Continuous Insulin Infusion Research Articles

Preferable Conversion Rate from Intravenous to Subcutaneous Insulin in Hyperglycemic Emergencies in Diabetic Patients

To clarify the safe and effective conversion ratio from continuous intravenous insulin infusion (II) to subcutaneous long-acting insulin injection (SI) in diabetic ketoacidosis (DKA) or hyperosmolar hyper glycemic state (HHS), we conducted single center, retrospective, cohort study. Based on electronic medical records at our hospital from inception through September 2017, we extracted the subjects with DKA/HHS diagnosis. Other inclusion criteria were 1) no intermission between II and SI, 2) co-administered II and SI within 3 hours, and 3) aged ≥18 years old. We defined II requirement (IR) as the total II dose within 24 hours before conversion to SI. Then we divided subjects into 4 groups according to the percentage of SI to IR [group stratification: 0-39% (Q1), 40-69% (Q2), 70-89% (Q3), ≥90% (Q4)], and compared primary outcome which was the percentage achieving glycemic target of 80-180 mg/dl within 24 hours after the conversion. As the result, 44 subjects were included (male 52%, mean age 59 years old, mean HbA1c 11.6%, DKA 75%, median serous-CPR (CPR) 0.17 ng/ml). Median IR and the percentage of SI to IR were in inverse correlation; Q1=51 units (U), Q2=25.2U, Q3=27.2U, and Q4=7.1U (p=0.0001). In primary analysis, the median percentage achieving the glycemic target was highest with 67.5% in Q4, and was comparatively lower in the other groups; Q1=13.4% (p=0.01), Q2=16.7% (p=0.01), Q3=40% (p=0.089). In multivariate analysis adjusted with age, BMI, CPR and IR, ≥90% (β=14.6, SE=5.7, p=0.01) and ≥70% (β=9.1, SE=4.4, p=0.04) but not ≥40% were the significant factor to achieve the glycemic target. Hypoglycemia ≤70 mg/dl occurred only in 2% of entire subjects, and the incident rate were not different between the groups. In summary, our result indicated that at least 70% of the conversion ratio was required for the safe and effective conversion from SI to II in DKA/HHS. Disclosure H. Takamine: None. Y. Namiki: None. H. Hiiragi: None. T. Yamada: None. Y. Takano: None. U.N. Osada: None.

Optimization of Insulin Regimen and Glucose Outcomes with Short-Term Real-Time Continuous Glucose Monitoring in Adult Type 1 Diabetes Patients with Suboptimal Control on Multiple Daily Injections: The Adult DIACCOR Study.

The impact of a 7-day real-time continuous glucose monitoring (RT-CGM) on type 1 diabetes (T1D) management remains unclear in patients suboptimally controlled by multiple daily injections (MDI). The DIACCOR Study aimed to describe treatment decisions and glucose outcomes after a short-term RT-CGM sequence. This French multicenter longitudinal observational study included T1D patients with HbA1c >7.5% or history of severe hypoglycemia (SH) or recurrent documented hypoglycemia. A sensor was inserted at the inclusion visit, treatment changes were proposed by the investigator within 7-15 days ("INT" = MDI intensification, "CSII" = switch to continuous insulin infusion, or "ER" = educational reinforcement with no change in insulin regimen), and a 4-month follow-up visit (M4) was scheduled. Four hundred fifty-nine patients were recruited by 155 diabetologists, 17.0% had SH history, and 24.2% had recurrent hypoglycemia. Baseline HbA1c was 8.34% ± 1.21% (>7.5% in 79.6%). Overall, 253 (64.4%), 64 (16.3%), and 76 patients (19.3%) were, respectively, included in the "INT," "CSII," and "ER" subgroups. The number of patients who experienced SH or recurrent hypoglycemia dropped dramatically (7.9% vs. 17.0% and 10.8% vs. 24.2%, respectively). The same trend was observed for ketoacidosis and ketosis (0.3% vs. 3.3% and 2.2% vs. 4.8%). At M4, HbA1c was significantly reduced in the whole cohort to 7.98% ± 1.01% (P < 0.0001). The adjusted differences in HbA1c level in the INT, CSII, and ER subgroups were, respectively, -0.32%, -0.69%, and -0.50% (P < 0.0001 for all). In real-life setting, a 1-week diagnostic RT-CGM supports appropriate treatment changes in patients with uncontrolled T1D resulting in better glucose control and less hypoglycemia.

