Euglycemic diabetic ketoacidosis in the era of SGLT-2 inhibitors

Euglycemic diabetic ketoacidosis (EDKA) is an emerging complication of diabetes associated with an increasing use of sodium-glucose transporter type 2 (SGLT-2) inhibitor drugs. This review highlights the growing incidence of EDKA and its diagnostic challenges due to the absence of hallmark hyperglycemia seen in diabetic ketoacidosis (DKA). The paper presents a classification system for the severity of EDKA, categorizing it into mild, moderate, and severe based on serum pH and bicarbonate levels. Another classification system is proposed to define stages of EDKA based on anion gap and ketones at the time of diagnosis and during the treatment period. A treatment algorithm is proposed to guide clinicians in managing EDKA. This treatment algorithm includes monitoring anion gap and ketones to guide insulin and fluid management, and slower transition to subcutaneous insulin to prevent a relapse. Increased awareness of EDKA is essential for a timely diagnosis because an early diagnosis and treatment can improve clinical outcomes.

An agenda for research and action toward diverse and just futures for life on Earth

Decades of research and policy interventions on biodiversity have insufficiently addressed the dual issues of biodiversity degradation and social justice. New approaches are therefore needed. We devised a research and action agenda that calls for a collective task of revisiting biodiversity toward the goal of sustaining diverse and just futures for life on Earth. Revisiting biodiversity involves critically reflecting on past and present research, policy, and practice concerning biodiversity to inspire creative thinking about the future. The agenda was developed through a 2-year dialogue process that involved close to 300 experts from diverse disciplines and locations. This process was informed by social science insights that show biodiversity research and action is underpinned by choices about how problems are conceptualized. Recognizing knowledge, action, and ethics as inseparable, we synthesized a set of principles that help navigate the task of revisiting biodiversity. The agenda articulates 4 thematic areas for future research. First, researchers need to revisit biodiversity narratives by challenging conceptualizations that exclude diversity and entrench the separation of humans, cultures, economies, and societies from nature. Second, researchers should focus on the relationships between the Anthropocene, biodiversity, and culture by considering humanity and biodiversity as tied together in specific contexts. Third, researchers should focus on nature and economies by better accounting for the interacting structures of economic and financial systems as core drivers of biodiversity loss. Finally, researchers should enable transformative biodiversity research and action by reconfiguring relationships between human and nonhuman communities in and through science, policy, and practice. Revisiting biodiversity necessitates a renewed focus on dialogue among biodiversity communities and beyond that critically reflects on the past to channel research and action toward fostering just and diverse futures for human and nonhuman life on Earth.

An agenda for research and action toward diverse and just futures for life on Earth

Decades of research and policy interventions on biodiversity have insufficiently addressed the dual issues of biodiversity degradation and social justice. New approaches are therefore needed. We devised a research and action agenda that calls for a collective task of revisiting biodiversity toward the goal of sustaining diverse and just futures for life on Earth. Revisiting biodiversity involves critically reflecting on past and present research, policy, and practice concerning biodiversity to inspire creative thinking about the future. The agenda was developed through a 2-year dialogue process that involved close to 300 experts from diverse disciplines and locations. This process was informed by social science insights that show biodiversity research and action is underpinned by choices about how problems are conceptualized. Recognizing knowledge, action, and ethics as inseparable, we synthesized a set of principles that help navigate the task of revisiting biodiversity. The agenda articulates 4 thematic areas for future research. First, researchers need to revisit biodiversity narratives by challenging conceptualizations that exclude diversity and entrench the separation of humans, cultures, economies, and societies from nature. Second, researchers should focus on the relationships between the Anthropocene, biodiversity, and culture by considering humanity and biodiversity as tied together in specific contexts. Third, researchers should focus on nature and economies by better accounting for the interacting structures of economic and financial systems as core drivers of biodiversity loss. Finally, researchers should enable transformative biodiversity research and action by reconfiguring relationships between human and nonhuman communities in and through science, policy, and practice. Revisiting biodiversity necessitates a renewed focus on dialogue among biodiversity communities and beyond that critically reflects on the past to channel research and action toward fostering just and diverse futures for human and nonhuman life on Earth.

Clinical assessment for high-risk patients with non-alcoholic fatty liver disease in primary care and diabetology practices

BACKGROUND

Primary care practitioners (PCPs) and diabetologists are at the frontline of potentially encountering patients with NASH. Identification of those at high risk for adverse outcomes is important.

AIM

To provide practical guidance to providers on how to identify these patients and link them to specialty care.

METHODS

US members of the Global Council on NASH evaluated the evidence about NASH and non-invasive tests and developed a simple algorithm to identify high-risk NASH patients for diabetologists and primary care providers. These tools can assist frontline providers in decision-making and referral to gastroenterology/hepatology practices for additional assessments.

RESULTS

The presence of NASH-related advanced fibrosis is an independent predictor of adverse outcomes. These patients with NASH are considered high risk and referral to specialists is warranted. Given that staging of fibrosis requires a liver biopsy, non-invasive tests for fibrosis would be preferred. Consensus recommendation from the group is to risk-stratify patients based on metabolic risk factors using the FIB-4 as the initial non-invasive test due to its simplicity and ease of use. A FIB-4 score ≥1.3 can be used for further assessment and linkage to specialty care where additional technology to assess liver stiffness or serum fibrosis test will be available.

