Good Glucose Control Research Articles

Efficacy and Safety of Insulin Glargine in Type 2 Diabetic Patients with Renal Failure

Aim and Background: In patients with type 2 diabetes mellitus complicated with renal failure achieving good glucose control and reduction of risk of hypoglycemia should be balanced. The aim of this study was to determine the safety and efficacy of insulin glargine in type 2 diabetic patients with diabetic nephropathy. Methods: A total of 89 subjects with type 2 diabetes (mean age 62.9 ± 10.7 and diabetes duration 13.9 ± 7.6 years) who had diabetic nephropathy (mean Glomerular FiltrationR [GFR] 34.1 ± 11.5 ml/min) were included in the study. Patients who were not optimally controlled or experienced frequent hypoglycemia on Oral Antidiabetic Drugs (OAD) or NPH insulin received insulin glargine at bedtime. The starting dose was 0.1 unit /Kg and adjusted to obtain target fasting blood glucose (5-7.2 mmol/l). The medical records were obtained before and 2 and 4 months after beginning insulin glargine. Results: At the end of four month treatment period, significant reduction in glycated hemoglobin (HbA 1 c) was observed (from 8.4% ± 1.6 to 7.7% ± 1.2) (p<0.001). The treatments were associated with significant reduction in fasting glucose levels (from 159.7 ± 67 to 119.4 ± 28.4mg/dl) (p<0.001).Patients’ Body Mass Index (BMI) did not increase at the end of study (26.2 ± 3.9 and 26.2 ± 3.8 kg/m2) (p=0.96). Mild symptomatic hypoglycemia was seen in 12.5% of subjects. No other side effects were noted throughout the study.

Improving Safety of Glucose Control in Intensive Care using Virtual Patients and Simulated Clinical Trials

Despite the potential clinical benefits of normalizing blood glucose in critically ill patients, the risk of hypoglycemia is a major barrier to widespread clinical adoption of accurate glycemic control. To compare five glucose control protocols, a validated insulin‐glucose system model was employed to perform simulated clinical trials. STAR, SPRINT, UNC, Yale and Glucontrol protocols were assessed over a medical‐surgical intensive care unit patient cohort. Results were interpreted separately for patients with low to high sensitivity to insulin, and low to high variability in metabolic state. STAR and SPRINT provided good glucose control with risk of severe hypoglycemia less than 0.05% across all patient groups. UNC also achieved good control for patients with low and medium levels of insulin sensitivity (SI), but risk of severe hypoglycemia was raised for patients with high SI. Glucontrol showed degradation of performance for patients with high metabolic variability.

Is There a Difference in Pregnancy and Glycemic Outcome in Patients with Type 1 Diabetes on Insulin Pump with Constant or Intermittent Glucose Monitoring? A Pilot Study

The aim of the study is to describe glycemic and insulin outcomes by trimester and maternal and fetal outcome in patients with type 1 diabetes using an insulin pump with constant or intermittent continuous glucose monitoring (CGM). Twenty-five women with type 1 diabetes with newly diagnosed pregnancy were treated with insulin pump therapy (Medtronic 722, Medtronic Minimed, Northridge, CA) for at least 1 year. Insulin pump and CGM (Medtronic Paradigm Real-Time) were implemented at least 3 months before conception. Patients were randomized in two groups: constant CGM group, 12 patients on insulin pump with glucose sensor, 24 h/day; and intermittent CGM group, 13 patients on insulin pump with intermittent glucose sensor, 14 days/month. The following parameters were analyzed: glycosylated hemoglobin (HbA1c), mean blood glucose, insulin requirement (in IU/kg/day), weight gain, severe hypoglycemic events, diabetic ketoacidosis, macrosomia, cesarean section, and neonatal hypoglycemia. Both groups achieved good glucose control during their pregnancies (P<0.05): 6.78±1.3% and 6.92±0.9% at the beginning of the study compared with 6.14±0.9% (constant CGM group) and 6.23±0.6% (intermittent CGM group) at the end of the study (last HbA1c before delivery). There was no significant decrease of HbA1c between the two groups. The constant CGM group had a significantly lower A1c in the first trimester compared with the intermittent CGM group. Maternal and fetal outcome did not show a significant difference between the two groups. Insulin pump therapy together with constant or intermittent CGM can improve diabetes control and pregnancy outcome in type 1 diabetes. The quality of the glucose profile at conception was the important factor for pregnancy outcome.

