Tight Blood Sugar Control Research Articles

Adherence to A Diabetic Care Plan Provides Better Glycemic Control in Ambulatory Patients With Type 2 Diabetes

Tight control of blood sugar improves the outcomes for diabetic patients, but it can only be achieved by adhering to a well-organized care plan. To evaluate the effect of a diabetes care plan with reinforcement of glycemic control in diabetic patients, 98 ambulatory patients with type 2 diabetes who visited our diabetes clinic every 3-4 months and who completed four education courses given by certified diabetes educators within 3 months after the first visit, were defined as the Intervention group. A total of 82 patients fulfilling the inclusion criteria for the Intervention group but who missed at least half of the diabetes education sessions were selected as controls. Both groups had comparable mean hemoglobin A1c (HbA1c) levels at baseline, which decreased significantly at 3 months and were maintained at approximately constant levels at intervals for up to 1 year. The HbA1c decrement in the Intervention group was significantly greater than that in the Control group over the 1-year follow-up period (HbA1c change: -2.5 +/- 1.8% vs. -1.1 +/- 1.7%, p < 0.01). The maximal HbA1c decrement occurred during the first 3 months, and accounted for 95.6% and 94.6% of the total HbA1c decrements in the Intervention and Control groups, respectively. In the multiple regression model, after adjustment for age, body mass index, and duration of diabetes, the Intervention group may still have a 12.6% improvement in HbA1c from their original value to the end of 1 year treatment compared with the Control group (p < 0.05). Diabetes care, with reinforcement from certified diabetes educators, significantly improved and maintained the effects on glycemic control in ambulatory patients with type 2 diabetes.

Uric Acid Levels Increase Risk for New-Onset Kidney Disease

Despite our best efforts, the past decade has seen little progress in the treatment of chronic kidney disease (CKD). The mainstay of therapy continues to be controlling BP, blocking the renin-angiotensin system, and, for the patient with diabetes, tight control of blood sugar. Even with optimal

Current status of tight blood sugar control

This review describes the current status and the clinical data related to the effects of tight glucose control in critically ill patients. In contrast to decreases in mortality and morbidity reported in one study in which insulin rate was titrated to keep blood glucose between 80 and 110 mg/dL, the benefits were not confirmed in multicenter prospective studies. Retrospective data found an association between a mean blood glucose level below 140 to 150 mg/dL and improved outcome. Currently unanswered issues include the optimal target for blood glucose, effects of blood glucose variability, hazards of hypoglycemia, and potential influence of the underlying disorder on the effects of tight glucose control. Therefore, recommendations regarding practical aspects of tight glucose control by intensive insulin therapy cannot be supported by currently available data. An intermediate target level for blood glucose of 140 to 180 mg/dL seems associated with the lowest risk-to-benefit ratio.

Application of Liquid Chromatography–Mass Spectrometry Technology for Early Detection of Microalbuminuria in Patients with Kidney Disease

Proteinuria is an early and sensitive marker of renal damage in many forms of chronic kidney disease. In diabetes mellitus, mild albuminuria occurs early in the course of renal damage, and this microalbuminuria, defined as urinary albumin excretion of 30–300 mg/day (∼20–200 μg/min), is the best noninvasive predictor of subsequent clinical diabetic nephropathy. Without proper treatment, early diabetic kidney damage progresses to end-stage kidney failure in 5–7 years. With early detection, however, the onset of kidney disease can be slowed, halted, and in some cases reversed through treatment with drugs such as inhibitors of angiotensin-converting enzyme and blockers of angiotensin-2 receptor, particularly if drug treatments is combined with tight blood sugar control and, possibly, decreased protein intake (1)(2). Therefore, strong interest is directed toward detecting patients at risk of diabetic nephropathy as early as possible (3). Current microalbuminuria assays use various immunochemical methods (4). These assays may lead to underestimation of albuminuria in some patients, possibly contributing to delayed diagnosis of early diabetic nephropathy, as indicated by data generated with a recently developed, FDA-cleared size-exclusion HPLC with ultraviolet detection (SEC-HPLC-UV) method (Accumin™, AusAm Biotechnologies). Urine sample analysis with this assay has yielded consistently higher albumin concentrations than immunoassays (5). In one study, microalbuminuria was detected by SEC-HPLC-UV in 53% of urine samples from diabetic patients that were normalbuminic according to an immunochemical method (6). In another study, the SEC-HPLC-UV method was reported to detect microalbuminuria 1–12 years earlier than widely used commercial tests (7). It has been hypothesized that the higher values obtained with the SEC-HPLC-UV assay are attributable to detection of modified forms of albumin. These redox and glycation modifications of the albumin do not change the size of the albumin markedly, and thus with the SEC-HPLC-UV method they are detected under the same peak as …

