Effects Of Tight Glycemic Control Research Articles

Safety and efficacy of tight versus loose glycemic control in acute stroke patients: A meta-analysis of randomized controlled trials.

Hyperglycemia is associated with worse stroke outcomes, but it is uncertain whether tight glycemic control during the acute stroke period is associated with a better outcome. We conducted a meta-analysis to compare the effect of tight glycemic control versus loose glycemic control in the acute phase of stroke patients. A literature search was performed to identify randomized controlled trials comparing the safety and efficacy of tight glycemic control with a relatively loose control of blood glucose of acute stroke (ischemic or hemorrhagic) patients within 24 h after stroke onset. We required that the blood glucose level of the patients should not be lower than 6.11 mmol/L at the time of enrollment, and for the intensive blood glucose control range, we defined the blood glucose level as lower than that of the control group. The primary efficacy outcome measure was deaths from any cause at 90 days. Secondary efficacy outcomes comprised the number of participants with modified Rankin score (mRS). We define mRS scores 0-2 as favorable scores, recurrent stroke, and the National Institute of Health Stroke Scale or the European Stroke Scale scores. We defined the number of participants with hypoglycemia as our primary safety outcome. Subgroup analysis was performed according to age, the variety of interventions, maintained glucose level, and status of hypoglycemia on National Institute of Health Stroke Scale (NIHSS) scores or European Stroke Scale (ESS) scores. Fifteen randomized controlled trials (RCTs) with 2957 participants meeting the including criteria were identified and included in this meta-analysis, although not all included data on every outcome measure. Data on the primary efficacy endpoint, mortality at 90 days, was available in 11 RCTs, a total of 2575 participants. There was no significant difference between the intervention and control groups (odds ratio (OR): 1.00; 95% confidence interval (CI): 0.81-1.23; P = 0.99). For secondary endpoints, there was no difference between intervention and control groups for a mRS from 0 to 2 (OR: 0.96; 95% CI: 0.80-1.15; P = 0.69; data from 9 RCTs available), or recurrent stroke (OR: 1.34; 95% CI: 0.92-1.96; P = 0.13; data from 3 RCTs available). For NIHSS scores or ESS scores, there was a small difference in favor of intensive controls (standardized mean difference: -0.29; 95% CI: -0.54 to -0.04; P = 0.02). There was a marked increase in hypoglycemia with tight control: (OR of 9.46 (95% CI: 4.59-19.50; P < 0.00001; data from 9 RCTs available). There was no difference between tight and loose glycemic control on mortality, independence, or recurrent stroke outcome in acute stroke, but an increase in hypoglycemia. There was a small effect improvement on neurological scales, but the relevance of this needs to be confirmed in future adequately powered studies.

Effects of an artificial pancreas on postoperative inflammation in patients with esophageal cancer

PurposesSubtotal esophagectomy for esophageal cancer (EC) is associated with high morbidity rates. Tight glycemic control using an artificial pancreas (AP) is one of the promising strategies to reduce postoperative inflammation and morbidities. However, the effects of tight glycemic control using AP in patients with EC are yet to be fully elucidated.MethodThis study reviewed 96 patients with EC who underwent subtotal esophagectomy. The postoperative inflammation parameters and morbidity rates were compared between patients who used the AP (n = 27) or not (control group, n = 69). AP is a closed-loop system that comprises a continuous glucose monitor and an insulin pump.ResultsThe numbers of white blood cells (WBC) and Neutrophils (Neut) were noted to be lower in the AP group than in the control group, but with no significant difference. The ratio in which the number of WBC, Neut, and CRP on each postoperative day (POD) was divided by those tested preoperatively was used to standardize the results. The ratio of WBC and Neut on 1POD was significantly lower in the AP group than in the control group. The rate of surgical site infection was lower in the AP group than in the control group.ConclusionAP significantly decreased WBC and Neut on 1POD; this suggests the beneficial effects of AP in alleviating postoperative inflammation.

Effect of Tight Glycemic Control on Pancreatic Beta Cell Function in Newly Diagnosed Pediatric Type 1 Diabetes