CONCLUSION

Due to the growing burden of NAFLD and NASH, PCPs and diabetologists are faced with increased patient encounters in their clinical practices necessitating referral decisions. To assist in identifying high-risk NASH patients requiring specialty care, we provide a simple and easy to use algorithm.

Medical Management of the Diabetic Patient

Diabetes prevalence is increasing in the United States. As of 2017, 30.3 million people in the United States have diabetes (9.4% of population). Of these, an estimated 7.2 million persons are undiagnosed. Prediabetes, a condition that is associated with peripheral neuropathy and is a precurser to diabetes, affects 83.1 million or 33.9% of adults in the United States. Diabetes is most commonly diagnosed by fasting plasma glucose or by an A1C test. An oral glucose tolerance test can also be used, but its use is primarily restricted to research settings.

Patients With Diabetes and Chronic Liver Disease Are at Increased Risk for Overall Mortality: A Population Study From the United States

IN BRIEF Chronic liver disease (CLD) and type 2 diabetes have both been linked to increased morbidity and mortality. In this study, the impact of CLD and diabetes on all-cause mortality was quantified at the population level using U.S. population data. Both type 2 diabetes and CLD were found to be independently associated with increased mortality (age-adjusted hazard ratio [aHR] 1.98 and 1.37 for diabetes and CLD, respectively), and having both diabetes and CLD substantially increased the risk of mortality (aHR 2.41).

Vaccination against hepatitis A and B in patients with chronic liver disease and type 2 diabetes: has anything changed?

BACKGROUND & AIMS

Given the severity of acute hepatitis in patients with chronic liver diseases (CLD) and patients with type 2 diabetes (DM), most of these patients are recommended to be vaccinated. The aim is to assess the recent changes in HAV and HBV vaccination rates in patients with CLD and DM in the U.S. using the most recent population data.

METHODS

We used the National Health and Nutrition Examination Surveys (NHANES) cycles 2009-2012 and 2013-2014, and compared those to previous cycles (1999-2004 and 2005-2008).

RESULTS

In general U.S. population, the rates of quality measure (QM, serologic immunity or history of vaccination) for HBV increased from 31.9% in 1999-2004 to 49.5% in 2013-2014 (P < 0.0001), synchronously with an increase in self-reported HBV vaccination: from 24.4% to 41.3% (P < 0.0001). A similar increase was noted for HAV: 12.0% in 1999-2004 to 33.4% in 2013-2014 in vaccination, 44.0% to 52.4% in HAV QM (all P < 0.0001). Greater recent increases in HBV QM were noted in non-HBV CLD patients: 34.7% to 56.8% in HBV QM and 22.7% to 51.1% in HBV vaccination (all P < 0.0001), while the changes in patients with diabetes were similar to those in general U.S. population despite the recent CDC recommendation (for the age 19-59): 31.0% to 45.1% (P = 0.007) in HBV QM, and 22.3% to 39.0% (P = 0.0004) in HBV vaccination.

CONCLUSIONS

Despite recommendations, HAV and HBV vaccination rates in patients with CLD and DM remain relatively low. Better vaccination strategies for these high risk patients should be undertaken.

Evidence for effective interventions to reduce mental health-related stigma and discrimination in the medium and long term: systematic review

BACKGROUND

Most research on interventions to counter stigma and discrimination has focused on short-term outcomes and has been conducted in high-income settings.

AIMS

To synthesise what is known globally about effective interventions to reduce mental illness-based stigma and discrimination, in relation first to effectiveness in the medium and long term (minimum 4 weeks), and second to interventions in low- and middle-income countries (LMICs).

METHOD

We searched six databases from 1980 to 2013 and conducted a multi-language Google search for quantitative studies addressing the research questions. Effect sizes were calculated from eligible studies where possible, and narrative syntheses conducted. Subgroup analysis compared interventions with and without social contact.

RESULTS

Eighty studies (n = 422 653) were included in the review. For studies with medium or long-term follow-up (72, of which 21 had calculable effect sizes) median standardised mean differences were 0.54 for knowledge and -0.26 for stigmatising attitudes. Those containing social contact (direct or indirect) were not more effective than those without. The 11 LMIC studies were all from middle-income countries. Effect sizes were rarely calculable for behavioural outcomes or in LMIC studies.

CONCLUSIONS

There is modest evidence for the effectiveness of anti-stigma interventions beyond 4 weeks follow-up in terms of increasing knowledge and reducing stigmatising attitudes. Evidence does not support the view that social contact is the more effective type of intervention for improving attitudes in the medium to long term. Methodologically strong research is needed on which to base decisions on investment in stigma-reducing interventions.

The link between mental health-related discrimination and suicidality: service user perspectives

BACKGROUND

Suicide is a major global public health issue. Mental illness is a risk factor for suicide, but as many individuals with a diagnosed mental health problem do not experience suicidal ideation or attempt suicide, other individual and societal factors must be considered. Mental illness-related discrimination is one potential risk factor.