Software-guided insulin dosing improves intrapartum glycemic management in women with diabetes mellitus

During labor, maintenance of maternal euglycemia is critical to decrease the risk of neonatal hypoglycemia and associated morbidities. When continuous intravenous insulin infusion is needed, standardized insulin dosing charts have been used for titration of insulin to maintain glucose in target range. The GlucoStabilizer software program (Indiana University Health Inc, Indianapolis, IN) is a software-guided insulin dosing system that calculates the dose of intravenous insulin that is needed based on metabolic parameters, target glucose concentration, and an individual's response to insulin. Although this tool has been validated and shown to reduce both hypoglycemia and errors in critical care settings, the utility of this software has not been examined in obstetrics. The purpose of this study was to determine whether the use of intravenous insulin dosing software in women with pregestational or gestational diabetes mellitus that requires intrapartum insulin infusion can improve the rate of glucose concentration in target range (70-100 mg/dL; 3.9-5.5 mmol/L) at the time delivery. We performed a retrospective cohort study comparing laboring patients with diabetes mellitus that required insulin infusion who were dosed by standard insulin dosing chart vs the GlucoStabilizer software program from January 2012 to December 2017. The GlucoStabilizer software program, which was implemented in May 2016, replaced the standard intravenous insulin dosing chart. Inclusion criteria were women with pregestational or gestational diabetes mellitus who were treated with an intravenous insulin infusion intrapartum for at least 2 hours. Maternal characteristics, glucose values in labor, and neonatal outcomes were extracted from delivery and neonatal records. The primary outcome was the percentage of women who achieved the target glucose range (defined as a blood glucose between 70-100 mg/dL; 3.9-5.5 mmol/L) before delivery. Parametric and nonparametric statistics were used to compare both groups; a probability value of <.05 was considered statistically significant. We identified 22 patients who were dosed by a standard insulin dosing chart and 11 patients who were dosed by the GlucoStabilizer software program during intrapartum management. The GlucoStabilizer software program was superior in achieving glucose values in target range at delivery (81.8% vs 9.1%; P<.001) compared with standard insulin dosing without increasing maternal hypoglycemia (0% vs 4.3%; P=.99). Patients whose insulin dosing was managed by the GlucoStabilizer software program also had lower mean capillary blood glucose values compared with the standard insulin infusion (102.9±5.9 mg/dL [5.7±0.33 mmol/L] vs 121.7±5.9 mg/dL [6.8±0.33 mmol/L]; P=.02). Before the initiation of the infusion, both groups demonstrated mean capillary blood glucose values outside of target range (122.6±8.8 mg/dL [6.7±0.49 mmol/L] for the GlucoStabilizer software program vs 131.9±10.1 mg/dL [7.3±0.56 mmol/L] for standard insulin treatment group; P=not significant). There were no significant differences in baseline maternal characteristics between the groups or neonatal outcomes. This study is the first to demonstrate that the use of software-guided intravenous insulin dosing in obstetrics can improve intrapartum glycemic management without increasing hypoglycemia in women with both pregestational and gestational diabetes mellitus that is treated with an insulin infusion.

Management of Diabetes in the Intrapartum and Postpartum Patient.

Achieving maternal euglycemia in women with pregestational and gestational diabetes mellitus is critical to decreasing the risk of neonatal hypoglycemia, as maternal blood glucose levels around the time of delivery are directly related to the risk of hypoglycemia in the neonate. Many institutions use continuous insulin and glucose infusions during the intrapartum period, although practices are widely variable. At Northwestern Memorial Hospital, the "Management of the Perinatal Patient with Diabetes" policy and protocol was developed to improve consistency of management while also allowing individualization appropriate for the patient's specific diabetic needs. This protocol introduced standardized algorithms based on maternal insulin requirements to drive real-time maternal glucose control during labor as well as provided guidelines for postpartum glycemic control. This manuscript describes the development and implementation of this protocol to encourage other institutions to adopt a standardized protocol that allows highly individualized intrapartum care to women with diabetes.