Near normalization of glucose levels instituted immediately after diagnosis of type 1 diabetes has been postulated to preserve pancreatic beta cell function by reducing glucotoxicity. Previous studies have been hampered by an inability to achieve tight glycemic goals. To determine the effectiveness of intensive diabetes management to achieve near normalization of glucose levels on preservation of pancreatic beta cell function in youth with newly diagnosed type 1 diabetes. This randomized, double-blind, clinical trial was conducted at 6 centers in the US (randomizations from July 20, 2020, to October 13, 2021; follow-up completed September 15, 2022) and included youths with newly diagnosed type 1 diabetes aged 7 to 17 years. Random assignment to intensive diabetes management, which included use of an automated insulin delivery system (n = 61), or standard care, which included use of a continuous glucose monitor (n = 52), as part of a factorial design in which participants weighing 30 kg or more also were assigned to receive either oral verapamil or placebo. The primary outcome was mixed-meal tolerance test-stimulated C-peptide area under the curve (a measure of pancreatic beta cell function) 52 weeks from diagnosis. Among 113 participants (mean [SD] age, 11.8 [2.8] years; 49 females [43%]; mean [SD] time from diagnosis to randomization, 24 [5] days), 108 (96%) completed the trial. The mean C-peptide area under the curve decreased from 0.57 pmol/mL at baseline to 0.45 pmol/mL at 52 weeks in the intensive management group, and from 0.60 to 0.50 pmol/mL in the standard care group (treatment group difference, -0.01 [95% CI, -0.11 to 0.10]; P = .89). The mean time in the target range of 70 to 180 mg/dL, measured with continuous glucose monitoring, at 52 weeks was 78% in the intensive management group vs 64% in the standard care group (adjusted difference, 16% [95% CI, 10% to 22%]). One severe hypoglycemia event and 1 diabetic ketoacidosis event occurred in each group. In youths with newly diagnosed type 1 diabetes, intensive diabetes management, which included automated insulin delivery, achieved excellent glucose control but did not affect the decline in pancreatic C-peptide secretion at 52 weeks. ClinicalTrials.gov Identifier: NCT04233034.

157-LB: Scanning Frequency and Glucose Variability in the First Trimester of T1DM Pregnancies Predict Time Spent in Very Low Glucose Range in the Last One—Analysis of Intermittently Scanned Continuous Glucose Monitoring

Scanning frequency and glucose variability in the first trimester of T1DM pregnancies predict time spent in very low glucose range in the last one: analysis of intermittently scanned continuous glucose monitoring Hypoglycemia is inevitable side effect of tight glycemic control in type 1 diabetes mellitus (T1DM) pregnancies. Using technology novel risk factors are revealed. Total of 34 patients (mean age 29.8 ± 6.1 yrs, BMI 23.6± 3.6 kg/m2, disease duration 15.2± 8.9 yrs) having very low glycemia in third trimester (&amp;lt; 3 mmol/L or 55 mg/dL) were included in the study. Patients used intermittently scanned continuous glucose monitoring (isCGM) FreeStyle Libre, Abott for a minimum of 3 months before conception and had glucose data availability &amp;gt; 80% of the time. Data from first trimester showed mean scanning frequency 12.17 ± 6.5 scans/day, estimated average glucose 7.2 ± 1.4 mmol/L, CV% 41.9 ± 6.5, GMI 6.4 ± 0.5, time below range &amp;lt;3.5 mmol/L or 64 mg/dL 10.7 ± 8.0 % and time spent in very low glucose range &amp;lt;3mmol/L or 55 mg/dL 5.4 ± 4.9 %. In last trimester mean scanning frequency was 16.3 ± 7.6 scans/day, estimated average glucose 6.1 ± 0.9 mmol/L, CV% 34.6 ±6.0 , GMI 5.9 ± 0.4 , time below range 11.0 ±9.3 %, time spent in very low glucose range 5.2 ± 4.8 %. Parameters from the first trimester of pregnancy significantly correlating with time spent in very low glucose range in the third trimester were scanning frequency (r −0.365, p 0.37) and CV % (r 0.465, p 0.006) . Linear regression analysis performed for CV% and scanning frequency showed R square 0.434 and p 0.002 in ANOVA. Two isCGM parameters from first trimester of pregnancy that influence on very low glucose rate in the third one are low scanning frequency and higher %CV. Combined they add to 43% of very low glucose occurrence. Patients who scan frequently in the first trimester of pregnancy and have low glucose variability spend less time in very low glucose range in the third trimester. For the others continuous glucose monitoring with hypo alerts should be offered. Disclosure M. Baretic: None. G. Leksic: None. M. Ivanisevic: None.

Outcomes in Patients With Hyperglycemia Affected by COVID-19: Can We Do More on Glycemic Control?