METHOD

Using mixed methods, the influence of discrimination on suicidality amongst 194 individuals diagnosed with depression, bipolar or schizophrenia spectrum disorders was investigated. Qualitative interviews with a sub-sample of 58 individuals who reported a link between experience of discrimination and suicidality were analysed using framework analysis. Quantitative methods were used to examine the model derived from qualitative analyses.

RESULTS

Results indicate that the experience of discrimination led 38% of the overall sample of 194 participants, to suicidal feelings and 20% reported that it contributed to making a suicide attempt. The qualitative model derived from interviews with a sub-sample of 58 participants suggested that the experience of discrimination is experienced as a stressor that exceeds coping resources, leading to a negative self-image and a perception of decreased supportive networks/social structure. The anticipation of further negative events and treatment, and the perception of a lack of supportive networks led individuals in this study to feelings of hopelessness and suicidality. Quantitative analyses provided support for the model.

CONCLUSIONS

These data suggest that both psychological therapies aimed at improving coping skills and population-level anti-stigma interventions that reduce the occurrence of discrimination may provide some protection against suicide amongst individuals with mental health problems.

How does a decision aid help people decide whether to disclose a mental health problem to employers? Qualitative interview study

Background Decisions about whether to disclose mental health problems to employers are complex, with potential personal, employment and legal implications. Decision aids are evidence based tools, designed to help individuals make specific choices between treatment options. We previously developed a decision aid-Conceal Or ReveAL (CORAL)-to assist service users with decisions about disclosure to employers. As part of a mixed methods exploratory RCT, which demonstrated that the CORAL decision aid was effective in reducing decisional conflict, we aimed to explore its mechanism of action and to optimise the intervention for a future full scale trial. Methods In depth interviews were conducted with individuals receiving vocational support from a mental health trust and participating in the intervention arm of the pilot trial. Thematic analysis was conducted to identify the main themes relating to participants' perceptions of the CORAL decision aid. Results Thirteen participants were interviewed and five main themes were identified: sense of self and values; sense of control; anticipation of disclosure; experience of disclosure; and mechanism of action of the decision aid. Conclusions Data from our 13 participants suggest that the CORAL decision aid acts on several dimensions of decisional conflict: clarifying the pros and cons of different choices; increasing knowledge; structuring the decision making process; and clarifying needs and values. The current study indicated that it would be most effective when delivered by a professional well versed in employment and mental health matters such as a vocational adviser. The need for employers and policymakers to reduce the negative impact of disclosure is also highlighted.

What is the impact of mental health-related stigma on help-seeking? A systematic review of quantitative and qualitative studies

BACKGROUND

Individuals often avoid or delay seeking professional help for mental health problems. Stigma may be a key deterrent to help-seeking but this has not been reviewed systematically. Our systematic review addressed the overarching question: What is the impact of mental health-related stigma on help-seeking for mental health problems? Subquestions were: (a) What is the size and direction of any association between stigma and help-seeking? (b) To what extent is stigma identified as a barrier to help-seeking? (c) What processes underlie the relationship between stigma and help-seeking? (d) Are there population groups for which stigma disproportionately deters help-seeking?

METHOD

Five electronic databases were searched from 1980 to 2011 and references of reviews checked. A meta-synthesis of quantitative and qualitative studies, comprising three parallel narrative syntheses and subgroup analyses, was conducted.

RESULTS

The review identified 144 studies with 90,189 participants meeting inclusion criteria. The median association between stigma and help-seeking was d = - 0.27, with internalized and treatment stigma being most often associated with reduced help-seeking. Stigma was the fourth highest ranked barrier to help-seeking, with disclosure concerns the most commonly reported stigma barrier. A detailed conceptual model was derived that describes the processes contributing to, and counteracting, the deterrent effect of stigma on help-seeking. Ethnic minorities, youth, men and those in military and health professions were disproportionately deterred by stigma.

CONCLUSIONS

Stigma has a small- to moderate-sized negative effect on help-seeking. Review findings can be used to help inform the design of interventions to increase help-seeking.

The impact of type 2 diabetes and obesity on the long-term outcomes of more than 85 000 liver transplant recipients in the US

BACKGROUND

Type 2 diabetes is known to negatively impact the outcome of chronic liver disease.

AIM

To evaluate the impact of diabetes on the outcomes of liver transplants (LT).

METHODS

Study cohort included adults (>18 years) who received LT in the US between 1994 and 2013 (The Scientific Registry of Transplant Recipients). Pre- and post-transplant diabetes was recorded in patients with mortality follow-up.

RESULTS

We included 85 194 liver transplant recipients. Of those, 11.2% had history of pre-transplant diabetes. The most common indications for liver transplant were hepatitis C (36.4%), alcohol-related liver disease (20.6%), primary liver malignancy of unspecified aetiology (14.7%), cryptogenic cirrhosis (8.0%), hepatitis B (4.6%) and non-alcoholic steatohepatitis (3.9%). A total of 96.5% transplants were from deceased donors, and 7.9% donors had history of diabetes. During an average 6.5 years of follow-up, 31.3% recipients died and 8.8% had a graft failure. In multivariate survival analysis [at least 5 years of cohort follow-up (N = 35 870)], after adjustment for age, ethnicity, insurance type, history of chronic diseases, HCV infection and noncompliance, independent predictors of recipient mortality included the presence of pre-transplant diabetes [adjusted hazard ratio (95%CI) = 1.21 (1.12-1.30)] and developing diabetes post-transplant [1.06 (1.02-1.11)]. Donor's history of diabetes was also independently associated with higher mortality [1.10 (1.02-1.19)]. Furthermore, donor's history of diabetes was also associated with an increased the risk of liver graft failure [1.35 (1.24-1.47)].