Blood glucose control and quality of health care in non‐insulin‐treated patients with Type 2 diabetes in Spain: a retrospective and cross‐sectional observational study

AimsTo assess blood glucose control and quality of health care provided to non-insulin-treated patients with Type 2 diabetes mellitus in routine clinical practice in Spain.MethodsIn this observational, retrospective, cross-sectional study, patients were grouped as either having good or suboptimal blood glucose control according to International Diabetes Federation or American Diabetes Association HbA1c goals. Clinical and socio-demographic data and compliance with the main standard level of care recommendations of the International Diabetes Federation were recorded during a routine visit. Correlates of glucose control were analysed by logistic regression.ResultsMany patients were grouped as having suboptimal control under International Diabetes Federation (61.9%) or American Diabetes Association (45.0%) criteria. The mean number of accomplished International Diabetes Federation recommendations (7.3 out of 11) was higher for endocrinologists (than for internists or primary care physicians), and significantly more patients under their care were in the good glucose control group (than with primary care physicians). More recommendations were associated with blood glucose control using International Diabetes Federation than American Diabetes Association criteria, demanding higher quality of health care for achieving stricter goals. Some recommendations were poorly observed, particularly those concerning patients’ education on diabetes, the prompt prescription of effective treatments and monitoring of complications. Diabetes complications were associated with being in the suboptimal control group. Patients’ education on diabetes and HbA1c monitoring were associated with being in the good control group.ConclusionsThese results demonstrate the need for improvement in the management of patients with non-insulin-treated Type 2 diabetes in actual clinical practice in Spain. Such improvement would entail a stricter adherence to International Diabetes Federation recommendations.

Nursing Practice Patterns: Timing of Insulin Administration and Glucose Monitoring in the Hospital

The purpose of this study was to describe diabetes nursing practice patterns related to the timing of morning insulin administration, blood glucose monitoring, and meal intake for patients with type 2 diabetes and to report how frequently nurses were able to meet the expected standard of care. Observations were made of 50 incidents of morning diabetes care on medical-surgical units in an acute care setting. Timeliness of rapid-acting insulin administration and glucose monitoring in relation to the morning meal were evaluated, as were the subsequent prelunch glucose levels. Patients did not receive rapid-acting insulin with in the standard recommended time of 10 minutes premeal/postmeal 84% of the time, nor did they receive glucose monitoring within the recommended 30 minutes premeal 57% of the time. There was no significant relationship found between timely insulin administration and glucose monitoring. There were no significant relationships found between care activities and prelunch glucose control or glucose variability. Coordinating insulin administration, glucose monitoring, and meal delivery within the tight time frames required for rapid-acting insulin is a significant challenge not being met. Timeliness of diabetes nursing care is not the sole determining factor to good glucose control in hospitalized patients. Standards regarding timing of these activities need to be evaluated.

Minimizing the risk of hypoglycemia with vildagliptin: Clinical experience, mechanistic basis, and importance in type 2 diabetes management

Even if the true incidence of hypoglycemia in type 2 diabetes mellitus (T2DM) remains difficult to estimate, with highly variable rates reported in the literature, it is likely more common than previously thought. While most hypoglycemic episodes in T2DM are considered “mild,” they still have a substantial clinical impact. Severe hypoglycemia also exists in T2DM, with recent landmark studies prompting much debate about the potential role of severe hypoglycemia in cardiovascular morbidity and mortality, even though there is currently no definitive evidence for causality. The challenge in the treatment of T2DM remains the achievement of optimal glycemic control to lower the risk for long-term complications while avoiding hypoglycemia. Successful treatment strategies should therefore include careful selection of therapies to prevent hypoglycemia, starting early in the disease management process, in order to best preserve counterregulation. The dipeptidyl peptidase-4 inhibitor, vildagliptin, is a good treatment option to minimize the risk of hypoglycemia over time, while maintaining good glucose control. Extensive clinical experience is available for vildagliptin, with data published for all stages of the condition and with the low hypoglycemic potential stemming from a solid mechanistic basis.