OBJECTIVEAn important prognostic factor in any form of infection seems to be glucose control in patients with type 2 diabetes. There is no information about the effects of tight glycemic control on coronavirus disease 2019 (COVID-19) outcomes in patients with hyperglycemia. Therefore, we examined the effects of optimal glycemic control in patients with hyperglycemia affected by COVID-19.RESEARCH DESIGN AND METHODSFifty-nine patients with COVID-19 hospitalized with moderate disease were evaluated. On the basis of admission glycemia >7.77 mmol/L, patients were divided into hyperglycemic and normoglycemic groups. Interleukin 6 (IL-6) and D-dimer levels were evaluated at admission and weekly during hospitalization. The composite end point was severe disease, admission to an intensive care unit, use of mechanical ventilation, or death.RESULTSThirty-four (57.6%) patients were normoglycemic and 25 (42.4%) were hyperglycemic. In the hyperglycemic group, 7 (28%) and 18 (72%) patients were diagnosed with diabetes already before admission, and 10 (40%) and 15 (60%) were treated without and with insulin infusion, respectively. The mean of glycemia during hospitalization was 10.65 ± 0.84 mmol/L in the no insulin infusion group and 7.69 ± 1.85 mmol/L in the insulin infusion group. At baseline, IL-6 and D-dimer levels were significantly higher in the hyperglycemic group than in the normoglycemic group (P < 0.001). Even though all patients were on standard treatment for COVID-19 infection, IL-6 and D-dimer levels persisted higher in patients with hyperglycemia during hospitalization. In a risk-adjusted Cox regression analysis, both patients with hyperglycemia and patients with diabetes had a higher risk of severe disease than those without diabetes and with normoglycemia. Cox regression analysis evidenced that patients with hyperglycemia treated with insulin infusion had a lower risk of severe disease than patients without insulin infusion.CONCLUSIONSInsulin infusion may be an effective method for achieving glycemic targets and improving outcomes in patients with COVID-19.

Abstract WP378: Insulin in the Management of Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

Background: The role of tight glycemic control in the management of acute ischemic stroke remains uncertain. Objective: Our goal is to evaluate the effects of tight glucose control with insulin therapy after acute ischemic stroke. Methods: We searched PubMed, CENTRAL, and EMBASE for randomized controlled trials (RCTs) that evaluated the effects of tight glycemic control (70 - 135 mg/dL) in acute ischemic stroke. Analysis was performed using fixed- and random-effects models. Outcomes were death, independence and modified Rankin Scale (mRS) score at ≥90 days follow-up, and symptomatic or severe hypoglycemia during treatment. Results: Twelve RCTs including 2,734 patients were included. When compared to conventional therapy or placebo, tight glycemic control was associated with similar rates of mortality at ≥90 days follow-up (pooled odds ratio [pOR], 0.99 [95% CI, 0.79 - 1.22], I 2 0%), independence at ≥90 days follow-up (pOR, 0.95 [0.79 - 1.14], I 2 0%) and mRS scores at ≥90 days follow-up (standardized mean difference, 0.014 [-0.15 - 0.17], I 2 0%). In contrast, tight glycemic control was associated with increased rates of symptomatic or severe hypoglycemia during treatment (pOR 5.2 [1.87 - 14.42], I 2 20%). Conclusion: Tight glucose control after acute ischemic stroke is not associated with improvements in mortality, independence or mRS score and leads to higher rates of symptomatic or severe hypoglycemia.

Insulin in the Management of Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

The role of tight glycemic control in the management of acute ischemic stroke remains uncertain. Our goal is to evaluate the effects of tight glucose control with insulin therapy after acute ischemic stroke. We searched PubMed, CENTRAL, and Embase for randomized controlled trials (RCTs) that evaluated the effects of tight glycemic control (70-135 mg/dL) in acute ischemic stroke. Analysis was performed using fixed-effects and random-effects models. Outcomes were death, independence, and modified Rankin Scale (mRS) score at ≥90 days follow-up, and symptomatic or severe hypoglycemia during treatment. Twelve RCTs including 2734 patients were included. Compared with conventional therapy or placebo, tight glycemic control was associated with similar rates of mortality at ≥90 days follow-up (pooled odds ratio [pOR], 0.99; 95% confidence interval [CI], 0.79-1.22]; I2= 0%), independence at ≥90 days follow-up (pOR, 0.95; 95% CI, 0.79-1.14; I2= 0%) and mRS scores at ≥90 days follow-up (standardized mean difference, 0.014; 95% CI, -0.15 to 0.17; I2= 0%). In contrast, tight glycemic control was associated with increased rates of symptomatic or severe hypoglycemia during treatment (pOR, 5.2; 95% CI, 1.7-15.9; I2=28%). Tight glucose control after acute ischemic stroke is not associated with improvements in mortality, independence, or mRS score and leads to higher rates of symptomatic or severe hypoglycemia.

Effects of perioperative tight glycemic control on postoperative outcomes: a meta-analysis.