Porphyria syndrome associated with diabetic nephrosclerosis and erythropoietin

The porphyrias are inherited or acquired metabolic disorders caused by a partial deficiency in one of the enzymes of the heme biosynthetic pathway. Eight enzymes are utilized in the synthesis of heme. An enzyme defect in one of the last seven enzymes will result in one of the seven different forms of porphyria, some of which have similar signs and symptoms. This article describes six diabetic, azotemic patients with no prior history of porphyria, who developed a syndrome similar to acute intermittent porphyria after initiation of treatment with erythropoietin. One of the patients developed the syndrome predialysis, whereas the remaining patients were on maintenance hemodialysis. The symptoms varied but all resolved when erythropoietin was discontinued and reappeared in four cases when erythropoietin was restarted. In all of the patients, the enzyme aminolevulinic acid-dehydratase (ALA-D) was low and the uroporphyrinogen synthase was normal. This enzyme abnormality suggests an acquired form of delta-aminolevulinic acid dehydratase porphyria (ADP). Lead toxicity, succinylacetone, and zinc deficiency are known to depress ALA-D, but these conditions were not present. The development of the acute porphyria syndrome while the patients were receiving pharmacological doses of erythropoietin, which resolved when the drug was stopped, suggests that by stimulating heme synthesis, erythropoietin may unmask an enzyme deficiency resulting in the clinical expression of ADP. The patients responded favorably to a regimen that included discontinuation of erythropoietin, tight blood sugar control, maintaining the hematocrit above 30%, and a KT/V, a measure of dialysis adequacy, of 1.5 in the hemodialysis group. Plasmapheresis accelerated the recovery when used in two patients.

Diabetes Management at the End of Life

Tight glycemic control has become the standard of care for prevention of the long-term side effects of diabetes mellitus. When individuals with diabetes approach the end of life from advanced cancer or another chronic illness, they often become anorexic. The result is an increased risk for hypoglycemic episodes. It is appropriate to shift the goal of therapy from tight control of blood sugar to maintaining comfort and enhancing quality of life.

Insulin Analogs Revisited

Insulin analogs have largely replaced conventional insulin preparations and extensive clinical studies have confirmed the beneficial action profile of these artificial insulin molecules. Tight blood sugar control is a major goal of intensified insulin therapy and this can be obtained much more efficiently when using insulin analogs. Currently, three rapidacting insulin analogs are in clinical use based on either a change of the amino acid sequence (insulin lispro) or exchanges of one (insulin aspart) or two (insulin glulisine) amino acids. Insulin glargine was the first long-acting insulin analog with a well documented low risk of nocturnal hypoglycemia. Insulin detemir is the most recent insulin analog with a longacting profile based on esterification with a fatty acid. For all insulin analogs safety considerations are mandatory and must take into account both the IGF-I and the insulin receptor. Enhanced mitogenic activity and a tumorigenic potential of an insulin analog may involve increased IGF-I receptor signaling and/or sustained insulin receptor activation. Both insulin and IGF-I receptors are involved in the regulation of tumor cell growth. Further, insulin/IGF-hybrid receptors are abundant in these cells and additional studies will be needed to assess the role of these receptors in the long-term action profile and safety of insulin analogs. Keywords: Insulin analogs, insulin receptor, IGF-I receptor, mitogenic signaling, hybrid receptors, tumor cells

