Insulin Therapy For Glycemic Control Research Articles

Strategies for Cardiovascular Disease Prevention in Type 1 Diabetes: A Comprehensive Review.

Cardiovascular disease (CVD) is a leading cause of morbidity and mortality among individuals with type 1 diabetes (T1D), necessitating effective prevention strategies. This comprehensive review consolidates current knowledge and evidence on preventing CVD in T1D patients. It begins by exploring the pathophysiological mechanisms that link T1D to an increased risk of CVD, highlighting factors such as chronic hyperglycemia, hypertension, dyslipidemia, and inflammation. The review also examines the epidemiology and specific risk factors for CVD in this population, emphasizing the need for rigorous risk assessment and screening. Lifestyle modifications, including dietary interventions, regular physical activity, and smoking cessation, are evaluated for their effectiveness in reducing CVD risk. Additionally, the review discusses pharmacological interventions, such as insulin therapy for glycemic control, antihypertensive medications, lipid-lowering agents, and antiplatelet therapy, underscoring their critical role in CVD prevention. Emerging therapies and future research directions are explored, focusing on novel pharmacological agents, advances in insulin delivery systems, and personalized medicine approaches. The importance of integrated care models involving multidisciplinary teams and the use of technology is highlighted as essential for comprehensive management. Challenges and barriers to implementing these strategies, including healthcare system limitations, patient adherence, and socioeconomic factors, are also addressed. This review provides a detailed synthesis of current strategies and future directions for preventing CVD in individuals with T1D, serving as a valuable resource for clinicians, researchers, and policymakers dedicated to improving cardiovascular outcomes in this high-risk population.

Efficacy of automated insulin delivery (AID) systems in type 1 diabetes: protocol of a systematic review and network meta-analysis of outpatient randomised controlled trials

IntroductionAutomated insulin delivery (AID), also known as artificial pancreas system or ‘closed-loop system’, represents a novel option for current treatments for type 1 diabetes (T1D). The objective of this systematic...

Adaptive support ventilation as an effective treatment option for central sleep apnea in an older adult with heart failure with preserved ejection fraction: a case report

BackgroundAdaptive support ventilation (ASV) is a proposed treatment option for central sleep apnea (CSA). Although the effectiveness of ASV remains unclear, some studies have reported promising results regarding the use of ASV in patients with heart failure with preserved ejection fraction (HfpEF). To illustrate the importance of suspecting and diagnosing sleep-disordered breathing (SDB) in older adults unable to recognize symptoms, we discuss a case in which ASV was effective in a patient with CSA and HfpEF, based on changes in the Holter electrocardiogram (ECG).Case presentation.An 82-year-old man presented to our hospital with vomiting on April 19, 2021. Approximately 10 years before admission, he was diagnosed with type 1 diabetes mellitus and recently required full support from his wife for daily activities due to cognitive dysfunction. Two days before admission, his wife was unable to administer insulin due to excessively high glucose levels, which were displayed as “high” on the patient’s glucose meter; therefore, we diagnosed the patient with diabetic ketoacidosis. After recovery, we initiated intensive insulin therapy for glycemic control. However, the patient exhibited excessive daytime sleepiness, and numerous premature ventricular contractions were observed on his ECG monitor despite the absence of hypoglycemia. As we suspected sleep-disordered breathing (SDB), we performed portable polysomnography (PSG), which revealed CSA. PSG revealed a central type of apnea and hypopnea due to an apnea–hypopnea index of 37.6, which was > 5. Moreover, the patient had daytime sleepiness; thus, we diagnosed him with CSA. We performed ASV and observed its effect using portable PSG and Holter ECG. His episodes of apnea and hypopnea were resolved, and an apparent improvement was confirmed through Holter ECG.ConclusionMedical staff should carefully monitor adult adults for signs of or risk factors for SDB to prevent serious complications. Future studies on ASV should focus on older patients with arrhythmia, as the prevalence of CSA may be underreported in this population and determine the effectiveness of ASV in patients with HfpEF, especially in older adults.

Different Gestational Diabetes Phenotypes: Which Insulin Regimen Fits Better?