Follow-up of cardiac function in infants of mothers with gestational diabetes mellitus

Objective To follow up the changes of postnatal cardiac sizes and function in infants of mothers with gestational diabetes mellitus （GDM）. Methods Eighteen GDM mothers with euglycemia （GDM group） and 24 gestational age matched normal pregnant women （control group）, having prenatal examination and delivered in Women＇s Hospital of Fudan University from January to August in 2007, received fetal echocardiographic examination in late pregnancy. Infants of these GDM mothers and 24 age-matched healthy infants of normal pregnancy （control group） received sonographic follow up. Cardiac sizes and function were evaluated and compared. Results At birth, there were six （33.3%） infants of large for gestational age （LGA） and 12（66.7%） appropriate for gestational age（AGA） in GDM group, while in the control group, there were two LGA （8.3%） and 22（91.7%） AGA infants （Х^2 =3. 840, P=0.05）. Both the interventricular septum and left ventricular walls in GDM fetuses were thicker than in control fetuses （P 〈 0.05）. No increase in the thickness of ventricular walls was observed till infantile period. However, the end-systolic thickness of left ventricular walls in LGA infants was still larger than in control infants [（4.55 ± 0. 37） mm vs （4.13±0.39） mm, P〈0.05], and end-diastolic left ventricular long-diameters were also larger [（37. 3±2. 3） mmvs （34.6±2.6） mm] （P〈0.05）. In GDM fetuses, the peak velocities of aorta and pulmonary artery and left cardiac output were higher than in the controls （P〈 0.01）, and right/left cardiac outputs ratios were lower （1.198±0.206 vs 1.430±0.321, t= 2.668,P=0.011）. Till infantile period, only right/left cardiac outputs ratios in AGA infants of GDM group were larger than in controls （P〈0.05）. GDM fetuses＇ left atrial shortening fraction and tricuspid E/A ratios were smaller （P〈0. 05）. In infantile period, only left atrial shortening fraction in GDM infants was still smaller than in controls （0.356±0.040 vs 0.386±0.041, t=-2.332, P=0.025）. Left and right ventricular Tel index in GDM fetuses were 0. 482±0. 129 and 0. 414±0. 094, both larger than those of control fetuses （0.309±0.074 and 0.283±0.072）（t=5.075 and 5. 129, P=0.000）. Till infantile period they both became significantly lower and no differences were found among LGA, AGA and control infants. Conclusions The cardiac sizes and function at 2-3 months of age, in infants of GDM mothers with good glucose control, became better than that in uterus. Key words: Diabetes, gestational; Infant; Ventricular function, left; Stroke volume; Follow up studies

Glucose Control in Severely Thermally Injured Pediatric Patients

To determine which glucose levels are associated with improved morbidity and mortality in thermally injured patients. Tight euglycemic control was rapidly implemented in intensive care units around the world, but there is increasing evidence that tight euglycemic control is associated with detrimental outcomes. Currently, no study exists that indicates which glucose range should be targeted. Two-hundred and eight severely burned pediatric patients with burns over 30% of their total body surface area were included in this trial. Several statistical models were used to determine the daily average and 6 AM glucose target that were associated with improved morbidity and mortality. Patients were then divided into good glucose controlled and poor glucose controlled patients and demographics, clinical outcomes, infection, sepsis, inflammatory, and hypermetabolic responses were determined. Statistical modeling showed that hyperglycemia is a strong predictor of adverse hospital outcome and that daily 6 am glucose level of 130 mg/dL and daily average glucose levels of 140 mg/dL are associated with improved morbidity and mortality postburn. When patients were divided into good glucose control and poor glucose control, we found that patients with glucose levels of 130 mg/dL exert attenuated hypermetabolic and inflammatory responses, as well as significantly lower incidence of infections, sepsis, and mortality compared with patients with poor glucose control, P < 0.05. Given the controversy over glucose range, glucose target, and risks and detrimental outcomes associated with hypoglycemia we suggest that in severely burned patient's blood glucose of 130 mg/dL should be targeted.