BackgroundThe optimal glycemic target during the perioperative period is still controversial. We aimed to explore the effects of tight glycemic control (TGC) on surgical mortality and morbidity.MethodsPubMed, EMBASE and CENTRAL were searched from January 1, 1946 to February 28, 2018. Appropriate trails comparing the postoperative outcomes (mortality, hypoglycemic events, acute kidney injury, etc.) between different levels of TGC and liberal glycemic control were identified. Quality assessments were performed with the Jadad scale combined with the allocation concealment evaluation. Pooled relative risk (RR) and 95% CI were calculated using random effects models. Heterogeneity was detected by the I2 test.ResultsTwenty-six trials involving a total of 9315 patients were included in the final analysis. The overall mortality did not differ between tight and liberal glycemic control (RR, 0.92; 95% CI, 0.78–1.07; I 2 = 20.1%). Among subgroup analyses, obvious decreased risks of mortality were found in the short-term mortality, non-diabetic conditions, cardiac surgery conditions and compared to the very liberal glycemic target. Furthermore, TGC was associated with decreased risks for acute kidney injury, sepsis, surgical site infection, atrial fibrillation and increased risks of hypoglycemia and severe hypoglycemia.ConclusionsCompared to liberal control, perioperative TGC (the upper level of glucose goal ≤150 mg/dL) was associated with significant reduction of short-term mortality, cardic surgery mortality, non-diabetic patients mortality and some postoperative complications. In spite of increased risks of hypoglycemic events, perioperative TGC will benefits patients when it is done carefully.

Oral Antidiabetic Agents and Cardiovascular Outcomes

Cardiovascular disease is the leading cause of morbidity and mortality among patients with type 2 diabetes; however, a direct protective effect of tight glycemic control remains unproven. In fact, until 2008, when concerns related to rosiglitazone prompted regulatory agencies to mandate assessment of cardiovascular safety of new antidiabetic agents, little was known about how these medications affected cardiovascular outcomes. Since then, there has been a considerable increase in the number of cardiovascular trials, which employ a noninferiority design and focus on high-risk populations to establish safety in the shortest time possible. In this article, we summarize the 4 major cardiovascular outcome trials of oral antidiabetic agents, completed so far. These include 3 dipeptidyl peptidase-4 inhibitors (saxagliptin, alogliptin, and sitagliptin) and 1 sodium-glucose cotransporter-2 inhibitor (empagliflozin). We briefly discuss potential mechanisms, limitations, and provide an overview of the ongoing studies in this field.

Acute Kidney Injury After Pediatric Cardiac Surgery: A Secondary Analysis of the Safe Pediatric Euglycemia After Cardiac Surgery Trial.

To understand the effect of tight glycemic control on cardiac surgery-associated acute kidney injury. Secondary analysis of data from the Safe Pediatric Euglycemia after Cardiac Surgery trial of tight glycemic control versus standard care. Pediatric cardiac ICUs at University of Michigan, C.S. Mott Children's Hospital, and Boston Children's Hospital. Children 0-36 months old undergoing congenital cardiac surgery. None. Cardiac surgery-associated acute kidney injury was assigned using the Acute Kidney Injury Network criteria with the modification that a greater than 0.1 mg/dL increase in serum creatinine was required to assign cardiac surgery-associated acute kidney injury. We explored associations between cardiac surgery-associated acute kidney injury and tight glycemic control and clinical outcomes. Of 799 patients studied, cardiac surgery-associated acute kidney injury occurred in 289 patients (36%), most of whom had stage II or III disease (72%). Cardiac surgery-associated acute kidney injury rates were similar between treatment groups (36% vs 36%; p = 0.99). Multivariable modeling showed that patients with cardiac surgery-associated acute kidney injury were younger (p = 0.002), underwent more complex surgery (p = 0.005), and had longer cardiopulmonary bypass times (p = 0.002). Cardiac surgery-associated acute kidney injury was associated with longer mechanical ventilation and ICU and hospital stays and increased mortality. Patients at University of Michigan had higher rates of cardiac surgery-associated acute kidney injury compared with Boston Children's Hospital patients (66% vs 15%; p < 0.001), but University of Michigan patients with cardiac surgery-associated acute kidney injury had shorter time to extubation and ICU and hospital stays compared with Boston Children's Hospital patients. Tight glycemic control did not reduce the cardiac surgery-associated acute kidney injury rate in this trial cohort. We observed significant differences in cardiac surgery-associated acute kidney injury rates between the two study sites, and there was a differential effect of cardiac surgery-associated acute kidney injury on clinical outcomes by site. These findings warrant further investigation to identify causal variation in perioperative practices that affect cardiac surgery-associated acute kidney injury epidemiology.

Effects of Glucose Concentration on Propofol Cardioprotection against Myocardial Ischemia Reperfusion Injury in Isolated Rat Hearts.

