11/10/24

Patient Advocate: 7.00pm banana 
7.45pm 5u lantus insulin 
10.00pm little bit of polao
11.25pm blood sugar 140
11.25pm 2u lispro insulin 
11.35pm dinner with as same as lunch dish





















PaJR PHR Moderator: @Narmeen Shah the hba1c trends every three months since the beginning of your EHR will be to see

Narmeen Shah: Sir I do not have old electronic reports as the exported file of this group conversation was only containing the text data.

PaJR PHR Moderator: Can ask @Patient Advocate to share all her Hba1c values since one year

Narmeen Shah: Ok sir.

Patient Advocate:





Patient Advocate: 11.10.24
8.30am milk 
10.15am 2u lispro insulin 
10.25am rice with pointed gourd, chayote,, papaya, long beans, egg and salad 
12.30pm blood suger 259
12.30am apple 
1.45pm 3u lispro insulin 
1.55pm lunch with same previous dish except egg and include fish 
6.00pm 1/2 sandesh
7.00pm banana 
8.30pm 5u lantus insulin 
9.00pm blood sugar 297
9.00pm 3.5u lispro insulin 
9.10pm dinner with as same as lunch dish


12/10/24

PaJR PHR Moderator: Has the patient advocate started using a different insulin syringe instead of the pen to facilitate 3.5U of lispro before dinner or using a pen insulin with better dose adjustment function?

👆As repeatedly mentioned here, we need to increase her pre breakfast lispro and not her pre lunch and pre dinner night lispro.

Thanks for sharing these trimester evaluation of her sugar control since her diabetes was first detected three trimesters back. @Narmeen Shah please note.

So just a narrative review may conclude that her first trimester sugars were far from ideal control while she recovered remarkably good control in her second trimester but again in the last trimester her control has fallen back to levels that were when she was first diagnosed

Patient Advocate: 12.10.24
8.00am blood sugar 61
8.00am milk

Sir
Fasting suger  ta normal er madhya thake tai lispro ta baraini l
Ajke jemon fasting 61 eschhe ajkeo 2u deoa hoyechhe
Ekhon etake abar ki kore second trimester jaygay niye jaoa jay ?

Narmeen Shah: Ok sir. 🍁

PaJR PHR Moderator: Fasting sugar ta 61 mane hypoglycemia ebong normal holo more than 70

Fasting ta kom aashche lantus er dose er jonye ebong lispro ta kaaj kore breakfast er upor. Khawar aage kom thakleo khawar du ghonta baader ta depend korbe lispro dose er upor ebong alpo kichu ta tar aager diner lantus er upor. Hypoglycemia thekeo porer sugar anek somoi bere jai jehetu body anek catecholamine secrete kore hypoglycemia ta compensate korar chesta kore
@Meta AI please translate above into English

Meta AI: Here's the translation of the text from Bengali to English:

"When fasting sugar is 61, it means hypoglycemia, and normal is above 70. Low fasting sugar indicates a need to adjust the Lantus dose, while Lispro works on breakfast. Even if you eat less, it will depend on the Lispro dose after two hours, and slightly on the previous day's Lantus dose. Hypoglycemia can also cause blood sugar to surge later as the body secretes catecholamines to compensate for the hypoglycemia."

This text appears to be discussing blood sugar management, specifically:

- Fasting blood sugar levels (normal > 70)
- Hypoglycemia (low blood sugar)
- Adjusting Lantus (long-acting insulin) and Lispro (fast-acting insulin) doses
- Blood sugar fluctuations after eating
- Body's response to hypoglycemia (releasing catecholamines)

Please consult a healthcare professional for personalized medical advice.

PaJR PHR Moderator: @Meta AI slight correction needed on third sentence. Its not "even if you eat less" but "even if your pre meal sugar is less", the two hour post meal will depend on not only the pre meal lispro dose but the amount of food consumed and less likely to be predicted on the basis of the pre meal blood sugar

Meta AI: Thank you for the correction. Here's the revised translation:

"When fasting sugar is 61, it means hypoglycemia, and normal is above 70. Low fasting sugar indicates a need to adjust the Lantus dose, while Lispro works on breakfast. Even if your pre-meal sugar is less, the two-hour post-meal reading will depend on both the pre-meal Lispro dose and the amount of food consumed. It's less likely to be predicted based solely on pre-meal blood sugar. Hypoglycemia can also cause blood sugar to surge later as the body secretes catecholamines to compensate for the hypoglycemia."

I've made the necessary adjustments for clarity and accuracy, incorporating your corrections:

1. Changed "even if you eat less" to "even if your pre-meal sugar is less".
2. Specified that the 2-hour post-meal reading depends on both Lispro dose and food consumption.
3. Added nuance that post-meal readings can't be reliably predicted from pre-meal blood sugar alone.

Thank you for refining the translation!

Participant 20: Interesting perspective because although we accept upto 2 hypoglycemic episodes per week, considering that this is a 3 year old child means Hypos are a strict no no

13/10/24

Patient Advocate: 10.00am 2u lispro insulin 
10.10am rice with pointed gourd, chayote, papaya, long beans, bitter gourd, pumpkin and salad 
12.00noon mosambi 
1.45pm 3u lispro insulin 
1.55pm lunch with same previous dish 
7.00pm prasad ( khichdi)
10.10pm 5u lantus insulin 
10.15pm blood sugar 251
10.15pm 3u lispro insulin 
10.25pm dinner with as same as lunch dish

14/10/24

Patient Advocate: 13.10.24
8.00am milk 
10.30am 2u lispro insulin 
10.40am rice with papaya, chayote, bitter gourd, tomato, egg and salad 
12.00noon mosambi 
1.45pm blood sugar 188
1.50pm 3u lispro insulin 
2.00pm lunch with same previous dish except egg and include fish 
5.30pm one sugar free sandesh 
9.00pm 5u lantus insulin 
9.50pm blood sugar 328
9.50pm 3u lispro insulin 
10.00pm dinner with as same as lunch dish