Bioecological control of organ failure: The role of enteral nutrition, probiotics and synbiotics

Surgical and medical emergencies, such as myocardial infarction, stroke, severe pancreatitis, trauma and burns, but also advanced medical and surgical treatments, from extensive surgical operations to stem cell transplantations, are associated with an unacceptably high morbidity and mortality. The most common cause is sepsis which, despite all advances in pharmaceutical medicine, is steadily increasing. Sepsis is mainly seen in elderly patients and patients with a malfunctioning innate immune system and subsequent elevated inflammatory response. In the past, multiple attempts have been made to control sepsis and subsequent organ failure, but with no or limited success, using branched chain amino acids, glutamine, growth hormone, insulin, insulin-like growth factor 1, various vitamins, as well as combinations of nutrients, including so-called immunoenhancing nutrition formulae. Aggressive perioperative enteral nutrition, tight control of blood sugar, supplementation of antioxidants, plant fibres and lactic...

New pathways and current concepts in intensive care medicine--a summary of important articles of the last month

One of the most outstanding critical care concepts of the last month is the definition of 5 therapy strategies by the Society of Critical Care for treatment of patients in septic shock. These strategies are: Low tidal volume of 6 ml/kg(-1) body weight in patients with ARDS, early goal-directed therapy, activated protein C therapy, moderate-dose corticosteroids, and tight control of blood sugar. Following further review of the main critical care medicine related journals for strategies to reduce mortality, the non-invasive ventilation is worthwhile mentioning. Moreover, this review summarizes articles on the topics of: Low-dose dopamine does not prevent acute renal insufficiency, increase of mortality is not related to albumin infusion, subglottic suctioning prevents early onset of ventilator associated pneumonia, prone position in ARDS patients has no influence on mortality, the safest site for central venous catheterization, and pulmonary-artery catheter directed therapy has no influence on mortality of high-risk surgical patients.

Drug therapy of diabetes in the elderly

The prevalence of type 2 diabetes mellitus is increasing in the elderly. Although type 1 diabetic patients are living longer, over 95% of elderly people affected with diabetes have type 2 diabetes. This segment of the population, comprising men and women older than 65 years of age, is more likely to develop coexisting illnesses predisposing to the development of diabetes and complicating its management. In addition to changes in lifestyle, inherent age-related changes in carbohydrate metabolism contribute to the development of type 2 diabetes in old age. The long-term outcome of tight blood sugar control in the elderly is not known. Nevertheless the principles of management of type 2 diabetes in the elderly are essentially the same as in young- or middle-aged diabetic patients. Lifestyle modifications remain the cornerstone of medical therapy. When diet and exercise fail to achieve proper glycemic control, oral pharmacologic therapy and/or insulin therapy is indicated. The recently available oral glucose lowering agents in the market along with the newer types of insulin can be used in elderly diabetic patients. The effect of aging on metabolism and drug elimination kinetics must, however, be taken into consideration. In particular, it should be borne in mind that the risk of hypoglycemia is more deleterious in the elderly and should be avoided. In this review, the various pharmacologic agents available for the management of diabetes will be reviewed and some pertinent clinical guidelines will be suggested.

Reducing mortality in sepsis: new directions

Considerable progress has been made in the past few years in the development of therapeutic interventions that can reduce mortality in sepsis. However, encouraging physicians to put the results of new studies into practice is not always simple. A roundtable was thus convened to provide guidance for clinicians on the integration and implementation of new interventions into the intensive care unit (ICU). Five topics were selected that have been shown in randomized, controlled trials to reduce mortality: limiting the tidal volume in acute lung injury or acute respiratory distress syndrome, early goal-directed therapy, use of drotrecogin alfa (activated), use of moderate doses of steroids, and tight control of blood sugar. One of the principal investigators for each study was invited to participate in the roundtable. The discussions and questions that followed the presentation of data by each panel member enabled a consensus recommendation to be derived regarding when each intervention should be used. Each new intervention has a place in the management of patients with sepsis. Furthermore, and importantly, the therapies are not mutually exclusive; many patients will need a combination of several approaches – an 'ICU package'. The present article provides guidelines from experts in the field on optimal patient selection and timing for each intervention, and provides advice on how to integrate new therapies into ICU practice, including protocol development, so that mortality rates from this disease process can be reduced.