ObjectiveMaternal characteristics and OGTT values of pregnancies complicated by gestational diabetes mellitus (GDM) were evaluated according to treatment strategies. The goal was to identify different maternal phenotypes in order to predict the appropriate treatment strategy.MethodsWe conducted a retrospective study among 1,974 pregnant women followed up for GDM in a tertiary referral hospital for high-risk pregnancies (Careggi University Hospital, Florence, Italy) from 2013 to 2018. We compared nutritional therapy (NT) alone (n = 962) versus NT and insulin analogues (n = 1,012) group. Then, we focused on different insulin analogues groups: long acting (D), rapid acting (R), both D and R. We compared maternal characteristics of the three groups, detecting which factors may predict the use of rapid or long-acting insulin analogue alone versus combined therapy.ResultsAmong women included in the analysis, 51.3% of them needed insulin therapy for glycemic control: 61.8% D, 28.3% combined D and R, and 9.9% R alone. Age >35 years, pre-pregnancy BMI >30, family history of diabetes, previous GDM, altered fasting plasma glucose (FPG), hypothyroidism, and assisted reproductive technologies (ART) were identified as maternal variables significantly associated with the need of insulin therapy. Altered 1-h and 2-h glucose plasma glucose level at OGTT, age >35 years, and previous GDM were found as independent predicting factors for the use of combined therapy with rapid and long acting analogues for glycemic control. On the contrary, pre-pregnancy BMI <25 and normal fasting plasma glucose values at OGTT were found to be significantly associated to the use of rapid insulin analogue only.ConclusionA number of maternal and metabolic variables may be identified at the diagnosis of GDM, in order to identify different GDM phenotypes requiring a personalized treatment for glycemic control.

Abstract 14849: Lifetime Benefit of Empagliflozin in Extending Survival Free From Insulin Initiation in Type 2 Diabetes and Cardiovascular Disease: An Actuarial Analysis of EMPA-REG OUTCOME

Background: Many patients with type 2 diabetes (T2D) will, over time, require insulin therapy for glycemic control. Treatment-attendant adverse effects of insulin such as weight gain and hypoglycemia may be especially problematic in those with CVD. Delaying the need for insulin initiation may therefore be an important therapeutic goal, especially in those with CVD. Methods: This actuarial analysis evaluated the 3,633 (52%) of 7,020 EMPA-REG OUTCOME participants who were not using insulin at baseline. Patients were randomized to the SGLT2 inhibitor empagliflozin (EMPA) 10mg, 25mg, or placebo (PBO). After the first 12 weeks, changes in background antihyperglycemic therapy were allowed. We estimated survival time free from insulin initiation (sustained over ≥2 consecutive study visits) over patients’ lifetimes by using baseline age as the time horizon. Age-based Kaplan-Meier survival curves were constructed for each year of age between 45 and 80 years. Differences in area under the survival curve between treatment arms represented treatment effects on time spent alive and free from insulin initiation. Results: During median follow-up of 3.2 years, insulin was required in 172 patients (7.1%) with EMPA and 196 (16.4%) with PBO. Lifetime benefits on insulin-free survival were inversely related to baseline age, ranging from 1.4 to 11.3 years. For a 45-year-old, estimated insulin-free survival was 20.1 years with EMPA and 10.0 years with PBO (difference: 10.1 years; 95% CI 5.7-14.5 years; P&lt;0.0001). At age 60 years, insulin-free survival was 16.7 vs. 10.5 years (difference: 6.2 [4.6-7.8]; P&lt;0.0001), and at age 75 years, 9.7 vs. 8.1 years (difference: 1.5 [0.0-3.1]; P=0.056). Conclusions: Assuming stable lifetime effects, we estimate that initiation of EMPA prolongs time alive free from need for insulin by 1.4 to over 11 years among adults with T2D and CVD. While benefits were most pronounced among younger patients, EMPA reduced the need for insulin across a broad age range.