CONCLUSIONS

Presence of type 2 diabetes pre- and post-transplant, as well as presence of type 2 diabetes in the donors, are all associated with an increased risk of adverse post-transplant outcomes.

Stem cell-based treatments for Type 1 diabetes mellitus: bone marrow, embryonic, hepatic, pancreatic and induced pluripotent stem cells

Type 1 diabetes mellitus--characterized by the permanent destruction of insulin-secreting β-cells--is responsive to cell-based treatments that replace lost β-cell populations. The current gold standard of pancreas transplantation provides only temporary independence from exogenous insulin and is fraught with complications, including increased mortality. Stem cells offer a number of theoretical advantages over current therapies. Our review will focus on the development of treatments involving tissue stem cells from bone marrow, liver and pancreatic cells, as well as the potential use of embryonic and induced pluripotent stem cells for Type 1 diabetes therapy. While the body of research involving stem cells is at once promising and inconsistent, bone marrow-derived mesenchymal stem cell transplantation seems to offer the most compelling evidence of efficacy. These cells have been demonstrated to increase endogenous insulin production, while partially mitigating the autoimmune destruction of newly formed β-cells. However, recently successful experiments involving induced pluripotent stem cells could quickly move them into the foreground of therapeutic research. We address the limitations encountered by present research and look toward the future of stem cell treatments for Type 1 diabetes.

Determinants of glucose tolerance in impaired glucose tolerance at baseline in the Actos Now for Prevention of Diabetes (ACT NOW) study

AIMS/HYPOTHESIS

The aim of the study was to examine the determinants of oral glucose tolerance in 602 persons with impaired glucose tolerance (IGT) who participated in the Actos Now for Prevention of Diabetes (ACT NOW) study.

METHODS

In addition to the 602 IGT participants, 115 persons with normal glucose tolerance (NGT) and 50 with impaired fasting glucose (IFG) were identified during screening and included in this analysis. Insulin secretion and insulin sensitivity indices were derived from plasma glucose and insulin during an OGTT. The acute insulin response (AIR) (0-10 min) and insulin sensitivity (S(I)) were measured with the frequently sampled intravenous glucose tolerance test (FSIVGTT) in a subset of participants.

RESULTS

At baseline, fasting plasma glucose, 2 h postprandial glucose (OGTT) and HbA(1c) were 5.8 +/- 0.02 mmol/l, 10.5 +/- 0.05 mmol/l and 5.5 +/- 0.04%, respectively, in participants with IGT. Participants with IGT were characterised by defects in early (DeltaI (0-30)/DeltaG (0-30) x Matsuda index, where DeltaI is change in insulin in the first 30 min and DeltaG is change in glucose in the first 30 min) and total (DeltaI(0-120)/DeltaG(0-120) x Matsuda index) insulin secretion and in insulin sensitivity (Matsuda index and S(I)). Participants with IGT in whom 2 h plasma glucose was 7.8-8.3 mmol/l had a 63% decrease in the insulin secretion/insulin resistance (disposition) index vs participants with NGT and this defect worsened progressively as 2 h plasma glucose rose to 8.9-9.94 mmol/l (by 73%) and 10.0-11.05 mmol/l (by 80%). The Matsuda insulin sensitivity index was reduced by 40% in IGT compared with NGT (p < 0.005). In multivariate analysis, beta cell function was the primary determinant of glucose AUC during OGTT, explaining 62% of the variance.

CONCLUSION

Our results strongly suggest that progressive beta cell failure is the main determinant of progression of NGT to IGT.

What are the best options for controlling prandial glycemia?

Epidemiologic studies suggest that postprandial hyperglycemia is more strongly linked to an increased risk for cardiovascular events than fasting or preprandial glucose levels. Although the results of prospective randomized studies proving causation of this finding are mixed, clinicians have given increased attention to target therapy to postprandial glucose than in the past. Rapid-acting insulin analogues, glucagon-like peptide-1 agonists, dipeptidyl peptidase-4 inhibitors, and acarbose all target the postprandial glucose levels. This wide range of therapies allows the clinician to mix and match agents of different classes to target the fasting, preprandial, and postprandial glucose to optimize the daily glucose pattern and reduce the risk of diabetic complications.

Actos Now for the prevention of diabetes (ACT NOW) study

BACKGROUND

Impaired glucose tolerance (IGT) is a prediabetic state. If IGT can be prevented from progressing to overt diabetes, hyperglycemia-related complications can be avoided. The purpose of the present study was to examine whether pioglitazone (ACTOS) can prevent progression of IGT to type 2 diabetes mellitus (T2DM) in a prospective randomized, double blind, placebo controlled trial.

