Tight Blood Glucose Control Research Articles

Predictors of a Good Outcome after Endovascular Stroke Treatment with Stent Retrievers.

Background and Purpose. Successful recanalization after endovascular stroke therapy (EVT) did not translate into a good clinical outcome in randomized trials. The goal of the study was to identify the predictors of a good outcome after mechanical thrombectomy with stent retrievers. Methods. A retrospective analysis of a prospectively collected database included consecutive patients treated with stent retrievers. We evaluated the influence of risk factors for stroke, baseline NIHSS score, Alberta Stroke Program Early CT (ASPECT) score, recanalization rate, onset-to-recanalization and onset-to-groin puncture time, and glucose levels at admission on good outcomes. The number of stent passes during procedure and symptomatic hemorrhage rate were also recorded. A modified Rankin Scale (mRS) score of 0–2 at 90 days was considered as a good outcome. Results. From January 2011 to 2014, 70 consecutive patients with an acute ischemic stroke underwent EVT with stent retrievers. The absence of a medical history of diabetes was associated with good outcomes. Apart from diabetes, the baseline demographic and clinical characteristics of patients were similar between subjects with poor outcome versus those with good outcomes. Median time from onset to recanalization was significantly shorter in patients with good outcomes 245 (IQR: 216–313 min) compared with poor outcome patients (315 (IQR: 240–360 min); P = 0.023). Symptomatic intracranial hemorrhage was observed in eight (21.6%) of 37 patients with poor outcomes and no symptomatic hemorrhage was seen in patients with good outcomes (P = 0.006). In multivariate stepwise logistic regression analysis, a favorable ASPECT score (ASPECT > 7) and successful recanalization after EVT were predictors of good outcomes. Every 10-year increase was associated with a 3.60-fold decrease in the probability of a good outcome at 3 months. The probability of a good outcome decreases by 1.43-fold for each 20 mg/dL increase in the blood glucose at admission. Conclusion. To achieve a good outcome after EVT with stent retrievers, quick and complete recanalization and better strategies for patient selection are warranted. We need randomized trials to identify the significance of tight blood glucose control in clinical outcome during or after EVT.

“Sugamama” – Gestational Diabetes Mobile ‘app’ innovation in integrated care Proof Of Concept

This proof of concept (POC) involves the user-centred design of a mobile application (app) and web-based system to promote self-management of women with gestational diabetes mellitus (GDM). During the brief period between diagnosis and birth we seek to maximise tight blood glucose control, known to impact on maternal and fetal outcomes. This is timely due to clinician burdens anticipated to increase by up to 30% with the adoption of new GDM diagnostic criteria. Incidence of GDM is on the rise due to the increasing percentage of overweight or obese pregnant women and the advancing age of first time mothers. The system has been designed from the ground up by clinicians, patients and subject matter experts and is grounded in theory. It offers the opportunity for remote management of patients; individualised patient care plans; automatic upload of blood glucose measurements via Bluetooth; triage of patients based on pre-determined parameters; flagging of those at high risk; consultations and referral; tracking of diet, exercise, weight, fetal movements, appointments and medications; appropriate and accessible education and support to patients, including those with low health literacy; and recording of occasions of clinical service for billing purposes. Care across acute and primary services and partnership with patients are supported. The system will integrate with secure messaging due to be introduced into the district. Patient’s own mobile devices will be utilised. The app is expected to significantly reduce the number of clinic visits required by stable well-managed gestational diabetics. These cost saving can be fed back into the system. Clinicians will be freed from non-core activities such as administrative tasks and data entry, enabling them to work to their full scope of practice, creating efficiencies and greater job satisfaction. Local needs will specifically be addressed and local policies, procedures and guidelines embodied in the app. Through app use, patient and clinician behaviours will be aligned thereby minimising clinical variation and adverse outcomes. The target population for the POC is English speaking women over the age of 18, diagnosed with GDM at RHW. A subsequent iteration of the app is planned to offer resources in additional languages. Primary stakeholders are: patient consumers; the RHW executive and diabetes service; Eastern Sydney and South Eastern Sydney Medicare Locals (representing communitybased primary services); Information Management Services Directorate, South Eastern Sydney Local Health District (SESLHD); Clinical Efficiency & Evaluation Unit, SESLHD; and New South Wales (NSW) Health. World Congress on Integrated Care 2014, Sydney, November 23-26, 2014. International Journal of Integrated Care – Volume 14, 8 December – URN:NBN:NL:UI:10-1-116666– http://www.ijic.org/ The POC will evaluate clinician and patient adoption of a novel model of care. Theories and methods stem from diverse areas of inquiry including: healthcare delivery; diabetes selfmanagement; health informatics; patient educational technology; transformational learning; social cognition; health literacy; implementation science; social marketing; and commerce. This is the first digital solution of its kind in Australia that we are aware of. Once the POC is successfully completed we aim to roll-out to other sites. There has been interest across our health district in adapting the model to diabetes and chronic disease in general. The system is due to go live in October 2014.