Comparison of Glycemic Control between Continuous Regular Insulin Infusion and Single-dose Subcutaneous Insulin Glargine Injection in Medical Critically Ill Patients.

Background and Aims:This study aimed to compare glycemic control between continuous intravenous regular insulin infusion and single-dose subcutaneous insulin glargine injection in medical critically ill patients.Subjects and Methods:A prospective noninferiority study was conducted in medical critically ill patients who developed hyperglycemia and required regular insulin infusion by the Intensive Care Unit glycemic control protocol. The eligible patients were switched from the daily regular insulin requirement to single-dose subcutaneous insulin glargine injection by a 100% conversion dose. Arterial blood glucose was checked every 2 h for 24 h. Success cases were blood glucose levels of 80–200 mg/dL during the study period. The mean time-averaged area under the curves (AUCs) of blood glucose levels between the two types of insulin were compared by t-test.Results:Of 20 cases, 14 cases (70%) were successful. The mean time-averaged AUCs of blood glucose levels between the two types of insulin were not significantly different (155.91 ± 27.54 mg/dL vs. 151.70 ± 17.07 mg/dL, P = 0.56) and less than the predefined noninferior margin. No severe hypoglycemic cases were detected during the study period.Conclusions:Single-dose subcutaneous insulin glargine injection was feasibly applied for glycemic control in medical critically ill patients. The glycemic control in the critically ill patients by a single dose of subcutaneous insulin glargine was comparable to standard intravenous regular insulin infusion. A conversion dose of 100% of the daily requirement of regular insulin is suggested.

Effects of glargine insulin on glycemic control in patients with diabetes mellitus type II undergoing off-pump coronary artery bypass graft.

Background:The prevalence of diabetes mellitus in patients requiring coronary artery bypass grafting (CABG) is noticeably high (20%–30%). These patients have inferior perioperative outcome, reduced long-term survival, and high risk of recurrent episodes of angina. To improve perioperative outcome surgical unit defined satisfactory glycemic control is desired during this period. Hence, the aim of our study is to compare the efficacy of glargine insulin combination with continuous human insulin infusion for perioperative glycemic control in patients with diabetes undergoing CABG.Materials and Methods:Fifty Patients, who were posted for off-pump CABG with diabetes mellitus type II, were randomized in two group, Group I normal saline + human insulin infusion during the perioperative period, Group II (glargine group): Glargine + human insulin infusion during perioperative period.Results:During surgery and in the postoperative period, random blood sugar and human insulin requirement are significantly higher in control group than glargine group. Other infection, step-up antibiotics, intensive care unit (ICU) stay, and hospital stay were significantly higher in control groups in postoperative period.Conclusion:Our study results suggest that glargine effectively manages blood glucose level with significantly greater control over postoperative morbidity.

Robust H∞ control of glycemia in Type 2 Diabetes Mellitus via continous insulin plus Metformin

Several studies have shown that an adequate therapy for glycemic control in patients with type 2 diabetes mellitus (T2DM) can delay or prevent complications derived from this condition. To achieve the control objectives an adequate therapy should be performed by using insulin alone or in combination with an oral hypoglycemic agent. However, the key point of glycemic control is to determine the amount of insulin to be delivered. In order to achieve the above different strategies have been proposed, one of them is the design of feedback control algorithms. In this article a robust feedback control algorithm of glycemia in T2DM was designed. The algorithm determines the continuous insulin infusion to be delivered to maintain normoglycemia considering a combined therapy with a dose of metformin. The problem approach was to find a controller that minimized in the sense of the H∞ norm: i) the difference between the glycemia of a T2DM patient and a healthy subject (tracking problem) and ii) the effect of disturbances due to glucose intake and noise from a glucose sensor.

Incidence of Hypoglycemia in Burn Patients: A Focus for Process Improvement.