METHODS/DESIGN

602 IGT subjects were identified with OGTT (2-hour plasma glucose = 140-199 mg/dl). In addition, IGT subjects were required to have FPG = 95-125 mg/dl and at least one other high risk characteristic. Prior to randomization all subjects had measurement of ankle-arm blood pressure, systolic/diastolic blood pressure, HbA1C, lipid profile and a subset had frequently sampled intravenous glucose tolerance test (FSIVGTT), DEXA, and ultrasound determination of carotid intima-media thickness (IMT). Following this, subjects were randomized to receive pioglitazone (45 mg/day) or placebo, and returned every 2-3 months for FPG determination and annually for OGTT. Repeat carotid IMT measurement was performed at 18 months and study end. Recruitment took place over 24 months, and subjects were followed for an additional 24 months. At study end (48 months) or at time of diagnosis of diabetes the OGTT, FSIVGTT, DEXA, carotid IMT, and all other measurements were repeated.Primary endpoint is conversion of IGT to T2DM based upon FPG >or= 126 or 2-hour PG >or= 200 mg/dl. Secondary endpoints include whether pioglitazone can: (i) improve glycemic control (ii) enhance insulin sensitivity, (iii) augment beta cell function, (iv) improve risk factors for cardiovascular disease, (v) cause regression/slow progression of carotid IMT, (vi) revert newly diagnosed diabetes to normal glucose tolerance.

CONCLUSION

ACT NOW is designed to determine if pioglitazone can prevent/delay progression to diabetes in high risk IGT subjects, and to define the mechanisms (improved insulin sensitivity and/or enhanced beta cell function) via which pioglitazone exerts its beneficial effect on glucose metabolism to prevent/delay onset of T2DM.

TRIAL REGISTRATION

clinical trials.gov identifier: NCT00220961.

Developing a user-generated measure of continuity of care: brief report

OBJECTIVE

This paper describes a measure of continuity of care, establishes its reliability and tests it in a field trial sample for evidence of its validity. In contrast to others, this measure has been generated from the perspectives of service users. As continuity of care is a concern particularly for those with severe mental illness, we have confined our work to this population group.

METHOD

Service users in focus groups and expert panels generated the measure. The researchers were themselves service users. Test-retest reliability was assessed with an independent sample. The measure was administered to a final independent field trial sample to determine their experiences of continuity of care and for further psychometric testing.

RESULTS

The measure generated by service users has satisfactory psychometric properties. Service users in the field trial sample were more satisfied when continuity, as assessed by this measure, was in place.

CONCLUSION

It is possible and valid to construct outcome measures in mental health entirely from the user perspective. This has not been done before.

Continuity of care in mental health: understanding and measuring a complex phenomenon

BACKGROUND

Continuity of care is considered by patients and clinicians an essential feature of good quality care in long-term disorders, yet there is general agreement that it is a complex concept. Most policies emphasize it and encourage systems to promote it. Despite this, there is no accepted definition or measure against which to test policies or interventions designed to improve continuity. We aimed to operationalize a multi-axial model of continuity of care and to use factor analysis to determine its validity for severe mental illness.

METHOD

A multi-axial model of continuity of care comprising eight facets was operationalized for quantitative data collection from mental health service users using 32 variables. Of these variables, 22 were subsequently entered into a factor analysis as independent components, using data from a clinical population considered to require long-term consistent care.

RESULTS

Factor analysis produced seven independent continuity factors accounting for 62.5% of the total variance. These factors, Experience and Relationship, Regularity, Meeting Needs, Consolidation, Managed Transitions, Care Coordination and Supported Living, were close but not identical to the original theoretical model.

CONCLUSIONS

We confirmed that continuity of care is multi-factorial. Our seven factors are intuitively meaningful and appear to work in mental health. These factors should be used as a starting-point in research into the determinants and outcomes of continuity of care in long-term disorders.

Algorithms for intravenous insulin delivery

This review aims to classify algorithms for intravenous insulin infusion according to design. Essential input data include the current blood glucose (BG(current)), the previous blood glucose (BG(previous)), the test time of BG(current) (test time(current)), the test time of BG(previous) (test time(previous)), and the previous insulin infusion rate (IR(previous)). Output data consist of the next insulin infusion rate (IR(next)) and next test time. The classification differentiates between "IR" and "MR" algorithm types, both defined as a rule for assigning an insulin infusion rate (IR), having a glycemic target. Both types are capable of assigning the IR for the next iteration of the algorithm (IR(next)) as an increasing function of BG(current), IR(previous), and rate-of-change of BG with respect to time, each treated as an independent variable. Algorithms of the IR type directly seek to define IR(next) as an incremental adjustment to IR(previous). At test time(current), under an IR algorithm the differences in values of IR(next) that might be assigned depending upon the value of BG(current) are not necessarily continuously dependent upon, proportionate to, or commensurate with either the IR(previous) or the rate-of-change of BG. Algorithms of the MR type create a family of IR functions of BG differing according to maintenance rate (MR), each being an iso-MR curve. The change of IR(next) with respect to BG(current) is a strictly increasing function of MR. At test time(current), algorithms of the MR type use IR(previous) and the rate-of-change of BG to define the MR, multiplier, or column assignment, which will be used for patient assignment to the right iso-MR curve and as precedent for IR(next). Bolus insulin therapy is especially effective when used in proportion to carbohydrate load to cover anticipated incremental transitory enteral or parenteral carbohydrate exposure. Specific distinguishing algorithm design features and choice of parameters may be important to establish freedom from hypoglycemia, eliminate the need for administration of concentrated dextrose during euglycemia, control variability within the treatment course of individual patients, achieve adaptability to differing blood glucose targets, and minimize variability of glycemic control between treatment courses of different patients or patient populations. Areas for future work include the reduction of nursing burden, the development of a theory that will account for lag time of interstitial monitoring and pharmacodynamic delay of insulin action, and management strategies for the narrow euglycemic range. It is hoped that hypoglycemia and variability of control will become negligible problems, and that fear of hypoglycemia no longer will deflect investigators and caregivers from providing optimal glycemic management.