15/10/24

Patient Advocate: 14.10.24
7.30am milk 
9.45am 2u lispro insulin 
9.55am rice with pointed gourd, tometo, pumpkin, chayote, papaya, egg and salad 
11.30am mosambi 
1.30pm blood sugar 418
1.30pm 3u lispro insulin 
1.40pm lunch with same previous dish 
6.30pm Meggie
9.00pm 6u lantus insulin 
9.30pm blood sugar 279
9.30pm 3u lispro insulin 
9.40pm dinner with as same as lunch dish

Patient Advocate: 15.10.24
7.45am blood suger 100
7.45am nuts 
7.55am milk 
9.45am 3u lispro insulin 
9.55am rice with papaya, chayote, bitter gourd, tomato, long beans, ribbed gourd, egg and salad
12.00noon blood sugar 224
12.00noon mosambi 
1.30pm 4u lispro insulin 
1.40pm lunch with same previous dish except egg and include fish 
5.30pm sour curd

Patient Advocate: 7.00pm banana 
8.30pm 6u lantus insulin 
9.30pm 3.5u lispro insulin 
9.40pm dinner with as same as lunch dish

16/10/24

Patient Advocate: 11.45pm blood sugar 324
Sir sugar level ta eto bere jachhe keno insulin onekta barano hoyechhe tao suger ta niche namchhe na keno?

PaJR PHR Moderator: Are you using an insulin pen or syringe?

Patient Advocate:



Patient Advocate: It is used for baby

PaJR PHR Moderator: And lantus?
The blood sugar outcomes are dependent on many factors such as diet, exercise and insulin doses. You have been sharing the patient's insulin doses and diet (images of the plates would have provided a better estimate of the quantity and quality of the diet she's consuming) but we don't have much clue about the patient's hourly activities and how they may have changed since last few days

Patient Advocate: 



PaJR PHR Moderator: Both by pen then?

Patient Advocate: Patient sakale ghum theke uthe half hour er mato parashuna lkore tharpor gharere bhitorei nach kheladhulo, erpor dupure kheye 2-3 ghanta ghumiye abar khela rate ghumano parjanya er majhe jadi bala hay parashuno kar tahole amader kachhe adh ghanta porbe l
Or daily  activity pray eirakam e l
Both are pen

PaJR PHR Moderator: Aei daily activities kimba khawar poriman ebong chinir matrai kono difference lokkho korechilen aei ko din?

Patient Advocate: Chini oke ekdom deoa hay na, 
Pujor madhay ghurte giye serakam kichhu deoa hoyni mishti jatiya kono jinish to nayi fastfood typer kono jinish hayto ekbar test korar janya deoa hoyechhilo l
Oke etodin theke dekhchi oi khaoyate eto barar katha nay l 
Ektu ghumer time e difference hoyechhilo,
Ektu besi rate ghumiye chhilo r sakale deri kore ghum theke uthto

PaJR PHR Moderator: Ghumer time tar jonyei tahole apatoto anuman korte habe je etar saathe ekta causal association thakte pare

Patient Advocate: Dekhi ekhon paroborti koyekdin

Narmeen Shah:












16.10.24
7.30am blood sugar 94
7.30am nuts 
7.45am milk 
9.30am 3u lispro insulin 
9.40am rice with pointed gourd, chayote, papaya , long beans, bitter gourd, tomato, ribbed gourd and salad 
11.45am apple 
1.30pm blood sugar 197
1.30pm 3.5u lispro insulin 
1.40am lunch with same previous dish 
5.30pm sour curd 
7.00pm banana 
8.30pm 6u lantus insulin 
9.30pm blood sugar 278
9.30pm 3.5u lispro insulin 
9.40pm dinner with as same as lunch dish

17/10/24

PaJR PHR Moderator: Thanks @Narmeen Shah for this update

Feedback from our pediatric endocrinologist

"The A1c in June most probably indicates that her T1D was in its “honeymoon” phase. I’m impressed that it actually lasted that long in someone so young."

PaJR PHR Moderator: 👆If she's really just recovering from the beta cell honeymoon phase that can explain why her insulin requirements are slowly increasing

18/07/24

Patient Advocate: 17.10.24
7.30am nuts 
7.45am milk 
9.30am 3u lispro insulin 
9.40am rice with pointed gourd, chayote, papaya, long beans, bitter gourd, tomato and salad 
11.45am blood sugar 249
12.00noon mixed fruit 
1.30pm 3.5u lispro insulin 
1.40pm lunch with same previous dish 
5.30pm sour curd 
7.00pm oats
9.00pm 6u lantus insulin 
9.30pm blood sugar 155
9.30pm 3u lispro insulin 
9.40pm khichdi and rice with same previous (lunch) vegetable 
11.45pm blood sugar 105

19/07/24

Patient Advocate: 18.10.24
7.30am nuts 
7.45am milk 
9.30am 3u lispro insulin 
9.40am rice with papaya, chayote, green banana, long beans, pointed gourd, tometo, egg and salad 
11.45am apple 
1.30pm blood sugar 152
1.40pm lunch with same previous dish except egg and include fish 
5.30pm sour curd 
7.00pm oats 
8.00pm one pc nadu ( til, sugar)
9.30pm blood sugar 237
9.30pm 3u lispro insulin 
9.40pm dinner with as same as lunch dish

PaJR PHR Moderator: 👆 lantus?

Patient Advocate: 8.30pm lantus 6u

19.10.24
7.30am blood sugar 81
7.30am milk
9.30am 2.5u lispro insulin 
9.40am rice with papaya, chayote, sponge gourd, tomato, long beans, pointed gourd, egg and w
11.45am apple
1.30pm blood sugar 330
1.30pm 3.5u lispro insulin 
1.40pm lunch with same previous dish except egg
5.30pm sour curd 
7.00pm banana 
8.30pm 6u lantus insulin 
9.30pm blood sugar 238
9.30pm 3u lispro insulin 
9.40pm dinner with as same as lunch dish

20/10/24

Patient Advocate: 20.10.24
7.30am nuts 
7.45am milk 
9.30am 3u lispro insulin 
9.40am rice with pointed gourd, chayote, brinjal, tomato, long beans, papaya, egg and salad 
11.45am mosambi 
1.30pm blood sugar 199
1.30pm 3u lispro insulin 
1.40pm lunch with same previous dish except egg and include fish 
5.30pm sour curd 
7.00pm oats