MON-703 Injection Technique over Insulin Dose - Nuances in Diabetes Therapy

IntroductionOptimal insulin injection technique is crucial for therapeutic success in patients with diabetes who require insulin therapy for glycemic control. One of the causes for failure to reach glycemic goals can be attributed to improper injection technique. Problems related to poor injection technique may arise at a later stage and hence, may lead to a major barrier to intended glycemic control. We present a patient with worsening glycemic control and significant insulin requirement due to ineffective injection technique. Our case highlights the importance of direct observation of the patient injecting insulin, even for those who have been on insulin therapy for years.Case PresentationA 55-year-old woman with T2DM and Class III obesity was referred for endocrine consultation with HbA1c >12% for 9 months despite adhering to 4.7 unit/kg/day basal bolus daily Insulin, Metformin 1000 mg twice daily and liraglutide 1.8 mg daily. Secondary causes of insulin resistance were ruled out. Initial review of injection technique on an insulin-injection pad failed to identify the error. However, a leakage was observed when patient was asked to demonstrate injection technique on herself, using the BD AutoShield Duo needle, which she was using at that time. Patient was advised to switch to BD nano needles and given proper training. Following this adjustment, her HbA1c improved to 6.9% within 3 months with a decrease in daily insulin requirement to 1 unit/kg/day.DiscussionIn optimizing glycemic control, proper insulin injection technique is as essential as the appropriate type and dose of insulin; however, this is often overlooked. Studies assessing proper insulin injection technique by direct observation are limited. Problems experienced by patients are rarely brought up and often neglected during the follow-up visits. Supervision of injection technique periodically can help identify injection errors.The BD AutoShield Duo offers the distinct advantages of concealing the needle which benefits those who have an aversion to needles and reduces the risks of accidental needlesticks. The force required to deliver a successful injection of insulin using this needle is greater in comparison to traditional needles. Such force and lack of direct visualization may potentially lead to failure of insulin delivery. Such challenges may be more obvious in patients with obesity.Our case highlights the importance of periodic review of insulin injection technique, particularly when glycemic control is suboptimal, and emphasizes the correct choice of insulin pen needle.

Comparison of the effects of insulin and SGLT2 inhibitor on the Renal Renin-Angiotensin system in type 1 diabetes mice

AimsSGLT2 inhibitors have been proposed as an adjunct to insulin therapy for glycemic control in type 1 diabetes (T1D) patients. However, concern has been raised due to an increase in renin–angiotensin-system (RAS) activity reported in a clinical trial in which an SGLT2 inhibitor was added while insulin dose was reduced in T1D patients. We previously reported that insulin inhibits intrarenal angiotensinogen (Agt) gene transcription and RAS activation. We hypothesized that insulin, rather than SGLT2 inhibition might regulate the intrarenal RAS. MethodsWe compared RAS activity in non-diabetic wild type mice, Akita mice (T1D model) and Akita mice treated with insulin or the SGLT2 inhibitor canagliflozin. ResultsTreatment of Akita mice with insulin or canagliflozin produced similar reductions in blood glucose, whereas insulin, but not canagliflozin, reduced elevated systolic blood pressure. Akita mice exhibited increased renal Agt mRNA/protein expression, which was attenuated by insulin, but not by canagliflozin. Furthermore, insulin was more effective than canagliflozin in lowering kidney weight and albuminuria. ConclusionsInsulin, but not canagliflozin, lowers intrarenal RAS activity in Akita mice. Our findings can be of potential clinical importance, especially for T1D patients who are not on RAS inhibitors at the time of adding SGLT2 inhibitors.

Is intensive insulin therapy the scapegoat for or cause of hypoglycaemia and poor outcome?

In 2009, the NICE-SUGAR study became a reference supporting the use of higher glycaemic target bands for glycaemic control. The important increased risk of hypoglycaemia and mortality associated with lower target band in this study contradicted previous studies showing lower target bands improved outcomes. In this analysis, virtual trials of the NICE-SUGAR protocol and the patient-specific model-based STAR protocol are compared to reported clinical results to evaluate the safety and efficacy of the NICE-SUGAR protocol design.Simulation results show STAR has higher safety and performance than NICE-SUGAR, with higher time in band, lower glycaemic variability, and lower incidence of both hyper- and hypo- glycaemia, which are all associated with improved outcomes. Compared to clinical results, the important difference in workload (9.4 vs 25.0 measurements per day) and insulin administration (50.2 ± 38.1 vs. 154.0 ± 209.2 U/d) shown in the simulations suggest poor clinical compliance to protocol in the NICE-SUGAR study. Thus, the increased clinical incidence of hypoglycaemia in the NICE-SUGAR study may have resulted from low compliance to protocol, and the interpretation of the results could have been biased by a non-compliant glycaemic control protocol design.In conclusion, NICE-SUGAR protocol design was not clinically feasible, shown in the low compliance, likely resulting in low safety, efficacy, and highly variable glycaemic outcomes. Hence, the use of intensive insulin therapy for glycaemic control targeting lower glycaemic bands has been wrongly blamed for increased hypoglycaemia and mortality. Glycaemic control must be safe and effective for all patient, before any further study can assess potential beneficial clinical outcomes.