Tight blood glycaemic and blood pressure control in experimental diabetic nephropathy reduces extracellular matrix production without regression of fibrosis.

Regression of albuminuria and renal fibrosis occurs in patients with diabetic nephropathy (DN) following tight control of blood glucose and blood pressure, however the pathways that promote regression remain poorly understood and we wished to characterize these using a rodent model. Diabetes was induced with streptozotocin in Cyp1a1mRen2 rats and hypertension was generated by inducing renin transgene expression with dietary indole-3-carbinol (I-3-C) for 28 weeks. At this point an 'injury cohort' was culled, while in a 'reversal cohort' glycaemia was tightly controlled using insulin implants and blood pressure normalized by withdrawing dietary I-3-C for a further 8 weeks. Pathways activated during and following reversal of diabetes and hypertension were assessed by microarray profiling. Tight control of blood glucose and blood pressure reduced albuminuria and renal hypertrophy, but had no impact on renal fibrosis. 85 genes were up-regulated specifically during the injury phase, including genes encoding multiple myofibroblast and extracellular matrix (ECM) proteins. Conversely, 314 genes remained persistently elevated during reversal including genes linked to innate/adaptive immunity, phagocytosis, lysosomal processing and degradative metalloproteinases (MMPs). Despite increased MMP gene expression, MMP activity was suppressed during both injury and reversal, in association with up-regulation of tissue inhibitor of metalloproteinase-1 (TIMP-1) protein. Physical separation of the TIMP-1/MMP complexes during zymography of tissue homogenate restored MMP activity. Normalization of blood glucose and pressure ameliorates albuminuria and inhibits excess ECM production, however persistent TIMP-1 expression hinders attempts at ECM remodelling. Therapies which counteract the action of TIMPs may accelerate scar resolution.

Improved A1C and Lipid Profile in Patients Referred to Diabetes Education Programs in a Wide Health Care Network: A Retrospective Study.

Diabetes is a chronic disease characterized by high blood glucose levels and caused either by a deficiency of insulin or a defect in the way the body responds to insulin.1,2 The increased prevalence of type 2 diabetes is believed to be the consequence of an aging population, increased physical inactivity and obesity, and genetic factors.3,4 Diabetes is one of the leading causes of blindness and renal failure,5,6 and people with diabetes who have an increased A1C level and uncontrolled lipid levels have increased rates of morbidity and mortality. Complications usually fall into three main groups: acute metabolic abnormalities, microvascular anomalies, and long-term cardiovascular disorders specific to diabetes.7 The main treatment goals for diabetes are controlling blood glucose and cholesterol levels and maintaining a normal blood pressure.8 Tight control and management of blood glucose and blood pressure has been proven to prevent or delay complications of diabetes.9 Involving patients in their care through self-management is of utmost importance to achieving these goals. Yet, self-management is difficult to attain and maintain because of the complexity of the processes involved and the lack of motivation and skills on the part of some patients.10 Frequently reported barriers to self-management11,12 include knowledge deficits, poor patient-provider communication, low self-efficacy, limitations of time or resources, financial constraints, lack of individualized and coordinated care, and lifestyle differences among family members. An extensive review of 16 studies identified barriers from five different perspectives: psychosocial, socioeconomic, physical, environmental, and cultural.13 It is widely believed that educating patients about diabetes may be a mechanism to encourage and support them in assuming active responsibility for self-management. Based on this belief, several educational programs have been developed.14,15 Diabetes education, also known as diabetes …

Renin inhibitors in diabetes and hypertension: an update.