PaJR PHR Moderator: 👍

Patient Advocate: 8.30pm 6u lantus insulin 
9.30pm blood sugar 259
9.30pm 3u lispro insulin 
9.40pm dinner with as same as lunch dish

PaJR PHR Moderator: Would be nice to give lantus slightly earlier during her snacks at 7PM

Patient Advocate: Ok Sir

21/10/24

Patient Advocate: 21=10=24
7.30am nuts 
7.45am milk 
9.30am 3u lispro insulin 
9.40am rice with papaya, chayote, ribbed gourd, tomato, long beans, egg and salad 
11.45am apple 
1.30pm blood sugar 361
1.30pm 4u lispro insulin 
1.40pm lunch with same previous dish except egg
[11:28 PM, 10/21/2024] Patient Advocate: 5.30pm sour curd 
7.00pm banana 
8.30pm 6u lantus insulin 
9.30pm blood sugar 224
9.30pm 3u lispro insulin 
9.40 pm dinner with as same as lunch dish

22/10/24

PaJR PHR Moderator: Human narrative observations of the data toward further analysis:

The pre lunch sugar values were high and it clearly wasn't supported by the intervention combination of yesterday's long acting lantus and pre breakfast lispro 

The pre dinner sugar values were also high and it clearly wasn't supported by the previously taken pre lunch lispro (as it's effect would have worn off in the time between lunch and dinner) as well as previous day's long acting lantus (as it's effect would have worn off by this time) and the 8:30 PM lantus taken the same day (as it's effect wouldn't have started)

Solution toward optimization: Meal and Insulin intervention spacing needs to be optimised based on above human observation and analysis.

@Meta AI please analyse the insulin intervention and glucose outcomes data below and suggest measures toward optimization of the glucose outcomes:

Patient Advocate 2F Diabetes1: 20.10.24
7.30am nuts 
7.45am milk 
9.30am 3u lispro insulin 
9.40am rice with pointed gourd, chayote, brinjal, tomato, long beans, papaya, egg and salad 
11.45am mosambi 
1.30pm blood sugar 199
1.30pm 3u lispro insulin 
1.40pm lunch with same previous dish except egg and include fish 
5.30pm sour curd 
7.00pm oats
Patient Advocate 2F Diabetes1: 8.30pm 6u lantus insulin 
9.30pm blood sugar 259
9.30pm 3u lispro insulin 
9.40pm dinner with as same as lunch dish
Patient Advocate 2F Diabetes1: 21=10=24
7.30am nuts 
7.45am milk 
9.30am 3u lispro insulin 
9.40am rice with papaya, chayote, ribbed gourd, tomato, long beans, egg and salad 
11.45am apple 
1.30pm blood sugar 361
1.30pm 4u lispro insulin 
1.40pm lunch with same previous dish except egg
Patient Advocate 2F Diabetes1: 5.30pm sour curd 
7.00pm banana 
8.30pm 6u lantus insulin 
9.30pm blood sugar 224
9.30pm 3u lispro insulin 
9.40 pm dinner with as same as lunch dish

Meta AI: Based on the provided insulin intervention and glucose outcomes data, here's an analysis and suggestions for optimization:

Key Observations:

1. High post-meal glucose spikes (199, 259, 361, 224)
2. Inconsistent glucose control throughout the day
3. Similar meal composition, but varying glucose responses
4. Lispro insulin doses seem inadequate for meal coverage
5. Lantus insulin dose (6 units) may not be sufficient for basal needs

Recommendations:

Lispro Insulin Adjustments:

1. Increase mealtime Lispro doses:
    - 4-5 units for breakfast and lunch
    - 5-6 units for dinner (considering higher evening glucose)
2. Consider split dosing for larger meals (e.g., 2-3 units before, 2-3 units after)

Lantus Insulin Adjustments:

1. Increase basal Lantus dose to 8-10 units at bedtime to better cover overnight fasting glucose

Additional Strategies:

1. Carb counting: Estimate carbohydrate content in meals to adjust Lispro doses accordingly
2. Dose timing: Administer Lispro 15-30 minutes before meals to align with peak insulin action
3. Snack optimization: Choose snacks with lower glycemic index (e.g., fruits, nuts) and adjust portion sizes
4. Physical activity: Encourage regular exercise, especially post-meal walks, to improve insulin sensitivity
5. Monitoring: Increase blood glucose monitoring frequency, especially post-meals and before bed
6. Consultation: Schedule a consultation with a healthcare professional or registered dietitian for personalized guidance

Next Steps:

1. Review and adjust insulin doses based on the above recommendations
2. Monitor glucose responses and adjust doses accordingly
3. Consider continuous glucose monitoring (CGM) or flash glucose monitoring for more detailed insights

Please consult a healthcare professional before making any changes to insulin doses or treatment plans.

Patient Advocate: 22.10.24
7.30am blood suger 81
7.30am nuts
7.45am milk

PaJR PHR Moderator: This is the effect of the 8:30 PM lantus from yesterday and one needs to be careful it doesn't gradually build up to early morning hypoglycemia.

Better to space the lantus at 7PM before the banana as suggested earlier

Patient Advocate: 9.30am 3u lispro insulin 
9.40am rice with papaya, chayote, bitter gourd, sponge gourd, long beans, radish egg and salad 
11.45am mosambi 
1..30pm blood sugar 268
1.30pm 3.5u lispro insulin 
1.40pm lunch with same previous dish except egg and include fish 
3.45pm blood sugar 168
7.00pm banana 
7.45pm  7u lantus insulin 
9.30pm blood sugar 191
9.30pm 3u lispro insulin 
9.40pm dinner with as same as lunch dish

23/10/24

PaJR PHR Moderator: Feedback from our pediatric endocrinologist NJ:
Has the family of the child with T1D met with a dietician? I think her diet needs to adjusted. 
Also, what’s her growth like? Height, weight?
Is there  growth chart?

PaJR PHR Moderator: Ore bortoman height weight ebong growth chart ta share korun

PaJR PHR Moderator: @Narmeen Shah I thought we had uploaded her previous paper based growth chart in her case report earlier but I'm currently unable to find it. Would you be able to prepare an electronic growth chart instead of the paper based one by collecting the numbers from @Patient Advocate ?