A review of instruments developed to measure outcomes for carers of people with mental health problems

OBJECTIVE

Community-based care for mental disorders places considerable burden on families and carers. Measuring their experiences has become a priority, but there is no consensus on appropriate instruments. We aimed to review instruments carers consider relevant to their needs and assess evidence for their use.

METHOD

A literature search was conducted for outcome measures used with mental health carers. Identified instruments were assessed for their relevance to the outcomes identified by carers and their psychometric properties.

RESULTS

Three hundred and ninety two published articles referring to 241 outcome measures were identified, 64 of which were eligible for review (used in three or more studies). Twenty-six instruments had good psychometric properties; they measured (i) carers' well-being, (ii) the experience of caregiving and (iii) carers' needs for professional support.

CONCLUSION

Measures exist which have been used to assess the most salient aspects of carers outcome in mental health. All require further work to establish their psychometric properties fully.

The therapeutic relationship in secondary mental health care: a conceptual review of measures

OBJECTIVE

The study aimed to determine the conceptual basis of measures of the patient-professional relationship used in routine mental health services research by reviewing their face, content and construct validity.

METHOD

A comprehensive literature search identified measures of the relationship used in mental health services research. The conceptual basis of each identified measure was identified by a review of measures' authors assessments of face, content and construct validity plus item analysis of the measures themselves.

RESULTS

The search identified 15 measures. The seven developed in psychotherapy were likely to be better validated conceptually; most were based on therapeutic alliance models. Measures developed specifically for mental health services were based on a wider range of models including global assessments of the relationship.

CONCLUSION

Most of the better validated measures originate in psychotherapy, but there is limited evidence for their validity in general mental health services. Four measures are recommended.

Hyponatremia in marathon runners due to inappropriate arginine vasopressin secretion

PURPOSE

Exercise-associated hyponatremia (EAH), as defined by a blood sodium concentration [Na+] less than 135 mmol/L, may lead to hypotonic encephalopathy with fatal cerebral edema. Understanding the pathogenetic role of antidiuresis may lead to improved strategies for prevention and treatment.

METHODS

Normonatremic marathon runners were tested pre- and post-race for creatine kinase, interleukin-6, cortisol, prolactin, and arginine vasopressin. Similar testing also was carried out in runners with encephalopathy caused by EAH, including 2 cases with fatal cerebral edema.

RESULTS

Normonatremic runners (n = 33; 2001) with a mean 3% decrease in body weight showed a 40-fold increase in interleukin-6 (66.6 +/- 11.9 pg/mL from 1.6 +/- 0.5 pg/mL, P = .001), which was significantly correlated with increases in creatine kinase (r = 0.88, P = <.0001), cortisol (r = 0.70, P = .0003), and prolactin (r = 0.67, P <.007), but not arginine vasopressin (r = 0.44, P = .07). Collapsed runners with EAH (n = 22; 2004) showed a mean blood urea nitrogen less than 15 mg/dL with measurable plasma levels of arginine vasopressin (>0.5 pg/mL) in 43% of cases. Two marathon runners with fatal cerebral edema additionally showed less than maximally dilute urines (>100 mmol/kg/H2O) and urine [Na+] greater than 25 mEq/L.

CONCLUSIONS

Cases of EAH fulfill the essential diagnostic criteria for the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Runners with hypotonic encephalopathy at subsequent races were treated with intravenous hypertonic (3%) saline on the basis of this paradigm, which resulted in rapid clinical improvement without adverse effects. Release of muscle-derived interleukin-6 may play a role in the nonosmotic secretion of arginine vasopressin, thereby linking rhabdomyolysis to the pathogenesis of EAH.

Better glycemic control in the hospital: beneficial and feasible

Hospitalized patients fare better if their blood glucose levels are strictly controlled. To manage blood glucose effectively, hospitals need to set up formal programs. Attending physicians, endocrinologists, and nurses need to work as a team. Standardized forms with management guidelines are valuable.

Intracellular residency is frequently associated with recurrent Staphylococcus aureus rhinosinusitis

AIM

The prevalence of intracellular Staphylococcus aureus organisms in the nasal mucosa of patients with recurrent infectious rhinosinusitis episodes was studied.