The coexistence of hypertension and diabetes increases the incidence of cardiovascular events and long-term morbidity and mortality. Blood pressure should be controlled with the most appropriate drugs as well as tight blood glucose control in patients with diabetes and hypertension. RAAS (Renin Angiotensin Aldosterone System) blockers have an important role in the treatment of these patients, in this sense, ACEi and ARB remained the major treatment option in hypertension guidelines. The most recent RAAS blocker to be approved by the FDA was aliskiren in 2007, a renin inhibitor. Studies showed that aliskiren is as effective as other antihypertensive drugs and has a safety profile similar to placebo. The potent renin inhibitor aliskiren directly inhibits the RAAS system at its rate limiting step and differently from other RAAS blockers; it decreases plasma renin activity (PRA). Although the relationship of increased PRA levels and cardiovascular risk has been shown, it is unclear if the PRA decrease provided by aliskiren has an impact on clinical outcomes and cardiovascular endpoints. On the other hand, large trials like ASPIRE, AVANT-GARDE, ALTITUDE, ASTRONAUT, which investigated the combination of aliskiren with other RAAS blockers, failed to show the expected outcomes or resulted with an increased incidence of adverse effects, which raised more questions. As a result of the ALTITUDE trial, combination of aliskiren with an ACEi or ARB is not recommended in patients with hypertension and diabetes, or at least moderate renal dysfunction. Trials designed to prove aliskiren's efficacy in new indications like diabetes, may face similar problems related to dual RAAS blockade because in the majority of cases, the optimal treatment is achieved with an ACEi or ARB. In this conjuncture, the increase in adverse events seen with aliskiren might be related to dual RAAS blockade rather than aliskiren directly. For instance, it is unclear whether the adverse event incidence would be the same, less, or higher if ALTITUDE was designed to investigate ACEi and ARB combination without aliskiren. In fact, every new molecular entity and mechanism of action faces the same barriers. For the time being, differentiating points like PRA lowering effects as an add-on therapy to calcium channel blockers or hydrochlorothiazide, and the populations that might have additional benefit, should be carefully investigated.

Decreased Mortality with Tight Glycemic Control in Critically Ill Patients: A Retrospective Analysis in a Large Community Hospital System

To measure the efficacy and possible adverse consequences of tight blood glucose (BG) control when compared to relaxed control. A retrospective, observational study was conducted at a community-based teaching hospital system among adult, nonmaternity hospitalized patients admitted to the intensive care unit (ICU). Tight glycemic control of BG was compared with less strict BG control, and the following outcome measurements were compared: BG, average length of stay (ALOS), severe hypoglycemia, and mortality. Between 2008 and 2012, 18,919 patients were admitted to the ICU. The mortality rate was significantly lower (P = .0001) in patients with an average BG between 80 and 110 mg/dL (8%) and 111 and 140 mg/dL (9.4%) than in patients with average BG between 141 and 180 mg/dL (12.9%). Using tight glycemic control (80 to 110 mg/dL), the ALOS in the ICU decreased from 4 to 2.9 days (P<.0001) among all patients, and from 4.2 to 2.1 days (P<.0001) among patients who had undergone coronary artery bypass graft. Comparatively, the ALOS for the hospital decreased from 9.4 to 8 days. The incidence of severe hypoglycemia (BG <40 mg/dL) was higher (P = .01) in the tight BG control group (4.78%) compared with the relaxed control group (3.5%). This rate was lower than in previously published studies that analyzed the use of tight control. Tight glycemic control using protocolbased insulin administration resulted in a decrease in mortality and ALOS among all patients in the ICU. The incidence of severe hypoglycemic episodes was slightly higher in the tightly controlled group but remained lower than in previously published studies.

New insulin glargine 300 Units · mL-1 provides a more even activity profile and prolonged glycemic control at steady state compared with insulin glargine 100 Units · mL-1.