Narmeen Shah: Sure sir. 👍

Patient Advocate: Thik achhe aaj bikele kore debo

23.10.24
7.30am blood suger 52
7.30am nuts 
7.45am milk and dates

PaJR PHR Moderator: 6u lantus theke 6.5U barano uchit chilo.
Ae charao 22/10/24 a jokhon fasting already 81 tokhon lantus baranor to manei hoi na jokhon amra jani je lantus er probhab fasting er uporei beshi!

PaJR PHR Moderator: @Meta AI translate to English
6u lantus theke 6.5U barano uchit chilo.

Ae charao 22/10/24 a jokhon fasting already 81 tokhon lantus baranor to manei hoi na jokhon amra jani je lantus er probhab fasting er uporei beshi!

PaJR PHR Moderator: Any hypoglycemic symptoms?

Meta AI: Here's the translation of the text from Bengali to English:
"Should have increased from 6 units of Lantus to 6.5 units. But considering on 22/10/24 when fasting sugar was already 81, increasing Lantus doesn't make sense since we know Lantus primarily affects fasting sugar."

In this text, the speaker is discussing insulin dose adjustments, specifically:

- Questioning whether to increase Lantus (long-acting insulin) from 6 units to 6.5 units
- Noting that on October 22, 2024, fasting blood sugar was 81, which is relatively normal
- Recognizing that Lantus primarily impacts fasting blood sugar, so increasing the dose might not be necessary given the already normal fasting level."

Patient Advocate: এখানে 8-10 এর কথা AI মারফত বলা হয়েছে 
Lantus এ 0.5 এর option নেই
No Sir
Before lunch sugar ta je abar bere gelo

PaJR PHR Moderator: AI ke trust kore nijei decision newar aage amader ekhane janano uchit chilo gotokal bikele!
Otai body'r reaction to hypoglycemia!
Symptoms na howa ta aro dangerous jemon amra aageo kichu scientific paper er madhyome janiyechilam jetar link ta case report a archive kora ache

PaJR PHR Moderator: @Meta AI please translate

"PaJR Moderator: Any hypoglycemic symptoms?
Patient Advocate 2F Diabetes1: এখানে 8-10 এর কথা AI মারফত বলা হয়েছে 
Lantus এ 0.5 এর option নেই
Patient Advocate 2F Diabetes1: No Sir
Patient Advocate 2F Diabetes1: Before lunch sugar ta je abar bere gelo
PaJR Moderator: AI ke trust kore nijei decision newar aage amader ekhane janano uchit chilo gotokal bikele!

PaJR Moderator: Otai body'r reaction to hypoglycemia!

Symptoms na howa ta aro dangerous jemon amra aageo kichu scientific paper er madhyome janiyechilam jetar link ta case report a archive kora ache"

Meta AI: Here's the translation of the text from Bengali to English:

"PaJR Moderator: Are there any hypoglycemic symptoms?

Patient Advocate 2F Diabetes1: Here, AI suggested increasing Lantus by 0.5 units, but that's not an option.

Patient Advocate 2F Diabetes1: No, Sir.

Patient Advocate 2F Diabetes1: Blood sugar increased before lunch.

PaJR Moderator: We should have trusted AI's decision earlier!

PaJR Moderator: That's the body's reaction to hypoglycemia! No symptoms make it even more dangerous, as we learned from scientific papers and case reports archived earlier.

This conversation appears to be between a patient advocate and PaJR Moderator, discussing:

1. Hypoglycemic symptoms (or lack thereof)
2. AI-recommended Lantus dose increase
3. Blood sugar fluctuations
4. Trusting AI decisions
5. The dangers of asymptomatic hypoglycemia (mentioned in scientific papers and case reports)

Please note that this conversation involves medical topics and personal health decisions. Consult a healthcare professional for personalized advice."

PaJR PHR Moderator: @Meta AI what you translated for 23/10, 09:59 by PaJR Moderator is clearly wrong!

PaJR PHR Moderator: @Meta AI no I meant 9:58 by PaJR Moderator

Meta AI: I apologize for the mistake. Please provide more context or clarify what PaJR Moderator meant by his message on 23/10, 09:59, and I will re-translate it accurately.

The original message is:

PaJR Moderator: Otai body'r reaction to hypoglycemia! Symptoms na howa ta aro dangerous jemon amra aageo kichu scientific paper er madhyome janiyechilam jetar link ta case report a archive kora ache

Please provide your correction, and I'll make sure to improve my understanding and translation.

PaJR PHR Moderator: @Meta AI the original message is "AI ke trust kore nijei decision newar aage amader ekhane janano uchit chilo gotokal bikele!"

Should have translated to "Instead of Trusting AI and taking a direct decision without consulting the team, the patient advocate should have shared his plan for escalating the lantus insulin dose yesterday evening for the team's inputs

Meta AI: I don’t understand Bengali yet, but I’m working on it. I will send you a message when we can talk in Bengali.

Meta AI: Thank you for correcting me.

The correct translation of PaJR Moderator' message (23/10, 09:58) is indeed:

"AI ke trust kore nijei decision newar aage amader ekhane janano uchit chilo gotokal bikele!"

Should translate to:

"Instead of trusting AI and taking a direct decision, it would have been better to share the plan for escalating the Lantus insulin dose yesterday evening for the team's inputs."

Or, more concisely:

"Should have shared the Lantus dose escalation plan with the team yesterday, instead of relying solely on AI."

I'll ensure more accurate translations moving forward. Thank you!

Narmeen Shah: @Patient Advocate please send the picture of growth sheet of the baby.

Patient Advocate: Hight- 38.5 Inch
Weight - 14.2kg

PaJR PHR Moderator: The picture will look like this.


PaJR PHR Moderator: Please share the trends in the graph since last 9 months.