The anesthetic propofol confers cardioprotection against myocardial ischemia-reperfusion injury (IRI) by reducing reactive oxygen species (ROS). However, its cardioprotection on patients is inconsistent. Similarly, the beneficial effect of tight glycemic control during cardiac surgery in patients has recently been questioned. We postulated that low glucose (LG) may promote ROS formation through enhancing fatty acid (FA) oxidation and unmask propofol cardioprotection during IRI. Rat hearts were isolated and randomly assigned to be perfused with Krebs-Henseleit solution with glucose at 5.5 mM (LG) or 8 mM (G) in the absence or presence of propofol (5 μg/mL) or propofol plus trimetazidine (TMZ). Hearts were subjected to 35 minutes of ischemia followed by 60 minutes of reperfusion. Myocardial infarct size (IS) and cardiac CK-MB were significantly higher in LG than in G group (P < 0.05), associated with reduced left ventricular developed pressure and increases in postischemic cardiac contracture. Cardiac 15-F2t-isoprostane was higher, accompanied with higher cardiac lipid transporter CD36 protein expression in LG. Propofol reduced IS, improved cardiac function, and reduced CD36 in G but not in LG. TMZ facilitated propofol cardioprotection in LG. Therefore, isolated heart with low glucose lost sensitivity to propofol treatment through enhancing FA oxidation and TMZ supplementation restored the sensitivity to propofol.

Dynamic risk factors associated with non-severe hypoglycemia in patients treated with insulin glargine or exenatide once weekly.

Glycemic control in patients with type 2 diabetes is a dynamic process, and changes in risk factors affecting the incidence of hypoglycemia are not well understood. This study explored the association of longitudinal interactive effects of clinical risk factors and concomitant medications on hypoglycemia risk in patients treated with insulin glargine (IG) or exenatide once weekly (EQW). Pooled patient-level 52-week longitudinal data of treatment with EQW (n = 541) or IG (n = 223) from three controlled trials were analyzed. Proportions of patients with at least one episode of hypoglycemia in the EQW and IG groups were 23% and 54%, respectively. Compared with patients with HbA1c ≥7% (53 mmol/mol) over time, patients with HbA1c <7% had significantly higher hypoglycemia risk in both groups (95% confidence intervals [CI] of odds ratios [OR]: EQW-1.21, 2.81; IG- 6.26, 9.84). The patterns of interaction effect of changing body mass index (BMI) and HbA1c on hypoglycemia risk differed in the two treatment groups: patients with with BMI >35 kg/m(2) had a 119% increased hypoglycemia risk in the EQW group, but a 57% reduced risk in the IG group. Sulfonylurea-treated patients in the EQW and IG groups had 4.7- and 3-fold additional hypoglycemia risk, respectively, versus non-sulfonylurea-treated patients. This study revealed differential effects of tight glycemic control and itsinteraction with treatment-induced changes in BMI on hypoglycemia risk its interaction in patients treated with EQW and IG. The residual adverse effect of sulfonylurea was higher in EQW-treated patients.

Effectiveness of tight glycemic control on mortality and morbidity of patients undergoing cardiac surgery in hospital: a systematic review protocol

REVIEW QUESTION/OBJECTIVE Broadly, the overall objective of this review is to identify the effectiveness of tight glycemic control on mortality and morbidity of patients undergoing cardiac surgery. Additional objectives are to identify: The effectiveness of tight glycemic control on mortality and morbidity of adult (young adult and aged) patients during the intra and post-operative period after cardiac surgery in hospital. The effectiveness of tight glycemic control on mortality and morbidity among diabetic patients during the intra and post-operative period after cardiac surgery in hospital. INCLUSION CRITERIA Types of participants This review will consider studies that include adult patients over the age of 18 years, undergoing any type of cardiac surgery who have gone through glycemic control during and/or after the surgery (the period may be up to 30 days or their full length of stay in hospital). Both diabetic (type1 and type 2 regardless of past glucose control treatment modality) and non-diabetic patients will be included in the study. Patients undergoing surgeries other than cardiac surgeries will not be included in this review. Types of interventions This review will consider studies that evaluate effectiveness of tight glycemic control as per study definition, on all patients receiving glucose control in intra and/or post-operative following cardiac surgery. Types of comparators This review will consider comparators such as usual care, normal or moderate glycemic control on all patients receiving glucose control in intra and/or the post-operative period of cardiac surgery. Types of outcomes This review will consider studies that TRUNCATED AT 250 WORDS

Effect of intensive glycemic control on platelet reactivity in patients with long-standing uncontrolled diabetes