To characterize the pharmacokinetics (PK) and pharmacodynamics (PD) of a new insulin glargine comprising 300 units · mL(-1) (Gla-300), compared with insulin glargine 100 units · mL(-1) (Gla-100) at steady state in people with type 1 diabetes. A randomized, double-blind, crossover study (N = 30) was conducted, applying the euglycemic clamp technique over a period of 36 h. In this multiple-dose to steady-state study, participants received once-daily subcutaneous administrations of either 0.4 (cohort 1) or 0.6 units · kg(-1) (cohort 2) Gla-300 for 8 days in one treatment period and 0.4 units · kg(-1) Gla-100 for 8 days in the other. Here we focus on the results of a direct comparison between 0.4 units · kg(-1) of each treatment. PK and PD assessments performed on the last treatment day included serum insulin measurements using a radioimmunoassay and the automated euglycemic glucose clamp technique over 36 h. At steady state, insulin concentration (INS) and glucose infusion rate (GIR) profiles of Gla-300 were more constant and more evenly distributed over 24 h compared with those of Gla-100 and lasted longer, as supported by the later time (∼ 3 h) to 50% of the area under the serum INS and GIR time curves from time zero to 36 h post dosing. Tight blood glucose control (≤ 105 mg · dL(-1)) was maintained for approximately 5 h longer (median of 30 h) with Gla-300 compared with Gla-100. Gla-300 provides more even steady-state PK and PD profiles and a longer duration of action than Gla-100, extending blood glucose control well beyond 24 h.

DPP-4 inhibitors-renoprotection in diabetic nephropathy?

There is no doubt that rates of chronic kidney disease are escalating and that this rise is the main contributor to the increasing prevalence of diabetic nephropathy. It is also clear that the increase in kidney failure continues despite tight blood glucose and blood pressure control, as well as renin-angiotensin system blockade. In response, research into novel therapies to treat diabetic nephropathy is expanding, but to date nothing has translated into clinical use. The dipeptidyl peptidase-4 (DPP-4) inhibitors are oral, weight-neutral hypoglycemic drugs used to treat patients with type 2 diabetes. DPP-4 cleaves polypeptides with a proline/alanine in the penultimate position at the amino-terminal position. Hence, the net physiologic effect is a complex interplay between the resulting substrate/product profile in a particular disease milieu (rather than a specific signaling pathway). Cleaved substrates may either be activated, inactivated, or bear no functional relevance. DPP-4 inhibitors lower blood glucose levels by raising the half-life of short-lived endogenous incretins, such as GLP-1 and glucose-dependent insulinotropic polypeptide. However, the ability of DPP-4 to cleave a host of additional membrane-bound substrates that exert nonenzymatic properties by interacting or colocalizing with other membrane proteins/receptors suggests it may be a novel and …

A clinical and economic evaluation of Control of Hyperglycaemia in Paediatric intensive care (CHiP): a randomised controlled trial.