Patient Advocate:



Patient Advocate: Sir er majhe r kora hoy ni
Or age ekhon 3yrs 6month



Patient Advocate: 
9.30am 2.5u lispro insulin 
9.40am rice with pointed gourd, chayote, brinjal, long beans, radish, chayote, egg and salad 11.45am apple 
1.30pm blood sugar 278
1.30pm 3.5u lispro insulin 
1.40pm lunch with same previous dish except egg and include fish 
7.30pm oats
8.00pm 6u lantus insulin 
9.30pm blood sugar 138
9.30pm 2.5u lispro insulin 
9.40pm dinner with as same as lunch dish

24/10/24

Patient Advocate: 24.10.24
7.30am blood suger 61
7.30am nuts 
7.40am milk
9.30am 2.5u lispro insulin 
9.40am rice with long beans, papaya, chayote, bitter gourd, tomato, pointed gourd, sponge gourd, egg and salad 
11.45am apple 
1.30pm blood sugar 252
1.30pm 3.5u lispro insulin 
1.40pm lunch with same previous dish except egg and include fish 
7.00pm banana 
8.00pm 6u lantus insulin 
9.30pm blood sugar 231
9.30pm 3.5u lispro insulin 
9.40pm dinner with as same as lunch dish

25/10/24

Patient Advocate: 25.10.24
7.30am nuts 
7.45am milk 
9.30am 2.5u lispro insulin 
9.40am rice with pointed gourd, chayote, green banana, long beans, papaya, radish egg and salad 
11.45am apple 
1.30pm blood sugar 258
1.30pm 3.5u lispro insulin 
1.40pm lunch with same previous dish except egg and include fish 
6.30pm one pc nadu
7.00pm banana 
8.00pm 6u lantus 
9.30pm blood suger 312
9.30pm 4u lispro insulin 9.40pm dinner with as same as lunch dish

26/10/24

Patient Advocate: 26.10.24
7.30am blood suger 43
7.30am one pc nadu
7.30am nuts 
7.40am milk

PaJR PHR Moderator: Was the blood sugar rechecked after the carb intervention to hypoglycemia?
Did she have any symptoms?

PaJR PHR Moderator: 👆This illustrates as mentioned by our pediatric endocrinologist before, lispro doses are better hiked before breakfast than before dinner.

Also her hypoglycemia today appears to be not just the night lispro hike but also the previous lantus hike that precipitated her fasting hypoglycemia two days back

PaJR PHR Moderator: @Meta AI what is the best oral intervention for hypoglycemia?

Can one take coconut sweets such as naru to counter it? Are there any studies suggesting that slightly complex carbohydrates are good enough as hypoglycemia interventions than the general belief that it has to be the simplest and quickest absorbed carbohydrates for hypoglycemia interventions?

Meta AI: For treating hypoglycemia, the American Diabetes Association recommends consuming 15-20 grams of glucose or simple carbohydrates, followed by a snack or meal to stabilize blood sugar levels. Options include:

- Glucose tablets or gels
- Hard candies like Jolly Ranchers
- Fruit juice (1/2 cup)
- Regular soda (1/2 cup)
- Candy like Lifesavers

Complex carbohydrates can also work but are not the first choice due to slower absorption rates.

Studies suggest that whole, unprocessed foods like fruits, vegetables, and whole grains can effectively manage and prevent hypoglycemia due to their fiber content, which slows down carbohydrate digestion and absorption, providing a more sustained effect.

Regarding coconut sweets like naru:

- Naru (coconut rice cakes) contains some simple carbohydrates but also fiber and healthy fats, slowing down carbohydrate absorption.
- While naru can help alleviate hypoglycemia, its effectiveness compared to simpler carbohydrates is uncertain.

It's essential to consult a healthcare professional for personalized advice on managing hypoglycemia.

Sources:

1. American Diabetes Association. (2024). Hypoglycemia (Low Blood Sugar).
2. Diabetes UK. (2020). What to do when blood sugar levels are low.
3. Harvard Health Publishing. (2019). Preventing low blood sugar.

Would you like more information on hypoglycemia management or nutrition?

Patient Advocate: No symptoms

PaJR PHR Moderator: @Narmeen Shah can you share that article from your logged case report that describes outcomes of hypoglycemia unawareness in pediatric population of Diabetes


Patient Advocate: 9.30am 2.5u lispro insulin 
9.40am rice with papaya, chayote, green banana, tomato, long beans, bitter gourd, egg and salad 
12.00noon apple 
1.30pm blood sugar 260
1.30pm 3.5u lispro insulin 
1.40pm lunch with same previous dish except egg and include paneer

27/10/24

Patient Advocate: 7.00pm banana 
7.30pm sandesh one pc
8.00pm 6u lantus insulin 
9.30pm blood sugar 202
9.30pm 3u lispro insulin 
9.40pm dinner with as same as lunch dish
11.45pm blood sugar 63 and 3/4 teaspoon sugar

Patient Advocate: 27/10/24
7.30am milk 
9.30am 2.5u lispro insulin 
9.40am rice with papaya, chayote, green banana, long beans, bitter gourd, tomato, cabbage, radish, egg and salad 
11.45am blood suger 245
12.00noon apple and 
1.00pm munch chocolate one pc of Rs 5
1.30pm 3.5u lispro insulin 
1.40pm lunch with same previous dish except egg and include chicken

Participant 20: It seems the mid day sugars are consistently high at the moment.
Can you please (in a separate message) list out how much insulin is being given and at what times please?
Thank you.

PaJR PHR Moderator: @Meta AI 
Can you please list out how much insulin is being given and at what times from the data below?👇

Patient Advocate 2F Diabetes1: 9.30am 2.5u lispro insulin 
9.40am rice with papaya, chayote, green banana, tomato, long beans, bitter gourd, egg and salad 
12.00noon apple 
1.30pm blood sugar 260
1.30pm 3.5u lispro insulin 
1.40pm lunch with same previous dish except egg and include paneer
Patient Advocate 2F Diabetes1: 7.00pm banana 
7.30pm sandesh one pc
8.00pm 6u lantus insulin 
9.30pm blood sugar 202
9.30pm 3u lispro insulin 
9.40pm dinner with as same as lunch dish
Patient Advocate 2F Diabetes1: 27/10/24
7.30am milk 
9.30am 2.5u lispro insulin 
9.40am rice with papaya, chayote, green banana, long beans, bitter gourd, tomato, cabbage, radish, egg and salad 
11.45am blood suger 245
12.00noon apple and 
1.00pm munch chocolate one pc of Rs 5
1.30pm 3.5u lispro insulin 
1.40pm lunch with same previous dish except egg and include chicken

Meta AI: Here's the insulin dosage and timing information extracted from the data:

October 26

- 9:30 AM: 2.5 units Lispro insulin (fast-acting)
- 1:30 PM: 3.5 units Lispro insulin (fast-acting)

October 27

- 8:00 PM: 6 units Lantus insulin (long-acting)
- 9:30 PM: 3 units Lispro insulin (fast-acting)
- 9:30 AM: 2.5 units Lispro insulin (fast-acting)
- 1:30 PM: 3.5 units Lispro insulin (fast-acting)

Note:

- Lispro insulin is fast-acting, taken before meals.
- Lantus insulin is long-acting, taken once daily, typically at bedtime.