Survey on Transition from Inpatient to Outpatient for Patients on Insulin: What Really Goes on at Home?

To identify the diabetes-specific, posthospital discharge issues that may arise for patients sent home on insulin therapy. We designed and conducted a telephone survey covering predischarge issues such as survival skill education and insulin discharge instructions, postdischarge logistical problems such as obtaining diabetes medications and supplies, and overall glucose control. The questionnaire was administered by telephone 1 week after discharge from the hospital to adult patients sent home on long-acting insulin. We attempted to contact 61 patients who were eligible for the study. Eleven patients were unable to be reached by telephone despite multiple attempts. Forty-seven of 50 patients contacted agreed to be interviewed. Nearly 100% of patients received appropriate "survival skills" training, including instruction regarding self-monitoring of blood glucose, insulin administration, and treatment of hypoglycemia. Once discharged, 10 patients (21%) had difficulty obtaining diabetes medications and supplies. Thirty-seven patients (79%) felt that their blood glucose control was "good" in the week after they left the hospital compared with author perception of 25 patients having good glucose control (53%) on the basis of pre-defined criteria. Although patients received instruction on insulin dosing and when and who to call for problems and questions, specific guidelines on how to manage insulin in the setting of changing glucocorticoid dosages were not communicated to patients. On the basis of our findings, we anticipate implementing improvements in diabetes-specific discharge prescriptions, new guidelines on when patients should call for assistance, and specific orders on how to adjust insulin for changes in glucocorticoid dosages.

Intensive Glucose Control and Cardiovascular Outcomes in Type 2 Diabetes

Numerous observational studies have clearly shown a relationship between hyperglycaemia and cardiovascular (CV) disease. However, the United Kingdom Prospective Diabetes Study (UKPDS), which involved subjects with newly diagnosed type 2 diabetes, just failed to show that intensive glucose control significantly reduces CV events. The results of three subsequent large randomised controlled trials, the Action to Control Cardiovascular Risk in Diabetes (ACCORD), Action in Diabetes and Vascular Disease Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) and the Veterans Administration Diabetes Trial (VADT), that involved approximately 25,000 subjects with established type 2 diabetes also failed to show that intensive glucose control, aiming for a glycated haemoglobin (HbA(1c)) level<7%, significantly reduces CV events. The ACCORD trial even suggested that under certain circumstances, intensive glucose control is associated with an increased risk for CV and all-cause mortality. Although the exact mechanisms responsible for an increase in mortality in the ACCORD trial remain unknown, there was an association between increased rates of mortality with higher rates of severe hypoglycaemia in the intensive glucose control group. In contrast, a 10-year post-randomisation follow-up study of the tight glucose intervention arm of the UKPDS showed that intensive glucose control was associated with a significant reduction in the risk for myocardial infarction (MI), diabetes-related deaths and all-cause mortality. This suggests that early strict glucose control generates a legacy effect that is eventually translated into protection from CV events. Recent meta-analyses of the above randomised trails have also shown that intensive glucose control is associated with a reduced risk of MI, without a clear benefit on other CV diseases such as stroke. Furthermore, these analyses have also shown that intensive glucose control is associated with increased rates of severe hypoglycaemia but not increased rates of CV or all-cause mortality. Aiming for HbA(1c) levels of <7.0% still remains the general target for good glucose control. Under certain circumstances, aiming for lower HbA(1c) levels may be appropriate. This applies in the setting of newly diagnosed diabetes in relatively young individuals without significant co-morbidities and in patients treated with agents that minimise the risk of severe hypoglycaemia such as metformin. Whether this also applies to newer glucose-lowering agents that target the incretin system will depend on CV outcomes of long-term studies which are in progress.