Early research in adults admitted to intensive care suggested that tight control of blood glucose during acute illness can be associated with reductions in mortality, length of hospital stay and complications such as infection and renal failure. Prior to our study, it was unclear whether or not children could also benefit from tight control of blood glucose during critical illness. This study aimed to determine if controlling blood glucose using insulin in paediatric intensive care units (PICUs) reduces mortality and morbidity and is cost-effective, whether or not admission follows cardiac surgery. Randomised open two-arm parallel group superiority design with central randomisation with minimisation. Analysis was on an intention-to-treat basis. Following random allocation, care givers and outcome assessors were no longer blind to allocation. The setting was 13 English PICUs. Patients who met the following criteria were eligible for inclusion: ≥ 36 weeks corrected gestational age; ≤ 16 years; in the PICU following injury, following major surgery or with critical illness; anticipated treatment > 12 hours; arterial line; mechanical ventilation; and vasoactive drugs. Exclusion criteria were as follows: diabetes mellitus; inborn error of metabolism; treatment withdrawal considered; in the PICU > 5 consecutive days; and already in CHiP (Control of Hyperglycaemia in Paediatric intensive care). The intervention was tight glycaemic control (TGC): insulin by intravenous infusion titrated to maintain blood glucose between 4.0 and 7.0 mmol/l. This consisted of insulin by intravenous infusion only if blood glucose exceeded 12.0 mmol/l on two samples at least 30 minutes apart; insulin was stopped when blood glucose fell below 10.0 mmol/l. The primary outcome was the number of days alive and free from mechanical ventilation within 30 days of trial entry (VFD-30). The secondary outcomes comprised clinical and economic outcomes at 30 days and 12 months and lifetime cost-effectiveness, which included costs per quality-adjusted life-year. CHiP recruited from May 2008 to September 2011. In total, 19,924 children were screened and 1369 eligible patients were randomised (TGC, 694; CM, 675), 60% of whom were in the cardiac surgery stratum. The randomised groups were comparable at trial entry. More children in the TGC than in the CM arm received insulin (66% vs. 16%). The mean VFD-30 was 23 [mean difference 0.36; 95% confidence interval (CI) -0.42 to 1.14]. The effect did not differ among prespecified subgroups. Hypoglycaemia occurred significantly more often in the TGC than in the CM arm (moderate, 12.5% vs. 3.1%; severe, 7.3% vs. 1.5%). Mean 30-day costs were similar between arms, but mean 12-month costs were lower in the TGC than in CM arm (incremental costs -£3620, 95% CI -£7743 to £502). For the non-cardiac surgery stratum, mean costs were lower in the TGC than in the CM arm (incremental cost -£9865, 95% CI -£18,558 to -£1172), but, in the cardiac surgery stratum, the costs were similar between the arms (incremental cost £133, 95% CI -£3568 to £3833). Lifetime incremental net benefits were positive overall (£3346, 95% CI -£11,203 to £17,894), but close to zero for the cardiac surgery stratum (-£919, 95% CI -£16,661 to £14,823). For the non-cardiac surgery stratum, the incremental net benefits were high (£11,322, 95% CI -£15,791 to £38,615). The probability that TGC is cost-effective is relatively high for the non-cardiac surgery stratum, but, for the cardiac surgery subgroup, the probability that TGC is cost-effective is around 0.5. Sensitivity analyses showed that the results were robust to a range of alternative assumptions. CHiP found no differences in the clinical or cost-effectiveness of TGC compared with CM overall, or for prespecified subgroups. A higher proportion of the TGC arm had hypoglycaemia. This study did not provide any evidence to suggest that PICUs should stop providing CM for children admitted to PICUs following cardiac surgery. For the subgroup not admitted for cardiac surgery, TGC reduced average costs at 12 months and is likely to be cost-effective. Further research is required to refine the TGC protocol to minimise the risk of hypoglycaemic episodes and assess the long-term health benefits of TGC. Current Controlled Trials ISRCTN61735247. This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 26. See the NIHR Journals Library website for further project information.

Myricetin alleviates postprandial hyperglycemia in rats with diabetes mellitus (854.1)

Tight control of both fasting and postprandial blood glucose is essential in the treatment of diabetes mellitus. It has been suggested that postprandial hyperglycemia is more strongly associated with the risk of cardiovascular diabetic complications than is fasting hyperglycemia. Myricetin strongly inhibits α‐glucosidase in vitro, suggesting that it could have hypoglycemic activity in vivo. This study investigated the α‐glucosidase inhibitory activity of myricetin in vivo. Streptozotocin‐induced diabetic rat were administered a starch solution (1 g/kg) with and without myricetin (100 mg/kg) or acarbose (40 mg/kg) orally after an overnight fast, and postprandial plasma glucose levels were monitored. The administration of myricetin or acarbose significantly decreased the incremental plasma glucose levels 30‐180 min after a single oral dose of starch (p&lt;0.05). Myricetin or acarbose treatment significantly reduced the incremental areas under the glucose response curve (AUC). The AUC of the myricetin‐treated group was not significantly different from that of the acarbose‐treated group. Therefore, we conclude that myricetin is effective for controlling postprandial hyperglycemia in an animal model of diabetes mellitus.Grant Funding Source: This research was supported by NRF in Korea (2012015763)