Consult a healthcare professional for personalized guidance.

PaJR PHR Moderator: @Meta AI did you confuse the dates and times October 26 8:00PM, 9:30PM have also been mentioned as October 27?

Meta AI: You are correct, I mistakenly merged the information for October 26 and 27. Here is the corrected insulin dosage and timing information:

October 26

- 9:30 AM: 2.5 units Lispro insulin (fast-acting)
- 1:30 PM: 3.5 units Lispro insulin (fast-acting)

October 27

- 7:30 AM: (no insulin mentioned)
- 9:30 AM: 2.5 units Lispro insulin (fast-acting)
- 1:30 PM: 3.5 units Lispro insulin (fast-acting)
- 8:00 PM: 6 units Lantus insulin (long-acting)
- 9:30 PM: 3 units Lispro insulin (fast-acting)

Thank you for pointing out the error!

Participant 20: Looks like morning Lispro needs a mild increment? 3U perhaps?
How many Hypos reported in the last 1 week? Sorry I don't have access to AI from UK WhatsApp

PaJR PHR Moderator: 9:30 AM: 2.5 units Lispro insulin (fast-acting)

- 1:30 PM: 3.5 units Lispro insulin (fast-acting)

- 8:00 PM: 6 units Lantus insulin (long-acting)

- 9:30 PM: 3 units Lispro insulin (fast-acting)

Participant 20: If more than 2, perhaps she will need the Lantus moved to morning?

PaJR PHR Moderator: This has been repeatedly pointed out in the discussions above

Participant 20: I think yes the morning Lispro needs to go to 3.

Participant 20: I'm sorry sir I missed the gist. Apologies for the burden.

PaJR PHR Moderator: Lantus has been slowly shifted to 8PM. We were gunning for 7 PM for a few days/weeks

Participant 20: Why not gun for 8 AM?

PaJR PHR Moderator: I guess as all the hypos are in the morning fasting that's also a cognitive barrier to increase the lispro soon after

Fasting lantus?

Participant 20: The safer way would be to anticipate the Hypos in waking hours when feeding is timely and possible

Yes or with breakfast

PaJR PHR Moderator: And lispro?

This is interesting but perhaps the hypo due to hike of basal insulin would often be seen during overnight fasting?

Participant 20: With the morning meal. Which is why Lantus can be moved to 8 AM

If it were an adult the Hypos would be much more acceptable, however this is too risky for a child and I'll try to review literature on hypoglycemia on growth patterns in children

PaJR PHR Moderator: 👆 Lantus after 7:30AM milk? @Participant 20

Participant 20: Sounds perfect to me


"Whether episodes of severe hypoglycemia have long-term consequences is controversial. Early studies suggesting that the developing brain is sensitive to permanent neurological damage as a result of hypoglycemia have not been confirmed in more recent reports. Many studies have not found convincing evidence of neurological sequelae of the hypoglycemic events that are an inevitable complication of insulin therapy. The question, however, remains under active investigation. Continued prospective monitoring of hypoglycemia rates and consequences has become an essential component of diabetes management. "

Participant 20: This would also mean the morning 2.5 lispro can stay put.

PaJR PHR Moderator: Although she may need that to be hiked and pre dinner lispro dose reduced

PaJR PHR Moderator: 👆 I'm more worried about her hypoglycemia unawareness @Participant 20

Participant 20: Exactly! Even if aware can she communicate and recognise appropriately at that age? No

If Actrapid I would agree with the pre dinner but lispro is too short and wanes in 4 hours.

I think we could start with half Lantus tonight and half Lantus tomorrow 8 AM and full dose henceforth

PaJR PHR Moderator: @Narmeen Shah can you provide this entire case report URL


to Google LN or openAI LLM and ask it to list the number of documented hypoglycemia episodes during fasting vs during post lunch or post dinner or the most frequent time she had her hypoglycemia episodes and also provide a line graph of the episodes with time in the X axis and hypo episodes in y axis from the month this PaJR began?

Patient Advocate: 
6.00pm one pc nadu
7.00pm oats 
8.00pm 6u lantus insulin 
9.30pm blood sugar 163
9.30pm 2.5u lispro insulin 
9.40pm dinner with as same as lunch dish

28/10/24

Narmeen Shah: Ok sir.

Patient Advocate: 28=10=24
7.30am blood sugar 52
7.30am nadu
7.40am nuts 
7.45am milk

PaJR PHR Moderator: Should have reduced lantus dose by 1 unit yesterday!

See your increasing it by one unit from 6U to 7U made her go into hypoglycemia recently as her fasting sugars were already low normal range even when you hiked it by one unit. So instead of going down back by 1U to previous 6U dose, we needed to have gone down by 2U to 4U just to be on the safer side!

Did she have any noticeable symptoms in the morning?

Patient Advocate: No Sir

Participant: Maybe we can avoid lispro in the night as the child is developing hypo in the morning, it maybe due to the fact that lispro is exhausting the blood glucose in the next few hourz after dinner. Very rare  for lantus to cause hypo.

PaJR PHR Moderator: 👆This is the last post lispro evaluation we have in 18 October.

Yes @Participant we have shared with the team here (as archived in the case report by @Narmeen Shah or if you scroll above in case you haven't cleared the chat) as to how lispro doses should be less at night and more in the morning.

We have also discussed the medical cognition issues around why it may be prospectively difficult and counter intuitive for the parent to reduce the lispro dose when he notices the pre dinner to be 202 as yesterday or even 163 as on October 18!