Recent developments in pancreatic transplantation

Summary At this moment there are more than 10,000 pancreases transplanted into those with diabetes mellitus worldwide. The introduction of new immunosuppressants and refined technical procedures have resulted in a survival of 90% of the grafts and patients. In most cases a simultaneous kidney transplant is performed in patients requiring haemodialysis or peritoneal dialysis. This results in a normal daily life without insulin injections or dialysis treatment. A successful pancreas transplantation in combination with a kidney transplantation can protect the transplanted kidney from diabetic changes. The day in, day out, quality of life of these patients is dramatically increased. The longest pancreas transplant known to be still working is now more than 20 years old. The results from the DCCT study (1) are demonstrating that tight blood sugar control, in those with type I diabetes reduces the complications of diabetes. This is best accomplished by transplanting pancreas grafts into diabetic patients.

Keynote Address: The American Association of Anatomists' Sixth Annual Minority Student Luncheon, Experimental Biology ‘99, Washington, DC

Keynote Address: The American Association of Anatomists' Sixth Annual Minority Student Luncheon, Experimental Biology ‘99, Washington, DC

Early Diabetic Nephropathy

Diabetic nephropathy affects approximately 35% of patients with insulin-dependent diabetes mellitus and about 5% to 10% of patients with non-insulin-dependent diabetes mellitus. Diabetic kidney disease can be detected early by special methods that measure microalbuminuria in the range of 15 to 140 micrograms/min or 0.02 to 0.20 g/d. Specific strategies have been proved beneficial in patients with this early diabetic kidney disease, also called "incipient nephropathy." Protein restriction, tight control of blood sugar and blood pressure, and specific therapy with angiotensin-converting enzyme inhibitors have been shown independently to reduce microalbuminuria and preserve renal function in these patients. We review the pathogenesis of diabetic kidney disease and discuss the effects of these treatment strategies on the renal, cardiovascular, metabolic, and other abnormalities found in early (incipient) and overt diabetic nephropathy.

PREPREGNANCY CARE FOR DIABETICS MAY PREVENT CONGENITAL DEFECTS.

Although it is known that infants born to diabetic mothers have a high incidence of congenital malformations, the value of tight blood sugar control in

Hemodynamic factors in the pathogenesis of diabetic nephropathy.

The pathogenesis of the diabetic glomerular lesion is unknown. However, cumulative indirect evidence favors hemodynamic factors associated with the abnormal endocrine environment as the cause of diabetic angiopathy. Experimental evidence suggests that the increased hydrostatic pressures in capillary beds, a hallmark of the early stages of insulin-dependent diabetes, are associated with macromolecular leakage leading to the typical thickening of glomerular capillary basement membrane and increased glomerular mesangial matrix even prior to the occurrence of systemic hypertension. Patients with renal or carotid artery stenosis seem to be protected against diabetic nephropathy and retinopathy on the stenosed side. The first signal of diabetic nephropathy even before deterioration of the renal function is microalbuminuria detected by sensitive methods such as radioimmunoassay. Not only in hypertensive, but even in normotensive diabetic patients with microalbuminuria antihypertensive therapy has been shown to reduce albumin excretion rate and to slow the progression of diabetic nephropathy. Once overt diabetic nephropathy has been established, hypertension is a constant accompaniment of the disease. Thus, hypertension may be a cause as well as a result of diabetic nephropathy. Tight control of blood sugar in close association with antihypertensive treatment reducing blood pressure to a lower normal limit, possibly with agents that specifically decrease glomerular capillary hydraulic pressure are the corner stone in protection against progression of the diabetic angiopathy.