BackgroundIt has been previously shown that platelets of patients with diabetes are more reactive and less responsive to anti-platelet drugs compared with platelets from subjects without diabetes. Studies examining the effect of glycemic control on platelet reactivity have yielded conflicting data. Thus, in this study, we sought to explore the effect of tight glycemic control on platelet reactivity in patients with long standing uncontrolled diabetes. MethodsThe study included 30 patients with long-standing treated diabetes and a baseline HbA1c level of≥8.5%. All patients were treated with aspirin and statins. Patients were tested at baseline and after 3months of intensive glycemic and metabolic control. The treatment goal was to achieve a HbA1c level of ≤7%. Platelet reactivity was assessed by light transmission aggregation in response to 5 and 10μM ADP and to 0.5mg/ml arachidonic acid (AA). Additonally, platelet activation was assessed by plasma levels of soluble P-selectin using an enzyme-linked immunosorbent assay. ResultsThe mean duration of diabetes from the time of diagnosis was 20.46±9.31years. Baseline HbA1c was 9.4±0.8%. Following the intensive glycemic control period, the HbA1C level decreased to 8.1±0.8% (P<0.0001). Other laboratory parameters did not change significantly except for triglyceride levels, which decreased. None of the platelet aggregation studies nor P-selectin levels differed between baseline and after 3months of intensive glycemic control. ConclusionsIntensive glycemic control in patients with longstanding uncontrolled diabetes does not seem to result in a reduction in platelet reactivity.

Are closed-loop systems for intensive insulin therapy ready for prime time in the ICU?

Recent findings suggest that the effects of tight glycemic control (TGC) performing intensive insulin therapy (IIT) in medical and surgical ICU have had conflicting results. The purpose of this review is to summarize the current evidence in humans how closed-loop systems for IIT are ready for prime time in the ICU. Current evidence suggests that maintaining normoglycemia postoperatively can improve the outcome and reduce the mortality and morbidity of critically ill patients by TGC performing IIT according to the large randomized trials. However, trials examining the effects of TGC have had conflicting results. Systematic reviews and meta-analyses have also led to differing conclusions. The main reason these clinical trials and meta-analyses were negative results for TGC was because of the high incidence of hypoglycemia. This could not be prevented as there is no reliable technique currently able to avoid this condition during IIT. The development of accurate, continuous blood glucose monitoring devices, and closed-loop systems for computer-assisted blood glucose control in the ICU, will probably help avoid hypoglycemia in these situations. The challenge in the hospital setting demonstrated that a closed-loop glycemic control system is expected to the achievement of TGC with no occurrence of hypoglycemia induced by IIT after surgery. Closed-loop glycemic control systems for IIT are now ready for prime time in the ICU.

Tight Glycemic control in acute coronary syndromes: Prognostic implications

BackgroundElevated admission plasma glucose is associated with increased mortality in patients who are admitted with acute coronary syndromes. AimTo validate the hypothesis that tight glycemic control could reduce major adverse cardiac events in hyperglycemic patients with acute coronary syndromes. MethodsFifty adult patients admitted with acute coronary syndromes within 6h of presentation with “RBS>140mg/dl” were enrolled in this study to evaluate the effect of tight glycemic control using insulin actrapid infusion (aiming at RBS of 80–130mg/dl during the 1st 24h post admission) on decreasing infarct size, and major adverse cardiac events during ICU admission and 30days follow up. ResultsOf 50 patients enrolled in the study, 25 patients received insulin by infusion (group A), while the rest received insulin via S.C. route (group B). The glycemic control was significantly lower in group A.Heart failure at 7 and 30days was 4% and 12%, respectively, in group A vs. 20% and 24%, respectively, in group B. Hemodynamic instability was seen in 8% in group A vs. 28% in group B during the ICU stay. Mortality at 7 and 30days was 0% and 0%, respectively, for group A vs. 4% and 12%, respectively, for group B. ConclusionTight glycemic control in patients with acute coronary syndromes presenting with hyperglycemia on admission is beneficial.

Tight glycemic control increases metabolic distress in traumatic brain injury

To determine the effects of tight glycemic control on brain metabolism after traumatic brain injury using brain positron emission tomography and microdialysis. Single-center, randomized controlled within-subject crossover observational trial. Academic intensive care unit. We performed a prospective, unblinded randomized controlled within-subject crossover trial of tight (80-110 mg/dL) vs. loose (120-150 mg/dL) glycemic control in patients with severe traumatic brain injury to determine the effects of glycemic control on brain glucose metabolism, as measured by [18F] deoxy-D-glucose brain positron emission tomography. Brain microdialysis was done simultaneously. Thirteen severely injured traumatic brain injury patients underwent the study between 3 and 8 days (mean 4.8 days) after traumatic brain injury. In ten of these subjects, global brain and gray matter tissues demonstrated higher glucose metabolic rates while glucose was under tight control as compared with loose control (3.2 ± 0.6 vs. 2.4 + 0.4, p = .02 [whole brain] and 3.8 ± 1.4 vs. 2.9 ± 0.8, p = .05 [gray matter]). However, the responses were heterogeneous with pericontusional tissue demonstrating the least state-dependent change. Cerebral microdialysis demonstrated more frequent critical reductions in glucose (p = .02) and elevations of lactate/pyruvate ratio (p = .03) during tight glycemic control. Tight glycemic control results in increased global glucose uptake and an increased cerebral metabolic crisis after traumatic brain injury. The mechanisms leading to the enhancement of metabolic crisis are unclear, but delivery of more glucose through mild hyperglycemia may be necessary after traumatic brain injury.