METHOD

Twenty-seven consecutive adult patients who failed medical management of chronic rhinosinusitis (CRS) of multiple origins, associated or not with nasal polyposis, were consecutively enrolled for endonasal sinus surgery (including partial middle turbinectomy, middle antrostomy, ethmoidectomy, sphenoidotomy) and followed for a 12-month post-operative period.

RESULTS

Seventeen of these patients showed the presence of intracellular S. aureus as detected by confocal laser scan immunofluorescence microscopy in epithelial cells of surgical intranasal biopsy specimens. Nine of the patients with and two without intracellular bacteria yielded S. aureus in endoscopically guided cultures of middle meatus secretions, despite the recent administration of prophylactic antibiotics. Eleven of the 17 patients with intracellular S. aureus relapsed for rhinosinusitis within the 12-month follow-up period. Molecular typing of sequential S. aureus isolates demonstrated the persistence of unique patient-specific S. aureus clonotypes in nine of the patients with intracellular bacteria during the 12-month follow-up.

CONCLUSION

The presence of intracellular S. aureus in epithelial cells of the nasal mucosa is a significant risk factor for recurrent episodes of rhinosinusitis due to persistent bacterial clonotypes, which appear refractory to antimicrobial and surgical therapy.

Embryonic and adult stem cell-derived cardiomyocytes: lessons from in vitro models

For years, research has focused on how to treat heart failure by sustaining the overloaded remaining cardiomyocytes. Recently, the concept of cell replacement therapy as a treatment of heart diseases has opened a new area of investigation. In vitro-generated cardiomyocytes could be injected into the heart to rescue the function of a damaged myocardium. Embryonic and/or adult stem cells could provide cardiac cells for this purpose. Knowledge of fundamental cardiac differentiation mechanisms unraveled by studies on animal models has been improved using in vitro models of cardiogenesis such as mouse embryonal carcinoma cells, mouse embryonic stem cells and, recently, human embryonic stem cells. On the other hand, studies suggesting the existence of cardiac stem cells and the potential of adult stem cells from bone marrow or skeletal muscle to differentiate toward unexpected phenotypes raise hope and questions about their potential use for cardiac cell therapy. In this review, we compare the specificities of embryonic vs adult stem cell populations regarding their cardiac differentiation potential, and we give an overview of what in vitro models have taught us about cardiogenesis.

[Non-invasive bi-level ventilation in paediatric status asthmaticus]

Invasive ventilation in status asthmaticus is associated with an increased mortality and morbidity. To avoid intubation associated complications, non-invasive bi-level ventilation is often used in adults and children. We report the clinical history of an 11-month old infant, which encountered intubation criteria but was treated successfully by full-face mask non-invasive bi-level ventilation. Despite difficulties in application due to young age and lack of age related material, non-invasive bi-level ventilation is a good tool in the treatment of children with status asthmaticus.

Subcutaneous Insulin Therapy in the Hospital Setting: Issues, Concerns, and Implementation

OBJECTIVE

To summarize issues and recommendations regarding subcutaneous insulin therapy in various clinical settings in the hospital.

RESULTS

The inpatient insulin regimen must be tailored to the specific clinical circumstance of the individual patient. Because nutritional intake is not necessarily provided as discrete meals in the hospital, the insulin dose requirement can be subclassified into "basal" and "nutritional" needs. In addition, the insulin requirement is generally increased in the presence of acute illness and stress. Thus, components of the insulin requirement are divided into basal, nutritional, and correction insulin. When the physician writes insulin orders, the basal and nutritional components are written as programmed or scheduled insulin, and the correction-dose insulin is written as an algorithm to supplement the scheduled insulin. Total insulin requirements may vary widely. Practical guidelines and suggestions are presented for selection of appropriate insulins, the delivery route, and the logical apportionment to programmed and correction insulin doses for hospitalized patients who are eating or not eating. Moreover, the role of bedside blood glucose monitoring in the hospital setting is discussed.

CONCLUSION

Strict glycemic management in hospitalized patients has been shown to improve outcomes. Development and implementation of specific strategies for insulin delivery and improved methods for blood glucose monitoring should help to achieve target blood glucose levels safely.

Guidelines for glycemic control

Glycemic control in diabetes patients continues to evolve as new medications are introduced and clinical trial data become available. The American Diabetes Association (ADA) guidelines for 2004, for the first time, provide targets for both preprandial and postprandial glucose levels. The ADA, however, does not provide guidelines regarding specific medication therapy. This paper provides a detailed treatment algorithm that is easy to follow for nurse practitioners as well as primary care providers. Progress in our understanding of diabetes and new therapeutic agents will dictate modifications of treatment targets and guidelines, with the goal of making euglycemia achievable for all patients with diabetes.

