Glycemic Control Therapy Research Articles

The Glucoregulatory Benefits of Glucagon-Like Peptide-1 (7-36) Amide Infusion During Intensive Insulin Therapy in Critically Ill Surgical Patients

Intensive insulin therapy for tight glycemic control in critically ill surgical patients has been shown to reduce mortality; however, intensive insulin therapy is associated with iatrogenic hypoglycemia and increased variability of blood glucose levels. The incretin glucagon-like peptide-1 (7-36) amide is both insulinotropic and insulinomimetic and has been suggested as an adjunct to improve glycemic control in critically ill patients. We hypothesized that the addition of continuous infusion of glucagon-like peptide-1 to intensive insulin therapy would result in better glucose control, reduced requirement of exogenous insulin administration, and fewer hypoglycemic events. Prospective, randomized, double-blind, placebo-controlled clinical trial. Surgical or burn ICU. Eighteen patients who required intensive insulin therapy. A 72-hour continuous infusion of either glucagon-like peptide-1 (1.5 pmol/kg/min) or normal saline plus intensive insulin therapy. The glucagon-like peptide-1 cohort (n = 9) and saline cohort (n = 9) were similar in age, Acute Physiology and Chronic Health Evaluation score, and history of diabetes. Blood glucose levels in the glucagon-like peptide-1 group were better controlled with much less variability. The coefficient of variation of blood glucose ranged from 7.2% to 30.4% in the glucagon-like peptide-1 group and from 19.8% to 56.8% in saline group. The mean blood glucose coefficient of variation for the glucagon-like peptide-1 and saline groups was 18.0% ± 2.7% and 30.3% ± 4.0% (p = 0.010), respectively. The 72-hour average insulin infusion rates were 3.37 ± 0.61 and 4.57 ± 1.18 U/hr (p = not significant). The incidents of hypoglycemia (≤ 2.78 mmol/L) in both groups were low (one in the glucagon-like peptide-1 group, three in the saline group). Glucagon-like peptide-1 (7-36) amide is a safe and efficacious form of adjunct therapy in patients with hyperglycemia in the surgical ICU setting. Improved stability of blood glucose is a favorable outcome, which enhances the safety of intensive insulin therapy. Larger studies of this potentially valuable therapy for glycemic control in the ICU are justified.

Clinical Impact of Sample Interference on Intensive Insulin Therapy in Severely Burned Patients

Severely burned patients benefit from intensive insulin therapy (IIT) for tight glycemic control (TGC). The authors evaluated the clinical impact of automatic correction of hematocrit and ascorbic acid interference for bedside glucose monitoring performance in critically ill burn patients. The performance of two point-of-care glucose monitoring systems (GMSs): 1) GMS1, an autocorrecting device, and 2) GMS2, a noncorrecting device were compared. Sixty remnant arterial blood samples were collected in a prospective observational study to evaluate hematocrit and ascorbic acid effects on GMS1 vs GMS2 accuracy paired against a plasma glucose reference. Next, we enrolled 12 patients in a pilot randomized controlled trial. Patients were randomized 1:1 to receive IIT targeting a TGC interval of 111 to 151 mg/dl and guided by either GMS1 or GMS2. GMS bias, mean insulin rate, and glycemic variability were calculated. In the prospective study, GMS1 results were similar to plasma glucose results (mean bias, -0.75 [4.0] mg/dl; n = 60; P = .214). GMS2 results significantly differed from paired plasma glucose results (mean bias, -5.66 [18.7] mg/dl; n = 60; P = .048). Ascorbic acid therapy elicited significant GMS2 performance bias (29.2 [27.2]; P < .001). Randomized controlled trial results reported lower mean bias (P < .001), glycemic variability (P < .05), mean insulin rate (P < .001), and frequency of hypoglycemia (P < .001) in the GMS1 group than in the GMS2 group. Anemia and high-dose ascorbic acid therapy negatively impact GMS accuracy and TGC in burn patients. Automatic correction of confounding factors improves glycemic control. Further studies are warranted to determine outcomes associated with accurate glucose monitoring during IIT.