Human islet transplantation

that achieves insulin-independent, constant normoglycemic state and avoidance of hypoglycemic episodes is the replacement of a patient’s islet of Langerhans either by pancreas transplantation or by isolated islet transplantation. The cost of this benefit, however, is the need for immunosupressive treatment of the recipient with all its potential risks. Currently, only vascularized pancreas transplantation can re-establish long-term normoglycemia however this has been associate with significant morbidity and mortality. Approximately 25.000 patients worldwide underwent this procedure and it has been shown to improve quality of life and even reverse some secondary complications of diabetes.4 Simultaneous pancreas and kidney transplantation are presently considered the standard of care for selected patients with type I diabetes with end-stage renal failure.5 Diabetes is a major burden to healthcare economies despite the use of exogenous insulin injections. Type I diabetes mellitus is a chronic metabolic disorder that currently afflicts 5 million individuals in the world. It results from auto-immune mediated destruction of insulin secreting beta cells in islet of Langerhans of the pancreas.1 Long-term studies strongly suggest that tight control of blood glucose achieved by conventional or intensive insulin treatment, self blood glucose monitoring, and patient education can significantly prevent developing and retard the progression of chronic complications of this disease.2 On the other hand, the cost of this benefit was a threefold increase in the number of severe hypoglycemic episodes, a significant increase of body weight and dietary and other lifestyle restrictions affecting the quality of life.3 The only treatment for Type I diabetes mellitus Human islet transplantation

Insulin infusion on postoperative complications of coronary artery bypass graft in patients with diabetes mellitus.

Background:Cardiovascular events are common in patients with diabetes mellitus (DM), which make coronary artery bypass graft (CABG) a highly demanded surgery in this population. Tight control of blood glucose in patients with DM is beneficial in reducing postoperative complications; however, the adequate range has not been determined yet.Objectives:This study aimed to investigate the effect of semi-tight (moderate) control of DM on complications and serum glucose levels during and after CABG.Patients and Methods:In this prospective clinical trial, 18 and 31 patients with and without DM, respectively, who were referred to Shahid Chamran Hospital, Isfahan, Iran, for elective CABG surgery, were enrolled. For DM group, patients with controlled DM (i.e. glycosylated hemoglobin levels [HgA1C] ≤ 7%) were recruited. Blood glucose level (blood sugar, BS) was measured after anesthesia, during pumping, warming, off pumping, six and 12 hours after Intensive Care Unit (ICU) admission, and at discharging from the hospital. The hemodynamic state of the patients, bleeding, need of blood transfusion, infection, and duration of hospitalization were also monitored and recorded.Results:None of the BS measurements (FBS, after anesthesia, on-pump, warming, off pump, six and 12 hours after ICU admission, and at discharge) were significantly different between study groups (P > 0.05). Frequency of surgery site bleeding and blood transfusion need were not significantly different between these groups (P > 0.05).Conclusions:Semi-tight control of DM with insulin infusion during operation did not led to any difference in the type and rate of CABG complications between patients with well-controlled and those without DM; however, BS levels in patients with well-controlled DM could be more easily controlled.

Hyperglycemia in the pediatric intensive care unit: Innocent bystander or villain of the piece?

Hyperglycemia in the pediatric intensive care unit: Innocent bystander or villain of the piece?