A 3D insulin sensitivity prediction model enables more patient-specific prediction and model-based glycaemic control

Abstract Background Insulin therapy for glycaemic control (GC) in critically ill patients may improve outcomes by reducing hyperglycaemia and glycaemic variability, which are both associated with increased morbidity and mortality. However, initial positive results have proven difficult to repeat or achieve safely. STAR (Stochastic TARgeted) is a model-based glycaemic control protocol using a risk-based dosing approach. STAR uses a 2D stochastic model to predict distributions of likely future changes in model-based insulin sensitivity (SI) based on its current value, and determines the optimal intervention. Objectives This study investigates the impact of a new 3D stochastic model on the ability to predict more accurate future SI distributions, which would allow more aggressive insulin dosing and improved glycaemic control. Methods The new 3D stochastic model is built using both current SI and its prior variation to predict future SI distribution from 68,629 h of clinical data (819 GC episodes). The 5th–95th percentile range of predicted SI distribution are calculated and compared with the 2D model. Results Results show the 2D model is over-conservative compared to the 3D case for more than 77% of the data, predominantly where SI is stable (|%ΔSI| ≤ 25%). These formerly conservative prediction ranges are now ∼30% narrower with the 3D model, which safely enables more aggressive insulin dosing for these patient hours. In addition, distributions of predicted SI within the 5th–95th percentile range are much closer to the ideal value of 90% for more patients with the 3D model. Conclusions The new 3D model better characterises patient specific metabolic variability and patient specific response to insulin, allowing more optimal insulin dosing to increase performance and safety.

Study protocol of the randomised placebo-controlled GLOBE trial: GLP-1 for bridging of hyperglycaemia during cardiac surgery

IntroductionPerioperative hyperglycaemia is common during cardiac surgery and associated with postoperative complications. Although intensive insulin therapy for glycaemic control can reduce complications, it carries the risk of hypoglycaemia. GLP-1 therapy...

Safety and efficacy of saxagliptin for glycemic control in non-critically ill hospitalized patients

ObjectiveTo evaluate whether saxagliptin is non-inferior to basal-bolus insulin therapy for glycemic control in patients with controlled type 2 diabetes mellitus (T2DM) admitted to hospital with non-critical illnesses.Research design and...

Insulin therapy for glycaemic control in critically ill children

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: Our primary objective is to assess the effects of maintaining stricter glycaemic control using intensive insulin therapy versus conventional insulin therapy on length of stay in PICU and total length of stay in hospital for all paediatric intensive care patients. We will also assess the effects of intensive insulin therapy versus conventional insulin therapy on the following. In‐hospital morbidity and mortality for critically ill paediatric intensive care patients. Length of stay and duration of mechanical ventilation in paediatric intensive care patients. The incidence of nosocomial infection in all paediatric intensive care patients.

Assessment of predictors of insulin therapy in patients with gestational diabetes diagnosed according to the IADPSG criteria.