Background: Glycemic control in burn patients is critical for reducing infection and mortality. Objective: This study was conducted to assess the incidence and outcomes of hypoglycemia during continuous insulin infusions (CII). Methods: This institutional review board-approved study was a retrospective, single burn center, electronic chart review. Patients admitted between January 1, 2013, and October 31, 2014, who received a CII were included. Patients with incomplete data or who received <24 hours of CII were excluded. Results: Thirty-eight patients met inclusion criteria; 6 were excluded. The average patient was a 52-year-old Caucasian male with a 33% total body surface area burn and an acute physiology and chronic health evaluation (APACHE) II score of 20.Hypoglycemia was present for 87 of 6540 hours of CII therapy (1.1%). Two-thirds experienced a serum glucose <70 mg/dL and half <60 mg/dL. The most commonly assessed reasons for the hypoglycemic episodes were protocol violations (47%) and glucose variability (30%). After multivariable logistic regression, only history of diabetes remained a statistically significant risk factor with an odds ratio of 15.4 (95% confidence interval: 2.5-95.1). Four different CII protocols were prescribed. All protocols had a high glucose variability, as assessed by hours / day within goal range (13.1 ± 2.5, 14.1 ± 3.1, 14.3 ± 2.4, 9.8; P = .282). Conclusion: The amount of different protocols likely contributed to protocol violations and glucose variability. Our data demonstrate the need to create and consolidate usage to a single protocol in attempts to improve glycemic control.

The situation as regards diabetes mellitus type 1 in Andalusia. Care data, use of advanced therapies and human resources

The representation of Spain in European epidemiological studies on diabetes is limited, with only one centre in the Hvidoere study and another in the SWEET study. No Spanish studies have been published that combine epidemiological data and care resources. The aim of this study was to determine the epidemiological data, care resources, and use of new technologies in all Andalusian hospitals that care for children with Diabetes Mellitus type 1 (DM1) under 14 years. An electronic questionnaire of 18 questions was sent to all paediatric endocrinologists who treated children with diabetes in Andalusian hospitals. There was a mean of 3.12 (SD: 2.58) paediatric endocrinologist for every 100 patients, with a mean diabetes nurse educator ratio of 2.50 (SD: 3.94) per 100 patients and centre. Only 1 of the 29 centres had a psychologist, 9/29 had a day hospital, and 11/29 had a 24-hour telephone line. The mean of days of consultations exclusively for patients with DM1 was 1.56 days (SD: 1.21) per week. Continuous insulin infusion was used to treat 5% of patients, with a significant increase in centres with more than 150 patients. This study offers, for the first time, current data on the epidemiological situation related to health care data, comparing them with the recommendations of European standards, highlighting a low ratio of endocrinologists and educators in diabetes, absence of psychologists and low technology penetrance.

The situation as regards diabetes mellitus type 1 in Andalusia. Care data, use of advanced therapies and human resources

Abstract Introduction The representation of Spain in European epidemiological studies on diabetes is limited, with only one centre in the Hvidoere study and another in the SWEET study. No Spanish studies have been published that combine epidemiological data and care resources. The aim of this study was to determine the epidemiological data, care resources and use of new technologies in all Andalusian hospitals that care for children with diabetes mellitus type 1 (DM1) under 14 years. Material and methods An electronic questionnaire of 18 questions was sent to all paediatric endocrinologists who treated children with diabetes in Andalusian hospitals. Results There was a mean of 3.12 (SD: 2.58) paediatric endocrinologist for every 100 patients, with a mean diabetes nurse educator ratio of 2.50 (SD: 3.94) per 100 patients and centre. Only 1 of the 29 centres had a psychologist, 9/29 had a day hospital and 11/29 had a 24-h telephone line. The mean of days of consultations exclusively for patients with DM1 was 1.56 days (SD: 1.21) per week. Continuous insulin infusion was used to treat 5% of patients, with a significant increase in centres with more than 150 patients. Conclusions This study offers, for the first time, current data on the epidemiological situation related to healthcare data, comparing them with the recommendations of European standards, highlighting a low ratio of endocrinologists and educators in diabetes, absence of psychologists and low technology penetrance.

