Clinical recommendations in the management of the patient with type 1 diabetes on insulin pump therapy in the perioperative period: a primer for the anaesthetist

Insulin pump therapy is increasingly common in patients with type 1 diabetes. Many of these patients will require surgery at some point in their lifetime. Few doctors will have experience of managing these patients, and little evidence exists to assist in the development of guidelines for patients with insulin pump therapy, undergoing surgery.It is clear that during emergency surgery insulin pump therapy is not appropriate and should be discontinued, but patients undergoing some elective surgery can and should continue insulin pump therapy, without any adverse effect on their blood sugar control, or on the outcome of their surgery. Individual hospitals need to formalize guidance on the management of patients receiving continuous subcutaneous insulin therapy, to allow patients the choice to continue their therapy during surgery. This expert opinion presents anaesthetists with a suggested clinical framework to help facilitate continued insulin pump therapy, during elective surgery and into the postoperative period.

[Being a family today - ethics for assisted reproductive techniques]

Currently in France, all the children born as a result of an assisted reproduction procedure, represent 2.5% of all births. Although this proportion is not high, it is not to be neglected, particularly with regard to the sociological issues raised by assisted reproduction technologies (ART) - i.e. removing anonymity of gamete donation, post mortem insemination, ART access to single women and gay couples, surrogacy - to name four of the most prominent debates. What is new with ART is that a new therapeutic target of medicine is being developed, in other words procreation. Now it is no longer necessary for a man and a woman to resort to sex to have a child. This is a profound questioning of the representation of what appeared to be intangible, with some sort of divine aura. How, in this context, developing an ethics for ART? From a fethnographic field survey, we show here how this ethos of ART develops and how, therefore, we consider the multiple ways of being a family today.

Predictive factors of rituximab response in rheumatoid arthritis: results from a French university hospital

OBJECTIVE

To study the influence of several factors (rheumatoid factor [RF], anti-cyclic citrullinated peptide [anti-CCP], serum Ig level, and Epstein-Barr virus [EBV] load) on clinical response to rituximab (RTX) after 6 months in rheumatoid arthritis (RA) patients.

METHODS

Sixty-four patients receiving RTX (two 1-gm doses 2 weeks apart) for active RA were prospectively included. RF, anti-CCP, gamma globulin level, and EBV load were assessed prior to the first RTX cycle. Clinical responses were analyzed 6 months after RTX initiation using the European League Against Rheumatism criteria. Univariate and multivariate analyses were performed to identify factors associated with RTX response at 6 months.

RESULTS

The mean disease duration was 16.4 years and 46 patients (71.9%) had already received at least 1 anti-tumor necrosis factor agent prior to RTX. At 6 months, 46 patients (71.9%) had a good to moderate response to RTX. Anti-CCP positivity was associated with a good to moderate response (odds ratio [OR] 4, 95% confidence interval [95% CI] 1.04-15.5; P = 0.04). RF positivity (P = 0.26) and positive initial EBV load (P = 0.16) were not associated with a good to moderate response. Hyperimmunoglobulin was correlated with a poorer response to RTX than normal Ig levels (OR 0.04, 95% CI 0.005-0.28; P = 0.002).

CONCLUSION

Anti-CCP positivity was a predictor of good to moderate response to RTX in RA patients. On the other hand, high Ig levels were associated with a poorer outcome in contrast to previous findings. Further support from larger studies is necessary so as to optimize the management of the RA patients with high Ig levels.