Glycemic control and diabetes management in hospitalized patients in Brazil

BackgroundThe importance of tight blood glucose control among outpatients with diabetes mellitus is well established, however, the management of diabetes in the hospital setting is generally considered secondary in importance. This study sought to assess glycemic control and diabetes management in adult patients admitted to hospitals in Brazil.MethodsA cross-sectional and nationwide survey was conducted from July 2010 to January 2012. Eligible cases were 18 years of age or older, had a diagnosis of diabetes and a hospitalization length of stay ≥72 hours. Socio-demographic information, hospitalization details, and data on diabetes diagnosis, management and treatment were collected for all patients by chart review. Information on all blood glucose (BG) readings for a maximum of 20 consecutive days of hospitalization was recorded for each patient.ResultsOverall, 2,399 patients were surveyed in 24 hospitals located in 13 cities from all five Brazilian regions. The prevalence of patients presenting hyperglycemic (BG >180 mg/dL) or hypoglycemic (BG <70 mg/dL) events was 89.4% and 30.9% in patients in general wards, and 88.2% and 27.7% in those in Intensive Care Units (ICUs), respectively. In addition, a BG measure >180 mg/dL was recorded in two-thirds of the patient-days. A high proportion of patients were treated with sliding-scale insulin regimen alone in the general wards (52.0%) and in the ICUs (69.2%), and only 35.7% and 3.9% received appropriate insulin therapy in general wards (basal + bolus insulin) and in ICUs (continuous IV insulin), respectively.ConclusionsInpatient glycemic control and diabetes management needs improvement. Opportunities to improve care in Brazilian hospitals include expanded use of intravenous insulin and subcutaneous basal-bolus insulin protocols, avoiding use of sliding-scale insulin alone, increased frequency of blood glucose monitoring, and institution wide quality improvement efforts targeting both physician and nursing behavior.

Letter to the Editor - responses to Weisntein D, Simon M, Yehezkel E, Laron Z, Werner H. Insulin analogues display IGF-I-like mitogenic and antiactivity in cultured cancer cells.

We thank the team of Eli Lilly and Company for their critical appraisal of our study and for giving us the opportunity to clarify a number of points [1]. We agree with Kazda et al. that randomized clinical trials will best address any direct relationship between insulin analogues and cancer in man. We do not question the fact that tight control of blood glucose has dramatically advanced the lives of patients with diabetes. This article is protected by copyright. All rights reserved.

Tratamento cirúrgico da retinopatia diabética

A retinopatia diabetica e a causa mais frequente de cegueira na populacao ativa nos paises desenvolvidos. A prevalencia da retinopatia diabetica aumenta com a duracao da diabetes, e praticamente 100% dos pacientes com diabetes tipo I (DM I) e mais do que 60% dos pacientes com o tipo II (DM II) apresentarao algum sinal de retinopatia apos 20 anos. Alem de um controle sistemico rigoroso dos niveis glicemicos, lipidicos, colesterol e da pressao arterial, o exame oftalmologico de rotina, com a identificacao precoce da retinopatia diabetica, podem detectar anormalidades em estagios primarios, o que possibilita o tratamento ainda na fase inicial do problema; o uso adequado da fotocoagulacao e a utilizacao da terapia antiangiogenica pode reduzir o numero de pacientes com hemorragia vitrea ou descolamento tracional da retina. Infelizmente, em varios pacientes, a retinopatia progride mesmo com as melhores condutas tomadas pelo paciente e pelo oftalmologista, embora varios olhos podem se beneficiar com o tratamento cirurgico, a vitrectomia posterior via pars plana. Esta revisao apresenta as indicacoes atuais para cirurgia vitreorretiniana em pacientes portadores de retinopatia diabetica proliferativa.

Long-Term Renal Function Deteriorates at a Similar Rate Among Liver Transplant Patients With Preserved Renal Function at 1 Year and in the General Population: Is Chronic Calcineurin Inhibitor Nephrotoxicity Overrated?

BackgroundChronic calcineurin inhibitor (CNI) nephrotoxicity is associated with histologic kidney lesions, but the contribution of maintenance-dose CNI use to the decline over time in glomerular filtration rate (GFR) post liver transplantation (OLT) remains unclear. MethodsWe studied annual changes in estimated GFR >1 year posttransplant among 105 CNI-treated adult OLT patients with a GFR of 60–100 mL/min at 1 year during a mean follow-up of 7 years (20 years in 20 patients). ResultsThe annual GFR decline >1 year posttransplant was 0.2 mL/min per year (SD 3.8). This decline rate was unaffected by the decade of OLT, follow-up period, or GFR at 1 year, and showed no correlation with CNI blood levels. Of the 13 (12%) patients with a GFR deterioration >3 mL/min per year, 77% presented with hypertension, diabetes, and/or dyslipidemia. The decline in GFR >1 year post-OLT did not exceed the decline of 0.5–0.8 mL/min per year reported in the general population. Declines faster than 3 mL/min per year, which occurred no more frequently among patients than in the general population, seemed attributable to coexistent vascular risk factors. ConclusionsAmong OLT patients with preserved renal function at 1 year posttransplant, our findings challenge the clinical impact of chronic progressive CNI nephrotoxicity and highlight the importance of a tight control of blood pressures, glucose and lipid levels, and other modifiable risk factors in order to preserve long-term renal function.