Strict versus liberal insulin therapy in the cardiac surgery patient: An evidence-based practice development, implementation and evaluation project

BackgroundHyperglycemia post-cardiac surgery is associated with poor clinical outcomes. Recent studies suggest maintaining liberal glycemic control (<180mg/dL) using a continuous insulin infusion (CII) versus strict control achieves optimal outcomes and prevents hypoglycemia. PurposeTo develop, implement and evaluate a nurse managed liberal CII protocol. MethodsRetrospective review of 144 strict CII patient records and 147 liberal CII patient records. ResultsMean blood glucose was 159.8mg/dL (liberal CII) compared to 143.3mg/dL (strict CII) (p≤0.001). No surgical site infections occurred in either group. Mean ICU length of stay was 4.5days (liberal) versus 4.4days (strict) (p=0.74). Two 30-day mortalities occurred for the liberal cohort compared to no deaths in the strict group (p=0.49). Hypoglycemia incidence within 24h after surgery was 0.1% (liberal) compared to 0.3% (strict) compared to (p=0.16). ConclusionUse of a nurse managed liberal CII resulted in similar outcomes with fewer incidents of hypoglycemia.

Chronic renal artery insulin infusion increases mean arterial pressure in male Sprague-Dawley rats.

Hyperinsulinemia has been hypothesized to cause hypertension in obesity, type 2 diabetes, and metabolic syndrome through a renal mechanism. However, it has been challenging to isolate renal mechanisms in chronic experimental models due, in part, to technical difficulties. In this study, we tested the hypothesis that a renal mechanism underlies insulin hypertension. We developed a novel technique to permit continuous insulin infusion through the renal artery in conscious rats for 7 days. Mean arterial pressure increased by ~10 mmHg in rats that were infused intravenously (IV) with insulin and glucose. Renal artery doses were 20% of the intravenous doses and did not raise systemic insulin levels or cause differences in blood glucose. The increase in blood pressure was not different from the IV group. Mean arterial pressure did not change in vehicle-infused rats, and there were no differences in renal injury scoring due to the renal artery catheter. Glomerular filtration rate, plasma renin activity, and urinary sodium excretion did not differ between groups at baseline and did not change significantly with insulin infusion. Thus, by developing a novel approach for chronic, continuous renal artery insulin infusion, we provided new evidence that insulin causes hypertension in rats through actions initiated within the kidney.

Treatment of Hypertriglyceridemia-Induced Acute Pancreatitis With Insulin, Heparin, and Gemfibrozil: A Case Series.

Hypertriglyceridemia is the third most common worldwide cause of acute pancreatitis. Resolving the underlying etiology is imperative for optimal management. This is especially true with regard to hypertriglyceridemia, as this etiology may cause more severe acute pancreatitis and worse symptoms than other causes of the disease. Many pharmacological treatment options for hypertriglyceridemia-induced acute pancreatitis (HTGP) have been proposed; however, the safety and efficacy for specific treatment regimens remain nebulous. At our institution, 6 patients, whose average Ranson criteria score were 5 and presenting triglyceride concentrations were 3501 mg/dL, were managed with a continuous infusion of insulin, subcutaneous heparin, and oral gemfibrozil for HTGP. Maximum insulin infusion rates ranged from 0.8 to 20.9 U/h. Half of the patients received nongemfibrozil cholesterol medication. Five patients experienced a resolution of HTGP (median day 3). The only adverse drug event was hypoglycemia in a single patient. Combination therapy with heparin, insulin, and gemfibrozil is safe and efficacious in quickly lowering serum triglyceride concentrations in HTGP. This combination warrants further study.

S119 Axonal excitability studies in diabetic neuropathy

Diabetic polyneuropathy (DPN) is a complication of diabetes involving complex mechanisms. The introduction of automated threshold-tracking has led to a number of abnormal axonal excitability findings associated with diabetes without neuropathy (DWN) and DPN. The first abnormality described was a striking resistance to ischaemia in DWN. Superexcitability measurements showed that this ischaemic resistance was not due to a depolarized resting potential, but was related to the mean blood glucose over 24 h, indicating a rapid effect of glucose on nerve metabolism. Glycaemic control by insulin treatment in patients with diabetic neuropathy restored sensitivity to ischaemia. In contrast to DWN, patients with established DPN exhibited ‘fanning-in’ of threshold electrotonus and reduced superexcitability, indicating membrane depolarization. Using the rate of recovery of excitability following maximum voluntary contraction as a measure of electrogenic sodium pump activity, excitability measurements indicated that sodium pump function was normal in DWN, but reduced in DPN, accounting for the membrane depolarization. Further excitability studies have attempted to determine changes, other than resistance to ischaemia, that precede the development of neuropathy. Evidence that depolarization precedes neuropathy has been found both in Type 1 and Type 2 diabetics. An ischaemic cause was suggested by the finding that excitability abnormalities correlated better with vascular-related factors than with HgbA1c. Recently excitability studies have moved on from assessing pathophysiology to treatment. In Type 1 DWN, glycaemic control by continuous insulin infusion preserved membrane potential much better than comparable control by multiple injections, perhaps because glucose variability can cause microvascular dysfunction.