Participant: Ok Sir. Thank you.

PaJR PHR Moderator: When did you last notice hypoglycemia symptoms in the child? Can you describe those symptoms?

@Narmeen Shah can you prompt the LLM to pick up any documented hypoglycemic symptoms from your case report with the last recorded date?

Patient Advocate: 9.30am 2u lispro insulin 
9.40am rice with papaya, chayote, bitter gourd, tomato, long beans, pointed gourd, egg and salad 
11.45am mosambi 
1.30pm blood sugar 291
1.30pm 3.5u lispro insulin 
1.40pm lunch with same previous dish except egg 
7.00pm oats 
8.00pm 6u lantus insulin 
9.30pm blood sugar 209
9.30pm 2u lispro insulin 
9.40pm dinner with as same as lunch dish and papad

Narmeen Shah: Hypoglycemia Episodes

The sources document more hypoglycemia episodes after breakfast (fasting) than after lunch or dinner. 

* On 3/29/24, the patient's blood sugar was 35 before breakfast, and 56 after dinner. The patient advocate noted the patient had breast milk while sleeping after the dinner blood sugar test. 
* On 4/4/24, the patient had a blood sugar level of 50 at 7:30 am after having milk and puffed rice.
* On 4/5/24, the patient had a blood sugar of 58 at 11:30 am before lunch. It was noted that breakfast was delayed because of an ultrasound appointment. 
* On 4/25/24, the patient's after-dinner blood sugar was 59, after which the patient advocate gave her 1/3 of a teaspoon of sugar. Her blood sugar before breakfast that day was 98.
* On 4/27/24, the patient had a blood sugar level of 54 before breakfast.
* On 5/5/24, the patient's blood sugar after dinner was 65. Her blood sugar before breakfast the next morning was 102.
* On 5/24/24, the patient's blood sugar before lunch was 66. Later that night, her blood sugar was 54, after which the patient advocate gave her one sandesh.
* On 5/27/24, the patient's blood sugar was 39 at 4:30 pm, after which she was given one sandesh.
* On 5/29/24, the patient's blood sugar was 64 before breakfast, and 60 at 4 pm before dinner. A Cadbury chocolate was given at 4:15 pm.
* On 6/1/24, the patient had a blood sugar level of 60 at 4 pm, and was given a lollipop and jelly chocolate. 
* On 6/13/24, the patient's blood sugar was 36 at 11:50 pm, after which she was given one rasagolla and 1/2 teaspoon of sugar.
* On 6/23/24, the patient's blood sugar was 60 at 7:30 am, and 70 at 11:55 pm. Dates were given after the morning reading, and mutton was included in dinner.
* On 6/27/24, the patient had a blood sugar level of 54 before breakfast, and 61 at 4 pm, after which a lollipop was given. 

It is worth noting that the sources do not mention the specific criteria used to define a hypoglycemic episode. Also, the timing of blood sugar measurements in relation to meals was not always consistent.

Narmeen Shah: Hypoglycemia Episodes

*   The sources document five instances of hypoglycemia in the three-year-old patient.
*   The recorded instances of hypoglycemia occurred at the following times:
    *   July 2, 2024, at midnight: Blood sugar measured 63 two hours after dinner.
    *   July 3, 2024, at noon: Blood sugar measured 47, an hour and fifteen minutes after breakfast.
    *   July 12, 2024, at 9:45 pm: Blood sugar measured 44, prior to dinner.
    *   July 18, 2024, at 9:30 pm: Blood sugar measured 70, prior to dinner. The patient then ate a small piece of creamy cake.
    *   July 26, 2024, at 7:30 am: Blood sugar measured 74, prior to breakfast. The patient then ate nuts and dates.

*   Four out of the five documented hypoglycemic episodes occurred prior to dinner.
*   The remaining episode occurred in the morning prior to breakfast.
*   There were no documented episodes of hypoglycemia after meals.

It is important to note that this information is based on the provided sources and may not be exhaustive. Consulting a healthcare professional is essential for a comprehensive understanding of the patient's medical history and appropriate management.

Narmeen Shah: This document details the blood sugar levels of a 3-year-old child with Type 1 Diabetes throughout August 2024.  Here's what the sources indicate about the timing of her hypoglycemic episodes:

*   Fasting Hypoglycemia: The child experienced two documented episodes of hypoglycemia while fasting: 
    *   On 08/08/24, her blood sugar was 52 at 7:30 am. 
    *   On 16/08/24, her blood sugar was 64 at 7:30 am.
*   Post-Lunch/Dinner Hypoglycemia:  The sources do not list any instances of hypoglycemia immediately following lunch or dinner.
*   Other Notable Low Blood Sugar Readings: There were additional times when her blood sugar was below the typical target range, though not necessarily classified as severe hypoglycemia. For example:
    *   On 03/08/24 her blood sugar was 88 at 4:00 pm. 
    *   On 07/08/24 her blood sugar was 93 at 1:45 pm.
    *   On 11/08/24 her blood sugar was 96 at 4:00 pm. 

Most Frequent Time of Hypoglycemia: Based on the provided data, fasting was the most frequent time the child experienced documented hypoglycemia.  

Important Note:  The sources primarily focus on recording blood sugar levels at specific times and don't always mention if the child experienced symptoms of hypoglycemia. It's possible that other hypoglycemic episodes occurred but were not documented in these logs.

Narmeen Shah: Hypoglycemia Episodes: Fasting vs. Post-Meal

The sources document two instances of hypoglycemia. Both events occurred during fasting. 

*   On 12/09/2024 at 12:00 AM, the patient's blood sugar was 45. The Patient Advocate notes that 1 teaspoon of sugar was given.  
*   On 27/09/2024 at 11:45 PM, the patient's blood sugar was 66. The Patient Advocate notes that 0.5 teaspoon of plain sugar was given. No symptoms were observed in either case.

*There are no documented episodes of hypoglycemia occurring after lunch or dinner. 

The sources repeatedly express concern about the potential for asymptomatic hypoglycemia due to the lack of continuous glucose monitoring (CGM). This means that additional hypoglycemia episodes may have occurred but were not detected.