Oral modified insulin (HIM2) in patients with type 1 diabetes mellitus: results from a phase I/II clinical trial

An effective, orally administered insulin product would be of substantial benefit in the treatment of patients with diabetes mellitus. This phase I/II clinical trial was the first to investigate the safety and effectiveness of a single oral dose of a modified human insulin in controlling postprandial plasma glucose levels in patients with type 1 diabetes mellitus who were receiving basal continuous subcutaneous insulin infusion (CSII) therapy. Fourteen patients with type 1 diabetes mellitus were evaluated in an open-label, 2-center, dose-escalation, nonrandomized study of oral hexyl-insulin monoconjugate 2 (HIM2). After an overnight fast and prior to receiving a standardized meal (50% carbohydrates, 30% fat, 20% proteins; 650 calories), the patients received either no additional insulin (day 1), or 0.5 to 1.0 mg/kg of HIM2 (day 2). All patients received a basal insulin regimen by CSII throughout the study. Blood samples were collected for determination of glucose and insulin levels for 240 minutes post-dose. The postprandial glucose excursion versus time curves showed clear reductions in glucose values after both HIM2 doses (day 2) relative to no treatment (day 1), although the differences in the reductions were not statistically significant. When the data for both HIM2 doses were pooled, a statistically significant effect of HIM2 on glucose excursion (as measured by AUCex(30-240)) was observed. Mean +/- SD values for AUCex(30-240) were 501.35 +/- 124.1 mg. h/dL after no treatment and 375.81 +/- 215.5 mg. h/dL after HIM2 (Wilcoxon signed-rank test, P =.042). The results of this study suggest that oral HIM2, when added to a basal insulin regimen, was safe and may prove effective in controlling postprandial hyperglycemia in patients with type 1 diabetes mellitus. Further clinical investigation is necessary.

Transvaginal ultrasound in pregnancy: its acceptability to women and maternal psychological morbidity

OBJECTIVES

To assess the acceptability to women of antenatal transvaginal ultrasound scans; to compare the characteristics of women who accept the offer of a transvaginal scan with those who decline; to establish the prevalence of any psychological morbidity associated with the scan.

METHODS

The study was a cross-sectional questionnaire survey. Women were recruited from two hospitals in South London. The sample consisted of 755 pregnant women who had a transvaginal scan at 23 weeks' gestation to assess the risk of preterm delivery and 167 women who were offered the transvaginal scan but declined. Women completed a questionnaire at home. Those who reported finding the scan a difficult experience were sent a questionnaire 4 weeks post-scan to assess its longer term impact. The main outcomes were acceptability (assessed by individual questionnaire items); anxiety before and during the scan (Spielberger State-trait Anxiety Inventory); pain during the scan (Present Pain Intensity Scale of the McGill Pain Questionnaire); psychological trauma (Impact of Event Scale).

RESULTS

Over half (55.2%) of women accepted the offer of a transvaginal scan, according to hospital records. The majority of study participants who had transvaginal ultrasound reported finding the experience acceptable. Women experienced some anxiety before and during the scan and over a third experienced some (usually mild) pain during the procedure. Twelve women (1.6%) reported clinically significant levels of psychological trauma in relation to the scan.

CONCLUSIONS

Antenatal transvaginal ultrasound for assessing the risk of preterm delivery is an acceptable procedure for the majority of women. A significant minority decline the scan. The procedure has some psychological sequelae for some women.

Oral insulin product hexyl-insulin monoconjugate 2 (HIM2) in type 1 diabetes mellitus: the glucose stabilization effects of HIM2

This study was designed to determine plasma glucose and insulin levels after administration of three escalating doses of the oral insulin product hexyl-insulin monoconjugate 2 (HIM2) in fasting, insulin-deprived adult patients with type 1 diabetes. The study was also designed to assess the safety of the product. Sixteen patients with daily insulin requirements of 27-60 units and glycosylated hemoglobin levels of 5.8-11.1% completed the study. Patients' regular insulin regimens were discontinued at bedtime, and they fasted overnight. Blood glucose levels were stabilized overnight by intravenous insulin infusion. In the morning, intravenous insulin was discontinued 30 min prior to an oral dose of HIM2 (0.6, 0.8, or 1.0 mg/kg). A second oral dose of HIM2 was administered 120 min later. Plasma glucose and insulin levels were measured during a 240-min evaluation period after the first HIM2 dose. Identical HIM2 dosing and study procedures were repeated 1 week later with the same patients. Stable or declining plasma glucose levels were observed on 31 out of a total of 32 dosing days beginning at 20 min after the initial administration of HIM2. After plasma glucose levels declined or were stable for 30 min to 2 h, increases were observed for some patients. However, for the majority of patients (68.8%), plasma glucose levels were <150% of predose levels throughout the postdose evaluation period. Similar results were observed after repeating the study procedures 1 week later. Also, plasma glucose area under the concentration-time curves (AUCs) were inversely correlated with plasma insulin AUCs. HIM2 appeared to be safe and well-tolerated in this study; no episodes of symptomatic hypoglycemia were observed. Thus, HIM2 prevented the expected rise in plasma glucose concentrations in insulin-deprived adult patients with type 1 diabetes. The lack of hypoglycemic events in this exploratory study is encouraging and suggests that there may be less risk of severe hypoglycemia associated with HIM2 when compared with injectable insulin. The promising data in this study support the hypothesis that oral HIM2 reproduces the physiological pathway of insulin secreted by the pancreas - through the portal vein directly to the liver - suggesting a therapeutic advantage in the management of type 1 diabetes mellitus.