Identifying and reducing the incidence of post discharge Venous Thromboembolism (VTE) in orthopaedic patients: a systematic review.

BACKGROUND: The risk of venous thromboembolism for orthopaedic patients is often high due to the length of surgery, damage from trauma to bone and soft tissues and lengthy periods of immobility or reduced mobility. Although venous thromboembolism occurs mainly in inpatients a significant number of patients develop venous thromboembolism post discharge OBJECTIVES: To synthesise the best available evidence on strategies that effectively reduce post discharge venous thromboembolism in orthopaedic patients. INCLUSION CRITERIA: Patients regardless of age, gender or co-morbidities that have been admitted with an acute orthopaedic injury (unplanned) or a planned orthopaedic surgery/procedure and then followed up after discharge. Only papers describing the incidence and prophylaxis treatment used in non-Asian patients were considered for inclusion. Any interventions of combinations of chemoprophylaxis and/or mechanical prophylaxis to prevent venous thromboembolism incidence extending beyond hospital admission. Outcomes included diagnosis of venous thromboembolism following an orthopaedic admission/surgery for up to 6 months post discharge and the incidence of any significant bleeding or death related to venous thromboembolism or haemorrhage.The review considered any randomised controlled trials; in the absence of RCTs other research designs, such as non-randomised controlled trials and before and after studies, were considered SEARCH STRATEGY: Search strategy considered only papers in English from 2000 to March 2012. METHODOLOGICAL QUALITY: Papers selected for retrieval were assessed using standardised critical appraisal instruments from the Joanna Briggs Institute. DATA COLLECTION: Data was extracted from the studies using the standardised Johanna Briggs Institute data extraction form. DATA SYNTHESIS: Of the included studies none matched methodology, treatment or comparator that allowed meta-analysis. The results were therefore presented in a narrative form and were structured using patient population, then intervention and then analysis of results. RESULTS: 20 articles were included in the systematic review. The overall incidence of post discharge venous thromboembolism in orthopaedic patients is not possible to determine due to the variability in reporting criteria and poor follow-up. Use of Low Molecular Weight Heparins was generally shown to be effective in preventing venous thromboembolism. The new generation Factor Xa inhibitors were shown to improve venous thromboembolism prevention however had a slightly higher risk of bleeding. There was limited high level research presented to allow effective assessment of aspirin and/or mechanical compression devices. CONCLUSIONS: Prevention of post discharge venous thromboembolism is complex due to the number of variables that can influence its occurrence. The risk of post discharge venous thromboembolism varies among different patient populations so consideration must be given to matching the risk for each of those groups with available interventions.For higher risk orthopaedic patient groups such as those with large joint replacements and femoral fractures low molecular weight heparins should be considered and continued where possible post discharge for thirty days however the risk profile for venous thromboembolism and bleeding must be considered for both populations and individuals.Consideration in future research design must be given to factors such as: adequate follow-up time, and standardised criteria to measure the incidence of post discharge venous thromboembolism. • Save items Add to Favorites View more options Similar articles Effectiveness of nurse-led preoperative assessment services for elective surgery: a systematic review. [JBI Libr Syst Rev. 2010] The Effectiveness of Integrated Care Pathways for Adults and Children in Health Care Settings: A Systematic Review. [JBI Libr Syst Rev. 2009] Review The effect of insulin therapy algorithms on blood glucose levels in patients following cardiac surgery: A systematic review. [JBI Database System Rev Implem...] Continuous Subcutaneous Insulin Infusion (CSII) Pumps for Type 1 and Type 2 Adult Diabetic Populations: An Evidence-Based Analysis. [Ont Health Technol Assess Ser....] Review The effectiveness of ayurvedic oil-based nasal instillation (Nasya) medicines in the treatment of facial paralysis (Ardita): a systematic review. [JBI Database System Rev Implem...] See reviews... See all... Cited by 1 PubMed Central article A systematic scoping review on the consequences of stress-related hyperglycaemia. [PLoS One. 2018] Related information Cited in PMC Search details 27820532[uid] Search See more... Recent Activity ClearTurn Off Effectiveness of tight glycemic control in the medical Intensive Care Unit: a sy... PubMed 27820532[uid] (1) PubMed 27820349[uid] (1) PubMed Effectiveness of Tight Glycemic Control in the Medical Intensive Care Unit: A Sy... PubMed