Age-Specific Effectiveness and Safety of Newly Initiated Insulin Therapy in Japanese Patients with Uncontrolled Diabetes

IntroductionOne consequence of population aging is an increase in the number of elderly patients with diabetes mellitus. These elderly patients often experience atherosclerotic complications, and diabetes prevention and management are strongly desired to promote health and reduce the financial burden on the healthcare system. In this study, we conducted an age-specific evaluation of the effectiveness and safety of comprehensive management with newly initiated insulin therapy over a 1-year period in elderly (≥65 years) compared with non-elderly (≤64 years) Japanese patients with uncontrolled diabetes [glycated hemoglobin (HbA1c) ≥ 8% for ≥ 3 months].MethodsThis retrospective single-center cohort study was conducted in Japan. We screened all outpatients with diabetes mellitus who visited the clinic for diabetes treatment between December 2006 and March 2011. Of these patients, 132 with type 2 diabetes who were newly initiated on insulin therapy for continued poor glycemic control and undergoing comprehensive management through self-monitoring of blood glucose (SMBG) were registered to the study.ResultsThirty-two of 132 registered patients were excluded from the analysis. Among the 100 patients (67 non-elderly, 33 elderly) included in the analysis, median age and proportion of male patients was 69 years and 66.7%, respectively, among the elderly, and 52 years and 68.7%, respectively, among the non-elderly patients. After initiation of insulin therapy, median HbA1c levels improved from 9.6% to 7.2% in elderly patients, and from 10.8% to 7.3% in non-elderly patients at baseline and 12 months. Severe hypoglycemic events were not observed in either patient group; however, uncontrolled diabetes was ongoing in 31.8% of non-elderly and 15.4% of elderly patients, and obesity was associated with poor glycemic control.ConclusionOur results indicate that the effectiveness and safety of newly initiated insulin therapy are similar between elderly and non-elderly Japanese patients with uncontrolled diabetes, and highlight the importance of comprehensive management using SMBG to avoid hypoglycemia. Better glycemic control supported by adequate intensive management is required to improve mortality and morbidity.Electronic supplementary materialThe online version of this article (doi:10.1007/s13300-013-0049-4) contains supplementary material, which is available to authorized users.

Favorable Effects of Insulin Sensitizers Pertinent to Peripheral Arterial Disease in Type 2 Diabetes

OBJECTIVEThe aim of this manuscript was to report the risk of incident peripheral arterial disease (PAD) in a large randomized clinical trial that enrolled participants with stable coronary artery disease and type 2 diabetes and compare the risk between assigned treatment arms.RESEARCH DESIGN AND METHODSThe Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial randomly assigned participants to insulin sensitization (IS) therapy versus insulin-providing (IP) therapy for glycemic control. Results showed similar 5-year mortality in the two glycemic treatment arms. In secondary analyses reported here, we examine the effects of treatment assignment on the incidence of PAD. A total of 1,479 BARI 2D participants with normal ankle-brachial index (ABI) (0.91–1.30) were eligible for analysis. The following PAD-related outcomes are evaluated in this article: new low ABI ≤0.9, a lower-extremity revascularization, lower-extremity amputation, and a composite of the three outcomes.RESULTSDuring an average 4.6 years of follow-up, 303 participants experienced one or more of the outcomes listed above. Incidence of the composite outcome was significantly lower among participants assigned to IS therapy than those assigned to IP therapy (16.9 vs. 24.1%; P < 0.001). The difference was significant in time-to-event analysis (hazard ratio 0.66 [95% CI 0.51–0.83], P < 0.001) and remained significant after adjustment for in-trial HbA1c (0.76 [0.59–0.96], P = 0.02).CONCLUSIONSIn participants with type 2 diabetes who are free from PAD, a glycemic control strategy of insulin sensitization may be the preferred therapeutic strategy to reduce the incidence of PAD and subsequent outcomes.

Impact of Glycemic Control Strategies on the Progression of Diabetic Peripheral Neuropathy in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) Cohort

OBJECTIVEThe Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial demonstrated similar long-term clinical effectiveness of insulin-sensitizing (IS) versus insulin-providing (IP) treatments for type 2 diabetes on cardiovascular outcomes in a cohort with documented coronary artery disease. We evaluated the effects of randomized glycemic control strategy (IS vs. IP) on the prevalence and incidence of diabetic peripheral neuropathy (DPN).RESEARCH DESIGN AND METHODSDPN (defined as Michigan Neuropathy Screening Instrument [MNSI] clinical examination score >2) was assessed at baseline and yearly for 4 years. DPN prevalence and incidence were compared by intention-to-treat modeling by logistic generalized estimating equation models for prevalence and Kaplan-Meier estimates and Cox regression models for incidence rates.RESULTSResults are reported for 2,159 BARI 2D participants (70% males) with valid baseline and at least one follow-up MNSI score (mean age 62 ± 9 years, mean HbA1c 7.7 ± 1.6%, diabetes duration 10 ± 9 years). There were no differences in the prevalence of DPN between the IS and the IP groups throughout the 4 years of follow-up. In 1,075 BARI 2D participants with no DPN at baseline, the 4-year cumulative incidence rate of DPN was significantly lower in the IS (66%) than in the IP (72%) strategy group (P = 0.02), which remained significant after adjusting for the in-trial HbA1c (P = 0.04). In subgroup analyses, IS strategy had a greater benefit in men (hazard ratio 0.75 [99% CI 0.58–0.99], P < 0.01).CONCLUSIONSAmong patients with type 2 diabetes followed for up to 4 years during BARI 2D, a glycemic control therapy with IS significantly reduced the incidence of DPN compared with IP therapy and may add further benefit for men.