It is helpful for both diabetologists and obstetricians to identify patients with gestational diabetes who require insulin therapy for glycemic control during pregnancy. The aim of the present study was to assess potential predictors of insulin requirement in patients with gestational diabetes. One hundred thirteen patients with gestational diabetes [mean age 34.2±4.5years; pre-gestational body mass index (BMI), 23.6±6.0kg/m2] were included in this study. The associations between insulin requirement and the following factors were analyzed: clinical maternal characteristics, number of abnormal oral glucose tolerance test (OGTT) values, gestational age at diagnosis, plasma glucose levels measured during the OGTT, glycated hemoglobin (HbA1c) and glycated albumin levels, and serum C-peptide level before breakfast and 1 and 2h after breakfast. Thirty-six patients (32%) required insulin during pregnancy ("insulin group"); the remaining patients were treated with nutrition therapy ("nutrition group"). The insulin group had a higher pre-gestational BMI, higher fasting glucose level, higher area under the curve (AUC) for serum C-peptide level, higher HbA1c level, and a younger gestational age at diagnosis than the nutrition group (p<0.05, all). Logistic regression analysis showed that the pre-gestational BMI, AUC for serum C-peptide level, and the HbA1c level were independent predictors for the insulin group (p<0.05, all). The results suggest that a high insulin resistance and HbA1c level may be associated with insulin requirement in patients with gestational diabetes.

The effect of insulin therapy algorithms on blood glucose levels in patients following cardiac surgery: A systematic review.

A number of insulin infusion algorithms, with varying methods and effects, have been developed to guide the management of postoperative hyperglycemia in critically ill patients. The objective of this study was to investigate the effect of insulin therapy algorithms on blood glucose levels in patients in critical care environments following cardiac surgery. Types of participants: Adult patients aged 18 or older who were admitted to a critical care environment after cardiac surgery and who received insulin therapy for glycemic control during the acute postoperative phase of their admission. Types of intervention: The intervention of interest was continuous intravenous insulin therapy. Types of studies: Experimental study designs including randomized controlled trials, non-randomized controlled trials and controlled before and after studies published in the English language were included in this review. Types of outcomes: Primary outcomes of interest included objective measures of glycemic control and secondary outcomes of interest included the incidence of adverse events. The search aimed to find both published and unpublished studies through electronic databases, reference lists, key reports and the World Wide Web. An extensive search was undertaken for the following databases: Medline, CINAHL, PubMed, Embase, Scopus, the Cochrane Library, Dare, Social Science Index, ProQuest, and MedNar. Databases were searched up to March 2014. All studies selected were assessed by two reviewers independently for methodological quality prior to inclusion in the review using the standardized Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument critical appraisal tool. Any disagreements that arose between the reviewers were resolved through discussion. Quantitative data was extracted from papers included in the review using the standardized data extraction tool from Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument. All results were subject to double data entry. Statistical pooling of the data in meta-analysis was carried out using Review Manager meta-analysis software where possible. Odds Ratios, Relative Risks, Weighted Means Differences and their 95% Confidence Interval were calculated where appropriate. Where statistical pooling was not possible due to the heterogeneity of the studies the findings are presented in narrative form including tables and figures. Thirteen studies were included in the final review. Pooled data demonstrated significantly improved mean blood glucose levels (Weighted Means Differences -27.24, 95% Confidence Interval: -27.77 - -26.72), p < 0.00001 and achievement of target blood glucose levels range (Relative Risks 1.43, 95% Confidence Interval: 1.18 - 1.72), p = 0.0002, among participants who received the paper nomogram continuous intravenous insulin method of glucose control compared to the bolus regime group. Studies that investigated paper nomogram directed continuous intravenous insulin compared to computer calculator directed continuous intravenous insulin demonstrated a statistically significant improved mean blood glucose levels (Weighted Means Differences -23.74, 95% Confidence Interval: -24.45 - -23.02), p <0.00001 and higher percentage of time in which glucose levels were within the target range in the computer calculator group. A significantly lower incidence (p < 0.05) of hyperglycemia was observed in the computerized calculator directed CII group (1.3 ± 1.2%) compared to the paper nomogram CII (6.5 ± 2%). There is evidence of a benefit of continuous insulin infusions for patients following cardiac surgery with the computer calculator CII method achieving optimal glycemic control. The implementation of a computer calculator CII algorithm allows for individualized patient treatment. However, given the limited availability of the computer based algorithm, the implementation of a paper based algorithm would be justified. Future studies to compare the methods of computer calculator directed CII to paper nomogram directed CII should be undertaken using more rigorous research designs such as randomized controlled trials with sufficiently powered sample sizes. Definitions for both hypoglycemia and hyperglycemia should be standardized.