Narmeen Shah: The sources document one instance of hypoglycemia while fasting. On October 12, 2024, the patient's blood sugar was 61 at 8:00 am before eating.

There are two documented instances of hypoglycemia that occurred outside of fasting times. 

*   On October 5, 2024, the patient had a blood sugar of 100 at 11:45 pm. This was a few hours after dinner. 
*   On October 23, 2024, the patient had a blood sugar of 52 at 7:30 am. The sources note that the patient had nuts and milk and dates at 7:30 am and 7:45 am, respectively, so it is unclear whether this instance of hypoglycemia should be considered to have happened while fasting or after eating. 

Based on the available data, the patient experienced hypoglycemia more frequently while fasting. However, this conclusion is based on a limited number of readings and should be interpreted cautiously.

29/10/24

PaJR PHR Moderator: Thanks @Narmeen Shah Can you prompt the LLM to provide any documented symptoms on each of those dates and mention what were those symptoms as I'm sure not all the episodes were asymptomatic?

PaJR PHR Moderator: Inputs from our pediatric endocrinologist from NJ regarding her diet:

"I think a few changes to her breakfast are needed to bring down the pre-lunch highs:

They could start with: 
1) either reducing or eliminating rice, instead increase eggs and add milk. 

2) changing mid morning snack from fruits to a handful of peanuts or edamame beans (roasted soy beans) - excellent source of protein and fiber."

Patient Advocate: 29/10/24
7.45am blood suger 75
7.45am nuts 
8.00am milk

PaJR PHR Moderator: The cumulative effect of the previous one time 7U lantus has finally gone and this is perhaps the effect of yesterday's night lantus 6U. @Meta AI can you explain these cumulative effects of lantus perhaps causing hypoglycemia by drawing correlations with it's insulin kinetics? Please share valid references to support your statements

Meta AI: Lantus (insulin glargine) is a long

Patient Advocate: 9.30am 2.5u lispro insulin 
9.40am rice with pointed gourd, chayote, papaya, long beans, bitter gourd, pumpkin, cauliflower, egg and salad 
11.45am apple 
1.30pm blood sugar 184
1.30pm 2.5u lispro insulin 
1.40pm lunch with same previous dish except egg and include fish
[10:25 PM, 10/29/2024] Patient Advocate: 7.00pm banana 
8.00pm 6u lantus insulin 
9.30pm blood sugar 195
9.30pm 2.5u lispro insulin 
9.40pm dinner with as same as lunch dish

30/10/24

PaJR PHR Moderator: Fasting blood sugar values today?

Patient Advocate: 30.10.24
7.30am blood suger 49 and no symptoms 
7.30am mixed of milk puffed rice and banana

PaJR PHR Moderator: Please reduce her lantus to 5U at night!
👆 Had mentioned this here!

Splitting the dose of lantus half half is a good idea as also suggested by our pediatric endocrinologist.

However the issue here is that now the child will need 5 shots!

Patient Advocate: Ok Sir

Participant 20: I think the overnight Lantus is now extremely unsafe. Needs to be moved to morning.

Paticipant: why not remove Lispro?? i feel that as it is a short acting insulin, it is exhausting the glucose acquired through dinner in the next few hours and then its only the liver which is compensating via gluconeogenesis.. Lantus was introduced into the market specifically for its long duration and also coz it doesnt cause hypo.

Patient Advocate: 9.30am 2.5u lispro insulin 
9.40am rice with papaya, chayote, green banana, long beans, pointed gourd, bitter gourd, egg and salad 
11.45am apple 
1.30pm blood sugar 69
1.30pm 1.5u lispro insulin 
1.40pm lunch with same previous dish

PaJR PHR Moderator: Her hypoglycemia appears to be persistent today. Please inform the blood sugars at 3:40PM

Patient Advocate: 3.45pm after lunch blood suger 284
7.00pm banana 
8.00pm 6u lantus insulin 
9.30pm blood sugar 373
9.30pm 4u lispro insulin 
9.40pm dinner with as same as lunch dish

31/10/24

PaJR PHR Moderator: 👆?

Patient Advocate: Sir gatakal to abar bere gelo

Patient Advocate: 31.10.24
7.30am blood suger 49
7.30am nuts 
7.40am milk

PaJR PHR Moderator: Koi bereche!!?? Abar to aro kome geche!!

Apnake to anek bar bola hoyeche je hypoglycemia ta lantus er dose er jonye hocche!
[9:16 AM, 10/31/2024] PaJR PHR Moderator: Apni pre meal ta dekhe lispro insulin dose ta bibechona korchen kintu jokhon hi aei dhoroner 3 din dhore bipod poristhiti cholte thake tokhon dorkar aro regular at least seven point sugar monitoring er.

Fasting

Pre breakfast

2 hours post breakfast

Pre lunch

2 hours post lunch

Pre dinner

2 hours post dinner

Uporer 7 bar sombhob na hole ontoto dine 4 bar

Fasting

2 hours post breakfast

2 hours post lunch

2 hours post dinner 

Best holo ekta CGM monitoring device niye newa

PaJR PHR Moderator: Ekbar jokhon early morning hypoglycemia hoi tokhon shorirer bhitor kichu hormone release hoi jara automatically patient ke bachanor jonye blood sugar ta bariye dai kintu ekbar bere gele tokhon shorirer nijer insulin jehetu nei shara deener blood sugar ta tokhon bere jai

Patient Advocate: Aaj tahole 5u dibp

PaJR PHR Moderator: 👆sugar values guno o shob janaben

Patient Advocate:
9.30am 1.5u lispro insulin 
9.40am rice with pointed gourd, bitter gourd, pumpkin, chayote, green banana, long beans, egg, and salad 
11.45am mosambi 
1.30pm blood sugar 158
1.30pm 2u lispro insulin 
1.40pm lunch with same previous dish except egg and include fish 
7.00pm banana 
8.00pm 5u lantus insulin
9.45pm blood sugar 74
9.45pm 1.5u lispro insulin 
9.55pm dinner with as same as lunch dish

01/11/24

Patient Advocate: 12.00night blood sugar 42
1.5 teaspoon sugar

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Monthly Records - 2024:

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