In-Hospital Management of Diabetes.

In-Hospital Management of Diabetes.

Technical Challenges and Clinical Outcomes of Using a Closed-Loop Glycemic Control System in the Hospital

According to large randomized trials, results suggest that maintaining normoglycemia postoperatively through tight glycemic control (TGC) and intensive insulin therapy (IIT) can improve surgical outcomes as well as reduce mortality and morbidity in critically ill patients. 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 show negative results for TGC is the high incidence of hypoglycemia induced by IIT. This could not be prevented because there is no reliable technique that can 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 intensive care unit (ICU) will probably help avoid hypoglycemia in these situations. The STG closed-loop glycemic control system was introduced to our department to be used and evaluated for strict serum glucose control with no hypoglycemic episodes during IIT in the surgical ICU, to reduce the workload of ICU nurses, and to decrease incidents related to the management of blood glucose levels according to manual conventional venous infusion insulin therapy. The goal of our team was to use the STG closed-loop glycemic control system for perioperative TGC in surgical patients to solve the complications of IIT and reduce risk of hypoglycemia. The challenge at our hospital demonstrated that the STG closed-loop glycemic control system can be expected to achieve TGC with no occurrence of hypoglycemia induced by IIT after surgery.

Optimal blood glucose control in severely burned patients: a long way to go, but one step closer

Over the past years there has been a significant decrease in mortality and morbidity in patients suffering from severe burns due to improved burn wound management and approaches in critical care. Survival is no longer the exception, but unfortunately death still occurs. One of the key elements concerning state-of-the-art burn care is blood glucose control and insulin therapy; it is well known that burn-induced hyperglycaemia is associated with adverse clinical outcomes. However, controversy for insulin therapy and tight glycaemic control in critically ill and burn patients exists. The increased incidence of hypoglycaemia is the dominant argument against this treatment, because hypoglycaemia is also associated with an increased risk for death in critically ill patients. Taking all current data together, insulin therapy appears both a friend and a foe in the treatment of ICU patients. In order to overcome the limits of tight glycaemic control resulting from hypoglycaemic episodes, current efforts have been directed towards the development of protocols allowing for implementation of clinically feasible and safe guidelines. Among the strategies addressing this problem are closed loop techniques, which are supported by studies demonstrating their capability of exerting tight glycaemic control without the risk of developing hypoglycaemic episodes. Although closed loop techniques have become readily available, we require further evidence to ensure their safety in various ICU environments, notably in ICUs dealing with burn patients. Nonetheless, it is important to emphasise that glycaemic control and adequate insulin therapy are crucial factors for the final outcome (survival) and require our attention.

Responses to glycemic control therapy according to age, gender, level of adiposity, and duration of diabetes in type 2 diabetic patients

It is established that glycemic control measures involving diet and oral medication reduces glycated hemoglobin concentration (HbA1c) in type 2 diabetic patients. To determine whether glycemic levels after diabetic treatment is affected by age, gender, obesity, and diabetic duration in type 2 diabetic patients. A total of 52 type 2 diabetic patients participated in a 12-week diabetic management therapy involving oral medication (metformin) and lifestyle intervention (diet). We compared the glycated hemoglobin reduction after treatment between the elderly and non-elderly; males and females; obese and non-obese; and newly diagnosed and long-standing diabetics. After the diabetic treatment, participants' mean HbA1c level indicated a reduction of 1.1 ± 1.31%, weight loss of 2.46 ± 1.79 kg, and BMI reduction of 0.94 ± 0.69 kg/m 2 . A total of 23 (44.2%) patients had an acceptable HbA1c level of <6.5%. Significantly greater HbA1c reduction was observed in non-elderly, non-overweight/obese, and newly diagnosed diabetic patients compared to the elderly, overweight/obese, and long-standing diabetic patients respectively (P < 0.05 or P < 0.01). HbA1c reduction did not indicate sex differences. The present findings suggest lower responses to glycemic control therapy in elderly, overweight/obese, and long-standing diabetic patients when compared to the non-elderly, non-overweight/obese, and newly diagnosed diabetic patients. It is recommended that treatment criteria for type 2 diabetes should account for the age, level of adiposity, and diabetic duration of the patient in order to make optimal therapeutic decisions for the treatment of diabetes mellitus in adults.