Perioperative control of blood glucose level in cardiac surgery

It is well recognized that poor perioperative blood glucose (BG) control can increase the risk of infection, cardiovascular accidents, and even death in patients undergoing cardiac surgery. Since it has been reported that tight BG control (80-110 mg/dL) yields better outcomes in critically ill patients, it became a standard of care to control BG using intravenous insulin infusion in ICU. However, it has been debated in terms of the optimal target range whether a strict control with intensive insulin therapy is better than liberal control. Because strict BG control can often cause hypoglycemia, which in turn increases the hospital mortality. In fact, a meta-analysis of randomized clinical trials concluded that tight BG control was not associated with significantly reduced hospital mortality but was associated with an increased risk of hypoglycemia. According to the current published guidelines, it seems to be optimal to control BG level of 140-180 mg/dL in ICU. In terms of more strict BG control (110-140 mg/dL), it may be appropriate in selected patients as long as this can be achieved without significant hypoglycemia.

A change for good may not be always good! An interesting case of recurrent hypoglycaemia

Good control of plasma glucose levels always remains a desired goal for both diabetic patients and their physicians. However, unintended tight glucose control should always be alarming to the treating physician, although, it may seem to be a blessing to the patient. A downward trend in blood glucose profile in an elderly male with long standing diabetes generally points to developing renal insufficiency. Apart from that, other causes responsible for lowering of blood glucose have to be considered at times when clinical scenario is slightly different. Here, we present a case of an elderly man who presented with an unintended tight control of blood glucose over a period of few months, which upon neglecting culminated into recurrent hypoglycaemia. The etiology of recurrent hypoglycaemia in this patient was non-islet cell tumor hypoglycaemia (NICTH). The causes, pathophysiology, and management of NICTH are discussed briefly.

Glucosa-Insulin-Potassium (GIK) Solution Used with Diabetic Patients Provides Better Recovery After Coronary Bypass Operations

Tight blood glucose control has become a therapeutical goal for anesthetic management for patients scheduled for cardiac surgery, especially if they are diabetic patients. This study was created to confirm the benefits of intraoperative GIK solution usage during coronary bypass operation of diabetic patients. Patients with type 1 and 2 diabetes mellitus (DM) referred for coronary artery bypass grafting (CABG) were randomized to receive GIK solution (GIK--study group) in the first 24 hours intraoperatively or to receive official Clinical protocol without GIK solution (non GIK - control group). The primary clinical outcome was the cardiac index (CI) since it represents the most sensitive measure of cardiac work in the immediate postoperative period, and the secondary clinical outcomes were the glycemic control, insulin consumption, duration of mechanical ventilation (MV), potassium level and atrial fibrillation (AF) appearance. One hundred diabetic patients, divided into two groups, were included in the study. The cardiac index did not show a significant difference, although the study group had CI with only minor variations than those of the controlled group, hence the reason we considered the study group as the more stable. The atrial fibrillation showed a difference between two groups, with 14 (28%) patients with postoperative AF in the control group compared with 3 (6%) patients with postoperative AF in the study group. As potassium values were stable in study group, we concluded that it can be one of the reasons for less postoperative AF in this group. The duration of MV showed a significant difference (0,003) between the two groups as well. In the study group the average MV time was 534,38 minutes, compared with the control group with 749,20 minutes. The average value of glucose was 11.1 mmol/l in the control group vs. 9.8 mmol/l in the study group. The study group had less insulin consumption in order to maintain target glycemia (p = 0.001). In the non GIK group average insulin consumption was 44 IJ per patient vs. 28.5 IJ in the GIK group. Intraoperative GIK solution given to diabetic patients with CABG operation provides more stable CI, shorter time of MV, more stable values of potassium which provides normal rhythm and less AF onset, less insulin to maintain target glycemia. All the above mentioned provides more stable intraoperative hemodynamic and better recovery of diabetic