The effect of insulin therapy algorithms on blood glucose levels in patients following cardiac surgery: A systematic review protocol

Review question/objective The objective of this review is to determine the best available evidence related to the effect of insulin therapy algorithms on blood glucose levels in patients in critical care environments following cardiac surgery. More specifically, the review question to be answered is: Among adults within critical care environments who are in the acute postoperative phase (5 days) following cardiac surgery, what is the effect of insulin therapy algorithms for the control of blood glucose levels? Inclusion criteria Types of participants This review will consider studies that include adult patients aged 18 years and over admitted to a critical care unit following cardiac surgery and who received insulin therapy for glycemic control during the acute postoperative phase (five days) of admission. In this review studies that include participants with a known diagnosis of Diabetic Ketoacidosis will be excluded. Types of intervention(s)/phenomena of interest This review will consider studies that evaluate the use of intravenous insulin therapy algorithms to control blood glucose levels in acute postoperative phase patients in critical care environments following cardiac surgery. In this review, studies will be included if they make one of the following comparisons: 1. Intravenous insulin therapy algorithm compared to another insulin therapy algorithm. 2. Intravenous insulin therapy algorithm compared to no treatment. 3. Intravenous insulin therapy algorithm compared to a placebo. In this review, studies that include a Glucose-Insulin-Potassium (GIK) infusion as an intervention or a comparator will be excluded. Types of outcomes This review will consider studies that include the following outcome measures: Primary outcome: •Overall control of blood glucose levels as measured by time to target BGL range, time spent in BGL target range and time above or below target BGL range. Secondary outcome: •Incidence of adverse events, including: - Hypo/hyper glycemia, measured by standard point of care glucometers, arterial blood analysis, or venous blood analysis, with hypoglycemia defined as a BGL reading 7.8mmol/L(140mg/dL).13 - Sternal wound infection, identified by a positive wound culture or a positive wound exudate culture.14 - Mortality rate measured by in-hospital mortality (from day of operation to day of discharge) and/or 30 day mortality.15

Preoperative insulin secretion ability and pancreatic parenchymal thickness as useful parameters for predicting postoperative insulin secretion in patients undergoing pancreaticoduodenectomy

Periampullary malignant neoplasms have been increasing in Japan, mainly in response to an increase in the incidences of pancreatic cancer, and glucose intolerance due to deterioration of insulin secretion is an important problem. We investigated preoperative parameters to predict postoperative insulin secretion and the need for insulin therapy in patients undergoing pancreaticoduodenectomy (PD). Thirty-six patients with malignant neoplasms of periampullary lesions were enrolled. Preoperative pancreatic parenchymal thickness was evaluated by computed tomography. Insulin secretion and glucose tolerance were evaluated by a 75-g oral glucose tolerance test and an intravenous glucagon loading test. The relationships between postoperative insulin secretion and preoperative parameters and the cut-off values for predicting the need for postoperative insulin therapy for glycemic control were investigated. Pancreatic parenchymal thickness and other preoperative parameters, including the increment of serum C-peptide (Δ C-peptide), fasting plasma C-peptide (F-CPR), insulinogenic index (I.I.) and fasting plasma glucose (FPG), were significantly associated with postoperative insulin secretion. Multiple regression analyses revealed that preoperative Δ C-peptide or F-CPR was the most significant determinant of postoperative insulin secretion, followed by pancreatic parenchymal thickness. In the receiver operating characteristic curve, the best preoperative cut-off values for predicting the need for postoperative insulin therapy were a Δ C-peptide of 0.65 ng/mL, a F-CPR of 0.85 ng/mL and a pancreatic parenchymal thickness of 6.0 mm. Both preoperative insulin secretion and pancreatic parenchymal thickness effectively predict postoperative insulin secretion and identify subjects who need postoperative insulin therapy for glycemic control.