Nutrition du patient diabétique ayant une maladie rénale chronique

One third of the patients with Diabetes present a Chronic Kidney Disease. Despite cardiovascular events and increased mortality, Diabetes is the first cause of End Stage Renal Disease. The nutritional status of theses patients widely varies, from obesity to malnutrition, according to their type of diabetes, the severity of the renal disease, and the frequent concurrent diseases: it conditions their dietary counselling. The patients with type 2 diabetes and obesity have to moderate and well choose their alimentary lipids, for body weight control and to reduce their cardiovascular risk; this works in the context of a multifactorial approach as demonstrated by the Steno 2 trial. The use of insulin or conventional insulin-secretagogues (sulfonylureas, glinids) needs patients to be educated about their carbohydrate intake, especially when the good glucose control exposes to hypoglycaemia. Moderation of protein intake reduces proteinuria, an improved outcome has been demonstrated for patients with type 1 diabetes and nephropathy on a Low Protein Diet. The patients who require dialysis often deteriorate their nutritional status, the protein intake must be increased at this stage.

Metabolic Long-Term Follow-Up of Functioning Simultaneous Pancreas-Kidney Transplantation Versus Pancreas Transplantation Alone: Insights and Limitations

Pancreas transplantation involves a set of procedures that, in some cases, lead to different complications and outcomes. The aim of this study was to analyze the long-term effects of pancreas transplantation regarding carbohydrate and lipid metabolism parameters to determine differences between simultaneous pancreas-kidney (SPK) transplantation and pancreas transplantation alone (PTA). Sixty-four patients (46 SPK and 18 PTA), with an immunosuppression protocol based on tacrolimus plus mycophenolate mofetil and prednisone, were evaluated for at least 1 year after transplantation. No patient made use of any hypoglycemic or hypolipidemic drugs. Comparisons were performed between SPK and PTA patients using the chi-square test, Fischer's exact test, and unpaired Student's t test, as appropriate. Patients were 39.8+/-9.3 years old, predominantly male (60.9%), with a mean follow-up of 25.4+/-10.4 months after transplantation. The PTA group exhibited worse renal function and higher tacrolimus levels than the SPK group. Fasting glucose, 2 hr plasma glucose after overload, C-peptide, and HbA1C were within the normal range, with no statistically significant differences between the PTA and SPK groups. Insulin (INS) and the homeostasis model assessment of INS resistance index were above the normal range in both the groups. Lipids were also similar between groups. The majority of patients with long-term functioning pancreas transplant achieved good glucose control without use of exogenous INS or oral antidiabetic drugs, although they were hyperinsulinemic. There were no significant differences concerning glucose and lipid parameters between the SPK and PTA groups, even though the PTA patients exhibited higher tacrolimus levels and worse renal function.

Tackling diabetes through translation

Tackling diabetes through translation

Parental attitudes towards overnight closed-loop glucose control in children with type 1 diabetes.

This study examined parental attitudes towards overnight closed-loop (CL) glucose control in children and young people with type 1 diabetes (T1D). Twelve families recruited by the INsulin PUmp Therapy group (INPUT), a U.K. patient/carer-led support group for people with T1D, attended a focus meeting on CL. The concept of CL was explained, and clinical results and plans regarding the Artificial Pancreas Project at Cambridge were presented. Participants completed a questionnaire to evaluate parental feelings about T1D management and attitudes towards overnight CL insulin delivery. Nineteen parents (12 mothers and seven fathers) anonymously completed the questionnaire. Main concerns about diabetes were related to long-term complications (84%) and hypoglycemia (16%). Achieving good glucose control represented major challenge for carers (83%) with nighttime being the most difficult period to manage (56%), worrying most parents (71%) particularly because of fear of hypoglycemia (33%). The development of CL to manage diabetes was welcomed by all parents (100%) with 95% happy for their child to wear a continuous glucose monitor together with an insulin pump. All parents were ready to respond to additional alarms at night with 90% parents not worried about their child's overnight insulin delivery being controlled by a computer. Selected parents of children with T1D who are already insulin pump users express implied trust in the technology for overnight CL insulin delivery. Nighttime blood glucose control is the biggest challenge and concern for parents, and the development of a commercially available overnight CL system may be an important goal.