Predictors of exercise intervention dropout in sedentary individuals with type 2 diabetes.

While the benefits of exercise in people with type 2 diabetes mellitus is well-known, knowledge of factors associated with dropouts of exercise intervention trials is limited. Examining clinical and psychosocial factors related to dropout is a necessary first step to developing an effective exercise program. We examined the predictors of a randomized trial of exercise intervention dropout among sedentary individuals with type 2 diabetes mellitus. Participants (n = 140) were randomly allocated to a 6-month, 3 times per week exercise intervention, or to a control group. Psychological well-being was assessed using a 36-item Short Form Health Survey, the Profile of Mood States questionnaire, and an Exercise Self-Efficacy scale. Total percent body fat and abdominal subcutaneous and visceral fat were measured. Insulin resistance was assessed with the quantitative insulin sensitivity check index. Fitness was expressed as VO2 peak during treadmill testing. There were significantly more dropouts in the exercise group than in the control group (r = 20.220; P < .01). Those who dropped out of the study had less exercise self-efficacy for lifting weight (r = 0.187; P < .05). Physiological parameters associated with dropouts included low fitness (r = 0.255; P < .01), higher insulin resistance (r = 0.167; P < .05), higher total percent body fat (r = 20.213; P < .05), and higher subcutaneous abdominal fat (r = 20.220; P < .05). In the multiple logistic regression model, exercise group assignment, insulin resistance, and fitness remained significant predictors of dropouts. Special attention to the sedentary individuals with high insulin resistance and poor fitness should be incorporated into implementing exercise programs to improve diabetes treatment.

Gestational diabetes: maternal weight gain in relation to fetal growth, treatment modality, BMI and glycemic control

Objectives: We sought to determine the impact of maternal weight gain on fetal growth in gestational diabetes (GDM) in relation to treatment modality, body mass index (BMI) and glycemic control. Study design: Two thousand four hundred fifty-four GDMs were evaluated. Obesity was defined as BMI >29; good glycemic control ≤100 mg/dl; maternal age < and >30 years; parity ±1; large for gestational age (LGA) >90th percentile and small for gestational age (SGA) <10th percentile. Results: SGA rates were similar in all groups. Obese/overweight diet-treated women in glycemic control showed a four-fold higher rate of LGA compared to insulin-treated women. A 36-lb weight gain in insulin-treated patients had a six-fold higher risk. In poor glycemic control, LGA rates were higher in all BMI/weight gain categories. Logistic regressions for LGA/SGA revealed that level of glycemia, weight gain, parity, obesity and treatment (for LGA only) were significant. Conclusion: Different thresholds used for different maternal BMI categories in addition to the achievement of glycemic control and pharmacological therapy will enhance pregnancy outcome.

Association Between Serum Endogenous Secretory Receptor for Advanced Glycation End Products and Risk of Type 2 Diabetes Mellitus with Combined Depression in the Chinese Population

The role of the endogenous secretory receptor for advanced glycation end products (esRAGE) in depression of diabetes patients and its clinical significance are unclear. This study investigated the role of serum esRAGE in patients with type 2 diabetes mellitus with depression in the Chinese population. One hundred nineteen hospitalized patients with type 2 diabetes were recruited at Fujian Provincial Hospital (Fuzhou, China) from February 2010 to January 2011. All selected subjects were assessed with the Hamilton Rating Scale for Depression (HAMD). Among them, 71 patients with both type 2 diabetes and depression were included. All selected subjects were examined for the following: esRAGE concentration, glycosylated hemoglobin (HbA1c), blood lipids, C-reactive protein, trace of albumin in urine, and carotid artery intima-media thickness (IMT). Association between serum esRAGE levels and risk of type 2 diabetes mellitus with depression was also analyzed. There were statistically significant differences in gender, age, body mass index, waist circumference, and treatment methods between the group with depression and the group without depression (P<0.05). Multiple linear regression analysis showed that HAMD scores were negatively correlated with esRAGE levels (standard regression coefficient -0.270, P<0.01). HAMD-17 scores were positively correlated with IMT (standard regression coefficient 0.183, P<0.05) and with HbA1c (standard regression coefficient 0.314, P<0.01). Female gender, younger age, obesity, poor glycemic control, complications, and insulin therapy are all risk factors of type 2 diabetes mellitus with combined depression in the Chinese population. Inflammation and atherosclerosis play an important role in the pathogenesis of depression. esRAGE is a protective factor of depression among patients who have type 2 diabetes.