Tight Glycemic Control May Increase Regenerative Potential of Myocardium during Acute Infarction

We analyzed the effects of tight glycemic control on regenerative potential of myocardium during acute myocardial infarction. Seventy-five patients with their first acute myocardial infarction undergoing coronary bypass surgery were studied: 25 patients with glycemia below 140 mg/dl served as the control group; hyperglycemic patients (glucose>140 mg/dl) were randomized to intensive glycemic control (IGC; n=20; glucose goal, 80-140 mg/dl), conventional glycemic control (CGC; n=20; glucose goal, 180-200 mg/dl), or glucose-insulin-potassium (GIK; n=10; glucose goal, 180-200 mg/dl) for almost 3 d before surgery, using insulin infusion followed by sc insulin treatment. During surgery, myocyte precursor cells (MPC) (c-kit/MEFC2/GATA4-positive cells), oxidation of MPC DNA (c-kit/8-hydroxydeoxyguanosine-positive cells), senescent MPC (c-kit/p16INK4a-positive cells), and cycling cardiomyocytes (Ki-67-positive cells) were analyzed in biopsy specimens taken from the peri-infarcted area. Before surgery, plasma glucose reduction was greater in the IGC group than in the CGC and GIK groups (P<0.001 for both). IGC patients had higher MPC (P<0.01) and cycling myocytes (P<0.01), as well as less oxidized (P<0.01) and senescent MPC (P<0.01) in peri-infarcted specimens compared with both CGC and GIK patients. Tight glycemic control, by reducing senescent MPC, may increase regenerative potential of the ischemic myocardium.

Effectiveness of tight glycemic control in the medical Intensive Care Unit: a systematic review

Background Intensive Insulin Therapy (IIT) as a means to achieve tight glycemic control (TGC) has become controversial in the medical intensive care unit (ICU) or mixed medical-surgical ICU. The question still remains as to the benefit of tight glycemic control in all patient populations and the optimal target blood glucose range. Review questions/objectives What is the effectiveness of tight glycemic control on adverse outcomes in non-surgical critically ill patients? More specifically, what is the rate of hypoglycemia and mortality in medical intensive care patients who are treated with tight glycemic control regimens? What should be the recommended blood glucose range for patients in a non-surgical, medical ICU? Inclusion criteria Types of participants This review included studies with patients 18 years of age and older, females and males, all types of conditions or diseases, and all stages of severity admitted to a critical care or intensive care unit that required hyperglycemia management and had not had a surgical procedure. Types of intervention(s)/phenomena of interest This review included studies that evaluated the effectiveness of tight glycemic control or intensive insulin therapy as compared to conventional, moderate or liberal insulin therapy. Types of outcomes This review considered studies that included the following outcome measures: frequency and severity of hypoglycemia, and any type of reported mortality. Types of studies This review included only randomized controlled trials which met all of the inclusion criteria. Search strategy A three-step search strategy was utilized find both published and unpublished studies in English language only. An initial limited search of MEDLINE and CINAHL was completed followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms was then undertaken across all included databases. Thirdly, the reference list of all identified reports and articles was searched for additional studies. Methodological quality The reviewers used the JBI Critical Appraisal Checklist for Randomised Controlled Trials to assess methodological quality. Data collection Data was extracted using The JBI Data Extraction Form for Experimental/Observational studies. Data synthesis Due to the heterogeneous nature of the study methods, the findings of this systematic review are presented in a narrative summary. Meta-analysis was unable to be performed. Results The four studies in this systematic review include patients with a multitude of diagnoses and comorbidities which further complicates treatment and outcomes assessment. Until further studies prove otherwise, nonsurgical patients requiring glycemic management are best served with less intensive regimens than their surgical counterparts. Conclusions Further research is needed to establish clear, evidence-based guidelines for the management of hyperglycemia in all ICU patient populations. Implications for practice Based on the results of this review and data from the four included studies, glycemic management for medical patients in the intensive care unit should differ from that of surgical patients. Blood glucoses should be kept between 110-180mg/dL in order to prevent the unwarranted effects of hypoglycemic episodes. Implications for research Published studies compare outcomes for patients with dissimilar medical conditions and current protocols for glycemic management are still based on the results of surgical patient trials. Measurements for interventions and outcomes need to be standardized in order to ensure proper comparison and application of results.