DIABETES CONTROL – THE LEGACY OF A MEMORY

Achieving and maintaining good glycaemic control remains an important goal in the management of this common and prevalent disorder. Recent evidence from important megatrials, ACCORD, ADVANCE, VADT, UKPDS-10 year follow-up as well as the STENO-2 follow-up study, have cleared doubts concerning the benefits of targeting good glycaemic control. For the first time, we have the reassurance that macrovascular benefits can be realised from good glycaemic control. The legacy effect of prior good glucose control from the UKPDS-10 year follow-up, reinforces the results seen from the DCCT-EDIC (for Type 1 diabetes). The Intervention Phase of the UKPDS revealed benefits for reduction of microvascular complications, while it was only at the end of the Post-Trial Monitoring Phase where significant improvements in both micro and macrovascular outcomes were seen.(JUMMEC 2009; 12(2): 47-56)The other three Trials assessing the effect of glycaemic control on cardiovascular outcomes, although largely negative for CV benefit, give valuable insight towards appropriate patient characteristics for which aggressive glucose control can and should be instituted. Individualisingglycaemic targets, which has been the approach that many clinicians have been practising, has received new impetus albeit with clearer details.&nbsp;Getting to glycaemic goal early in the course of T2DM and Doing to Safely (Avoiding hypoglycaemia) are the key ingredients to successful management. The legacy of the memory of initial goodmetabolic/glycaemic control is investment in good health with benefits of reductions in both micro and more importantly, macrovascular disease, years later.&nbsp;Multifactorial interventions that include blood pressure, lipid lowering in addition to glucose control in these individuals with the Metabolic Syndrome result in more immediate beneficial additive effects on cardiovascular outcomes.

The Eurodiab study: What has this taught us about diabetic peripheral neuropathy?

Apart from tight blood glucose control, no other treatments have been shown to retard the progression of diabetic peripheral neuropathy (DPN). Therefore, identifying potential risk factors for DPN is important, particularly if they are modifiable. The Eurodiab baseline DPN study found a prevalence of 28% for DPN, with glycemic control and duration of diabetes being major determinants. It was also observed that a substantial proportion of those with good glucose control (hemoglobin A(1c) < 7%) were found to have DPN, which raised the possibility that other risk factors may be involved. Having excluded those with DPN at baseline, researchers followed 1172 type 1 diabetic subjects for 7.3 years (SD, 0.6) looking for risk factors for the development of DPN. DPN developed in 23.5% over the follow-up period; and apart from glycemic control and duration of diabetes, known to be important risk factors for DPN, traditional markers of macrovascular disease (eg, hypertension, smoking, obesity, and triglycerides) were found to be independent risk factors. The study was published in the New England Journal of Medicine and suggested that a need exists for clinical trials to confirm if modifying cardiovascular risk factors is an effective treatment for DPN.

Initiating Insulin Therapy in Type 2 Diabetic Patients Failing on Oral Hypoglycemic Agents