Risk factors for hypoglycaemia in in-patients with diabetes treated with continuous insulin intravenous infusion

Introduction. Hypoglycaemia is the most frequent complication of diabetes therapy. It leads to unpleasant symptoms and, if severe may, result in coma and even death. Hospitalized patients treated with intravenous insulin therapy are at particularly high risk of hypoglycaemia. Nursing staff play crucial role in preventing, early detecting and treatment of hypoglycaemia caused by insulin given intravenously. Material and methods. This observational, prospective and non-interventional study aimed at assessing prevalence and risk factor of hypoglycaemia during continuous intravenous insulin infusion (CIVII) in a hospital setting. Two hundred consecutive patients (48 with type 1 diabetes and 152 with type 2 diabe­tes) were enrolled into the study. Mean age of type 1 diabetes patients was 38 ± 14 years, and those with type 2 diabetes 61 ± 12 years (p < 0.0001), and their HbA 1c was 10.1 ± 2.9 and 10.1 ± 2.3%, respectively. Continuous intravenous insulin infusion was given for 2.5 ± 1.1 days (basal infusion and three 90-min prandial boluses) according to standard protocol. Results. Hypoglycaemia was noted in 48% of patients with type 1 diabetes and in 20% of those with type 2 diabetes (p < 0.001), most often in the second day of CIVII. In type 1 diabetes, the main risk factor for hypoglycaemia while on CIVII was diabetes duration (the longer duration, the higher the risk) and in type 2 diabetes — daily insulin dose, total and per kg of body weight (the lower the dose, the higher the risk). Conclusions. Continuous intravenous insulin infusion should be used with utmost care in type 1 diabetes patients with long duration of the disease and in those type 2 diabetes patients who show signs of low insulin resistance (little overweight, low insulin requirement).

Volume-Based Feeding in Enteral Nutrition: What About Diabetes?

Q At my hospital, we have a volume-based tube feeding practice. If a patient's tube feeding rate is adjusted up and down to ensure delivery of the 24-hour volume, how do you control blood glucose level? This would be especially important in a patient receiving an insulin infusion with hourly checks of blood glucose level. Is the blood glucose level significantly affected by changes in the tube feeding rate? If so, do you find that the standard ordered insulin scales are adequate?

Preserving and restoring bone with continuous insulin infusion therapy in a mouse model of type 1 diabetes

Those with type 1 diabetes (T1D) are more likely to suffer a fracture than age- and sex-matched individuals without diabetes, despite daily insulin therapy. In rodent studies examining the effect of bone- or glucose-targeting therapies on preventing the T1D-related decrease in bone strength, insulin co-therapy is often not included, despite the known importance of insulin signaling to bone mass accrual. Therefore, working toward a relevant pre-clinical model of diabetic bone disease, we assessed the effect of continuous subcutaneous insulin infusion (CSII) therapy at escalating doses on preserving bone and the effect of delayed CSII on rescuing the T1D-related bone deterioration in an established murine model of T1D. Osmotic minipumps were implanted in male DBA/2J mice 2weeks (prevention study) and 6weeks (rescue study) after the first injection of streptozotocin (STZ) to deliver insulin at 0, 0.0625, 0.125, or 0.25IU/day (prevention study; n=4–5 per dose) and 0 or 0.25IU/day (rescue study; n=10 per group). CSII lasted 4weeks in both studies, which also included age-matched, non-diabetic DBA/2J mice (n=8–12 per study). As the insulin dose increased, blood glucose decreased, body weight increased, a serum maker of bone resorption decreased, and a serum marker of bone formation increased such that each end-point characteristic was linearly correlated with dose. There were insulin dose-dependent relationships (femur diaphysis) with cross-sectional area of cortical bone and cortical thickness (micro-computed tomography) as well as structural strength (peak force endured by the mid-shaft during three-point bending). Likewise, trabecular bone volume fraction (BV/TV), thickness, and number (distal femur metaphysis) increased as the insulin dose increased. Delayed CSII improved glycated hemoglobin (HbA1c), but blood glucose levels remained relatively high (well above non-diabetic levels). Interestingly, it returned the resorption and formation markers to similar levels as those seen in non-T1D control mice. This apparent return after 4weeks of CSII translated to a partial rescue of the structural strength of the femur mid-shaft. Delayed CSII also increased Tb.Th to levels seen in non-T1D controls but did not fully restore BV/TV. The use of exogenous insulin should be considered in pre-clinical studies investigating the effect of T1D on bone as insulin therapy maintains bone structure without necessarily lowering glucose below diabetic levels.