Comorbid Diabetes and the Risk of Progressive Chronic Kidney Disease in HIV-Infected Adults

Approximately, 15% of HIV-infected individuals have comorbid diabetes. Studies suggest that HIV and diabetes have an additive effect on chronic kidney disease (CKD) progression; however, this observation may be confounded by differences in traditional CKD risk factors. We studied a national cohort of HIV-infected and matched HIV-uninfected individuals who received care through the Veterans Healthcare Administration. Subjects were divided into 4 groups based on baseline HIV and diabetes status, and the rate of progression to an estimated glomerular filtration rate (eGFR) <45 mL/min/1.73m was compared using Cox-proportional hazards modeling to adjust for CKD risk factors. About 31,072 veterans with baseline eGFR ≥45 mL/min/1.73m (10,626 with HIV only, 5088 with diabetes only, and 1796 with both) were followed for a median of 5 years. Mean baseline eGFR was 94 mL/min/1.73m, and 7% progressed to an eGFR < 45 mL/min/1.73m. Compared with those without HIV or diabetes, the relative rate of progression was increased in individuals with diabetes only [adjusted hazard ratio (HR) 2.48; 95% confidence interval (CI): 2.19 to 2.80], HIV only [HR: 2.80, 95% CI: 2.50 to 3.15], and both HIV and diabetes [HR: 4.47, 95% CI: 3.87 to 5.17]. Compared with patients with only HIV or diabetes, patients with both diagnoses are at significantly increased risk of progressive CKD even after adjusting for traditional CKD risk factors. Future studies should evaluate the relative contribution of complex comorbidities and accompanying polypharmacy to the risk of CKD in HIV-infected individuals and prospectively investigate the use of cART, glycemic control, and adjunctive therapy to delay CKD progression.

Cistitis y pielitis enfisematosas: otra complicación en el paciente diabético

Emphysematous cystitis and pyelitis: another complication in diabetic patients Emphysematous cystitis is a rare complication that is often associated with different risk factors mainly diabetes mellitus. Presents nonspecific clinical bladder irritation and abdominal pain usually revealed as a radiological finding. Abdominal computed tomography is the method of choice for diagnosis. Treatment requires strict glycemic control, early and intensive antibiotic therapy and urinary drainage that solve most cases. It can be complicated to affect any part of the urinary system which worsens the prognosis.

Successful Use of Omalizumab in an Inadequately Controlled Type 2 Diabetic Patient With Severe Insulin Allergy

A 62-year-old male patient with type 2 diabetes for 16 years developed a severe anaphylactic shock upon administration of intravenous, short-acting regular insulin. The patient’s medical history comprised allergic reactions to an unknown agent as a child as well as injection site reactions, urticaria, and dyspnea to subcutaneous NPH-insulin injections. The diagnostic work-up revealed a type 1 IgE-mediated insulin allergy by positive skin prick tests and elevated specific IgE levels against insulins of human, porcine, and bovine origin by ImmunoCAP-Assay. The insulins used were free of proinsulin. Skin prick tests with all solvents and additives of the insulin solutions were negative. Genetic sequencing of the patient’s insulin molecule revealed a normal insulin gene. Because of unsatisfactory glycemic control, specific desensitization (1) and maintenance therapy with insulin detemir was performed, but improvement of urticaria and …

The effects of precision, haematocrit, pH and oxygen tension on point-of-care glucose measurement in critically ill patients: a prospective study