Type 2 diabetes is a chronic disease characterized by coexisting insulin deficiency and insulin resistance, with the resultant hyperglycemia leading to micro- and macrovascular complications. A large number of intervention trials demonstrated that improving glycemic control achieves considerable reductions of such complications (1–7). It has been estimated using the homeostasis multiple assessment (HOMA) that, at the time of diagnosis, ∼50% of pancreatic β-cell function has been lost, with almost 4% further loss of function expected per year thereafter (8,9). Therefore, type 2 diabetes is a chronic progressive disease characterized by worsening hyperglycemia and escalating deterioration in the function of pancreatic β-cells and loss of β-cell mass (10). Because of the progressive nature of the disease, an evolving treatment strategy is therefore necessary to maintain both fasting and postprandial glycemic control. Recently, an American Diabetes Association (ADA) and European Association for the Study of Diabetes (EASD) Consensus recommended a target of A1C <7% for good glucose control in clinical practice (11). Insulin therapy is required when dietary restrictions and lifestyle modifications combined with oral hypoglycemic agents (OHAs) failed to provide acceptable metabolic control (12). One major lesson learned from the milestone U.K. Prospective Diabetes Study (UKPDS) is the increasing requirement for multiple therapies in patients with type 2 diabetes to achieve blood glucose (BG) target control (13). The augmentation of insulin to OHAs contributed to several beneficial metabolic effects, as recently reviewed (14). However, there is ongoing debate as to whether it is more rewarding to target postprandial BG concentrations with meal-related insulin, or to target fasting BG concentrations with basal insulin. Monnier et al. (15,16) provided data to explain the relative contribution of fasting and postprandial BG to A1C in patients with mild-to-moderate hyperglycemia (A1C <7.3%) than in those with more poorly …

Persistent arterial stiffness and endothelial dysfunction following successful pancreas–kidney transplantation in Type 1 diabetes

Successful simultaneous pancreas-kidney transplantation (SPK) in Type 1 diabetic (T1DM) patients results in improved cardiovascular outcome and survival. However, it is doubtful whether the impairment of cardiovascular and endothelial function in T1DM can be completely reversed. Pulse-wave velocity, stroke volume, heart rate, serological markers of endothelial dysfunction (soluble intercellular, vascular cell-adhesion molecules, E-selectin, and plasminogen-activator-inhibitor-1) were measured in 10 T1DM patients after SPK with non-diabetic glucose levels, 10 T1DM patients with poor [T1DM>8; glycated haemoglobin (HbA1c)>8%], and 10 with good glucose control (T1DM<7, HbA1c<7%), in 6 non-diabetic patients after kidney transplantation (KT) and 9 non-diabetic control subjects (CON), matching for major anthropometric characteristics. Pulse-wave velocity was increased in SPK (P < 0.02 vs. CON, KT, T1DM<7) and in T1DM>8 (P < 0.02 vs. T1DM<7). Systolic blood pressure was increased in SPK (P < 0.05 vs. CON). Stroke volume was reduced in SPK, T1DM>8 and T1DM<7 and KT (P < 0.01 vs. CON). Heart rate was elevated in SPK and in T1DM>8 (P < 0.0003 vs. CON and T1DM<7). In SPK, soluble intercellular and vascular cell-adhesion molecules were 100% and 44% higher (P < 0.03 vs. CON), respectively, while plasminogen-activator-inhibitor-1 was decreased in SPK (P < 0.02 vs. CON). T1DM patients after SPK experience arterial stiffness, a higher heart-rate and blood pressure, reduced stroke volume and serological signs of endothelial dysfunction. Thus, functional and structural cardiovascular alterations as a result of glucotoxicity, uraemia and hypertension in T1DM might not be completely resolved by SPK.

Effective Glycemic Control With Aggressive Hyperglycemia Management Is Associated With Improved Outcome in Aneurysmal Subarachnoid Hemorrhage