Diabetic ketoacidosis: Should current management include subcutaneous insulin injections?

Diabetic ketoacidosis is a well-known acute complication in patients with both type 1 andtype 2 diabetes mellitus. Although mortality has decreased considerably, it remains an importantcause for admission to intensive care units. Medical management includes intravenous fluidtherapy, insulin, correction of electrolyte abnormalities, and addressing the precipitating factorwhich in most cases is infection or non-compliance with insulin therapy. Usually patients withdiabetic ketoacidosis are admitted to the intensive care unit for continuous infusion of insulin;however, the development of rapid acting insulin analogues has made it possible to treatmild to moderate diabetic ketoacidosis with subcutaneous insulin. Although studies usingsubcutaneous insulin include only a small number of patients, this approach seems as effectiveas intravenous insulin infusions in patients with mild to moderate diabetic ketoacidosis. Diabeticeducation and close follow-up for patients admitted for diabetic ketoacidosis remain essentialto avoid recurrence and readmissions.Keywords: Diabetic ketoacidosis, acute complication in diabetes, rapid acting insulinanalogues, subcutaneous insulin in diabetic ketoacidosis

Management of Inpatient Hyperglycemia and Diabetes in Older Adults.

Adults aged 65 years and older are the fastest growing segment of the U.S. population, and their number is expected to double to 89 million between 2010 and 2050. The prevalence of diabetes in hospitalized adults aged 65–75 years and over 80 years of age has been estimated to be 20% and 40%, respectively. Similar to general populations, the presence of hyperglycemia and diabetes in elderly patients is associated with increased risk of hospital complications, longer length of stay, and increased mortality compared with subjects with normoglycemia. Clinical guidelines recommend target blood glucose between 140 and 180 mg/dL (7.8 and 10 mmol/L) for most patients in the intensive care unit (ICU). A similar blood glucose target is recommended for patients in non-ICU settings; however, glycemic targets should be individualized in older adults on the basis of a patient’s clinical status, risk of hypoglycemia, and presence of diabetes complications. Insulin is the preferred agent to manage hyperglycemia and diabetes in the hospital. Continuous insulin infusion in the ICU and rational use of basal-bolus or basal plus supplement regimens in non-ICU settings are effective in achieving glycemic goals. Noninsulin regimens with the use of dipeptidyl peptidase 4 inhibitors alone or in combination with basal insulin have been shown to be safe and effective and may represent an alternative to basal-bolus regimens in elderly patients. Smooth transition of care to the outpatient setting is facilitated by providing oral and written instructions regarding timing and dosing of insulin as well as education in basic skills for home management.

A New Optimized Percutaneous Access System for CIPII.

In recent years, continuous intraperitoneal insulin infusion (CIPII) has become a favored treatment alternative for patients with subcutaneous insulin resistance, mainly due to its ability of mimicking physiological conditions of insulin absorption. CIPII has been shown to improve glycemic control as well as to reduce hypoglycemic events and to lead to increased patient satisfaction and quality of life (QoL). Among CIPII delivery systems, Diaport stands out due to its low side effects, its demonstrated clinical efficacy and the potential for integration into closed-loop systems.