Critical care glycaemic control protocols commonly have treatment adjustment (target) ranges spanning ≤2 mmol/L. These require precise point-of-care glucose measurement, unaffected by other variables, to avoid measurement errors increasing glycaemic variability and hypoglycaemic episodes (both strongly associated with mortality in critically ill patients). A prospective 206 intensive care patient study was carried out. Arterial glucose concentrations were measured in duplicate using three point-of-care instruments (MediSense Precision PCχ, HemoCue DM and Radiometer 700), a central laboratory instrument (Siemens ADVIA), and in whole blood and plasma using the Yellow Springs Instruments 2300 instrument. Coefficients of variation for the MediSense, HemoCue, Radiometer and Siemens instruments were 5.1%, 2.5%, 2.1% and 2.3%, respectively. Compared with the Siemens instrument, the bias (95% limits of agreement) for the MediSense, HemoCue and Radiometer instruments were 0.0 (-1.4 to 1.4), 0.0 (-1.2 to 1.1) and -0.2 (-0.9 to 0.6) mmol/L, respectively. The whole blood-plasma glucose concentration difference was significantly affected by the haematocrit. MediSense and HemoCue instrument performances were substantially affected by haematocrit. MediSense instrument performance was also affected by pH and PaO(2). Radiometer instrument performance was not affected by haematocrit, pH or PaO(2). The MediSense instrument was too imprecise for use in critically ill patients. The haematocrit range seen is too great to allow fixed-factor conversion between whole blood and plasma values, substantially affecting the accuracy of both glucose meters. However, the Radiometer instrument was unaffected by the haematocrit, pH or pO(2), resulting in a performance equivalent to the laboratory method. Instrument performance differences may therefore partially explain the differing results of tight glycaemic control therapy trials.

“Medioglycaemia”: A new concept in glycaemic control in intensive care (ICU) units?

Introduction: Critically ill patients can experience stress-induced hyperglycaemia. Glycaemic control therapy (GCT) is administered to control patients’ blood glycaemic levels and reduce the incidence of infection, myocardial infarctions and organ failure. However, there are many factors influencing the effectiveness of glycaemic control for patients. This investigation aimed to review the method of Glycaemic Control Therapy (GCT) used in two hospital settings, to assess the effectiveness of glycaemic control on patients’ blood glycaemic levels and examine any barriers that may be in place. Method: A retnrospective audit was carried out on patients’ case notes in Intensive Care Units (ICU) within the East Midlands, UK. This method prevents the study outcomes being swayed because GCT has already taken place. To reduce selection bias the most recent available case notes were selected. All the patients who were admitted to these adult ICU’s between March and April 2010 had their case notes examined, those who were administered GCT were included in the study, this involved 79 from Hospital A and 50 from Hospital B. The patients’ notes were retrospectively audited. Results: Different glycaemic control protocols were being implemented in each hospital, despite both belonging to the same ICU network. In most incidences, regardless of age, diabetes status or diagnosis, patients were administered the same sliding scale insulin (SSI). It was also found that GCT commenced for 41.9% (n = 52) of ICU patients (across both Hospitals) when glycaemic levels were below the established threshold of 10mmol/L. Additionally, a new glycaemic range has been discovered, where 88.3% (n = 113) of patients (across both Hospitals) receiving GCT were not controlled in hypoglycaemia, normoglycaemia or hyperglycaemia. They had mean blood glycaemic levels maintained between 5.6 - 9.9 mmol/L, now being described as medioglycaemia. Conclusions: The majority of patients receiving GCT were controlled in medioglycaemia and therefore a new comprehensive guideline needs to be developed incorporating this new range. Recommendations also need to be established to adapt the titration regimen to individual patients, to improve the effectiveness and safety of glycaemic control.

Eficacia y seguridad del control de glucemia guiado por objetivo y dirigido por el personal de enfermería en una unidad de cuidados intensivos: un estudio prospectivo observacional

Objectiveto evaluate the effectiveness and safety of a nurse-led blood glucose control protocol in a medical ICU. Methoda descriptive, prospective study was carried out for a period of 13 months. All blood glucose values from patients on insulin therapy for intensive glycemic control were recorded daily. ResultsA total of 12,677 blood glucose determinations were performed on the 69 patients under glycemic control; 57.9% of the determinations had predetermined study target values for blood glucose (100-140mg/dl) and 68.8% of the determinations had physiological blood glucose values (80-140mg/dl); no values under 40mg/dl were obtained, and only 0.2% were between 40-60mg/dl. ConclusionsFor an adequate blood glucose control using intensive insulin therapy, individual management of insulin infusion regimen is essential, adjusted to the characteristics of each patient. A nurse-led intervention has allowed better results to be obtained in comparison with other studies in which different protocols for insulin infusion are used.

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.

Comprehensive diabetes cardiovascular treatment = sugar + blood pressure + lipids

Comprehensive diabetes cardiovascular treatment = sugar + blood pressure + lipids