Approach to the Patient with New-Onset Diabetes after Transplant (NODAT)

New-onset diabetes after transplantation (NODAT) refers to the occurrence of diabetes in previously nondiabetic persons after organ transplantation. The incidence rates of NODAT vary by organ transplanted and posttransplant interval. The estimated rates at 12 months posttransplant are 20-50% for kidney transplants, 9-21% for liver transplants, and approximately 20% for lung transplants. NODAT is associated with increased risks of graft rejection, infection, cardiovascular disease, and death. Besides the traditional risk factors for type 2 diabetes (age, family history, obesity, and ethnicity), exposure to immunosuppressive agents often precedes the occurrence of NODAT. Identification of risk factors through pretransplant screening is desirable, as is prompt diagnosis and appropriate treatment. NODAT is consistent with type 2 diabetes and responds to the usual antidiabetes agents. However, severe hyperglycemia during the early posttransplant period may necessitate the use of iv insulin infusion. Also, high-dose glucocorticoid therapy for induction of immunosuppression (or treatment of acute rejection) may require the use of insulin therapy for glycemic control. After hospital discharge, close monitoring of blood glucose during the first month and every 3 months for the first year is recommended. Consideration should be given to drug toxicities or interactions when prescribing antidiabetes agents in the posttransplant patient. In addition to hyperglycemia, the control of comorbidities such as dyslipidemia and hypertension needs to be optimized. Future areas of investigation include the development of immunosuppressive regimens with minimal diabetogenic effects, determination of the role of glycemic control on graft survival, and interventions for primary prevention of NODAT.

Changing practice with changing research: results of two UK national surveys of intensive insulin therapy in intensive care patients*

We conducted two telephone surveys of all United Kingdom adult intensive care units in 2007/8 and 2010 to assess practice with regard to intensive insulin therapy for glycaemic control in critically ill patients, and to assess the change in practice following publications in 2008 and 2009 that challenged the evidence for this therapy. Of 243 units that had a written policy for intensive insulin therapy in 2007/8, 232 (96%) still had a policy in 2010. One hundred and six (46%) units had updated their policy in response to new evidence, whereas 126 (54%) stated that it had remained the same. Where intensive care units had changed their policy, we found a significant increase in target limits and a wider target range. Regional variations in practice were also seen. Across seven regions, the percentage of units where the glycaemic control policy had been updated since 2007/8 varied from nil to 78.9%.

Insulin, intracerebral glucose and bedside biochemical monitoring utilizing microdialysis

Following subarachnoid hemorrhage, hyperglycemia is strongly associated with complications and with impaired neurological recovery. Targeted insulin therapy for glycemic control might, on the contrary, have harmful effects by causing too low cerebral glucose levels. The study published by Schlenk and colleagues in the previous issue of Critical Care shows that insulin caused a significant decrease in the interstitial cerebral glucose concentration although the blood glucose level remained unaffected. Since several studies utilizing various analytical techniques have shown that cerebral blood flow and cerebral glucose uptake and metabolism are insulin-independent processes, the observation remains unexplained.

Management of Chronic Pancreatitis

Chronic pancreatitis (CP) is an inflammatory disorder that results in permanent impairment of the glandular anatomy of the pancreas with or without functional abnormalities. The pathogenesis of CP is usually unclear, except in the case of alcohol-induced disease. The most common symptoms of CP are abdominal pain, diarrhea, and weight loss often requiring recurring hospitalization. Over time, pancreatic endocrine and exocrine dysfunction may develop as the disease progresses, and a variety of complications can occur. Among the possible complications are nutrient malabsorption and diabetes mellitus. The treatment of CP is difficult and challenging for every physician. Relieving pain is the first step in treating CP. This symptom needs to be controlled, often with narcotics, which can cause dependence. Diarrhea usually indicates the presence of steatorrhea, which is often treated with a high-calorie, high-protein, and low-fat diet to minimize symptoms of the underlying disease and to promote weight retention or gain. Pancreatic replacement therapy is used to combat maldigestion and malabsorption. Patients with diabetes may need insulin therapy for glycemic control. The use of parenteral nutrition for bowel rest is a standard approach in patients with symptomatic CP. The use of jejunal enteral feeding recently has been evaluated for efficacy in CP patients. The role of pancreatic endotherapy in the management of CP is evolving. Several reports have suggested that endoscopic therapy aimed at decompressing the obstructed pancreatic duct can be associated with pain relief in some patients. Surgery should be considered in patients who fail medical therapy.