Hyperglycemia strongly predicts poor outcome in patients with aneurysmal subarachnoid hemorrhage, but the effect of hyperglycemia management on outcome is unclear. We studied the impact of glycemic control on outcome of patients with aneurysmal subarachnoid hemorrhage. A prospective intensive care unit database was used to identify 332 patients with hyperglycemic aneurysmal subarachnoid hemorrhage admitted between January 2000 and December 2006. Patients treated with an aggressive hyperglycemia management (AHM) protocol after 2003 (N=166) were compared with 166 patients treated using a standard hyperglycemia management before 2003. Within the AHM group, outcome was compared between patients who achieved good (mean glucose burden <1.1 mmol/L) and poor (mean glucose burden >or=1.1 mmol/L) glycemic control. Poor outcome was defined as modified Rankin scale >or=4 at 3 to 6 months. Multivariable logistic regression models correcting for temporal trend were used to quantify the effect of AHM on poor outcome. Poor outcome in AHM-treated patients was lower (28.31% versus 40.36%) but was not statistically significant after correcting for temporal trend. However, good glycemic control significantly reduced the incidence of poor outcome (OR, 0.25; 95% CI, 0.08 to 0.80; P=0.02) compared with patients with poor glycemic control within the AHM group. No difference in the rate of clinical vasospasm or the development of delayed ischemic neurological deficit was seen before and after AHM protocol implementation. AHM results in good glucose control and significantly reduces the odds for poor outcome after aneurysmal subarachnoid hemorrhage in glucose-controlled patients. Further studies are needed to confirm these results.

Effects of Aggressive Approach to the Multiple Risk Factors for Diabetic Nephropathy on Proteinuria Reduction in Diabetes Type 2 Patients

Dietary interventions with protein and salt restriction, good glucose control, smoking cessation, aggressive blood pressure control, good control of cholesterol and triglycerides, use of ACE inhibitors and ARBs can delay the progression of diabetic nephropathy. The aim of this study was to present the effects of aggressive treatment of the multiple risk factors for diabetic nephropathy on proteinuria in patients with type 2 diabetes. In this study we included 15 patients with diabetes type 2 and insufficient regulation of glycaemia. The patients were followed for three months period. Glycated haemoglobin (HbA1c), fasting plasma glucose (FPG), postprandial plasma glucose (PPG), blood pressure, cholesterol and triglycerides and proteinuria were followed prior and after the study. Prior the study patients were treated with premix insulin divided in two daily doses + metformin after the lunch and they had insufficient regulation of glycaemia. During the study patients were treated with one daily dose of basal insulin, three doses of metformin (2550 mg), one daily dose of atorvastatin (20 mg) and one daily dose of ramipril (5 to 10 mg). Doses of insulin were titrated separately for each patients (0,7-1,0 IU/kg). Patients were advised to start with lifestyle modification, increased physical activity and dietary interventions with protein and salt restriction, energy restricted diet and smoking cessation. A total of 20 patients (male 12 and female 8) with diabetes type 2 were studied. The mean age of the subjects was 53+/-5,25 years. The mean diabetes duration was 4,05+/-1,96 years. The mean body mass index decreased from 28,1+/-1,67 kg/m2 to 25,9 +/-1,22 kg/m2 after the study. Mean HbA1c decreased from 8,82 +/- 0,53 % to 7,15 +/- 0,23 % (p<0,05). Mean fasting glycemia decreased from 8,79+/-0,58 mmol/dm3 to 7,03+/-0,18 mmol/dm3 (p < 0,05). Mean postmeal glycemia decreased from 9,93 +/- 0,77 mmol/dm3 to 7,62 +/- 0,42 mmol/dm3 (p<0,05). The mean cholesterol level decreased from 7,99 +/-0,64 mmol/dm3 to 5,93 +/- 0,65 mmol/dm3 (p<0,05). The mean triglicerides level decreased from 4,05 +/- 0,97 mmol/dm3 to 1,96 +/- 0,24 mmol/dm3 (p<0,05). The significant decrease of proteinuria was recorded, prior the study the mean albuminuria was 1,05 +/- 0,31 g/dm3 and after the study was 0,07 +/- 0,145 g/dm3 (p<0,05). Mean blood pressure prior the study was 153+/-8,69/91,5 +/- 3,78 mm Hg (p<0,05), after the study was 125 +/- 6,32/ 79,25+/-3,26 mmHg. Effective control of glycaemia, blood pressure, cholesterol and triglycerides, use of ACE inhibitors, dietary interventions with protein and salt restriction, smoking cessation, can delay the progression of nephropathy in type 2 diabetes.