De-Intensification from Basal-Bolus Insulin Therapy to Liraglutide in Type 2 Diabetes: Predictive Value of Mean Glycaemia during Fasting Test

BACKGROUND

Successful conversion from insulin therapy to glucagon-like peptide 1 receptor agonist (GLP-1RA) with basal insulin in well-controlled patients has already been demonstrated. However, the data concerning individuals with poor glycaemic control are scarce. The aim of this work was to assess the success rate of insulin therapy to liraglutide transition in poorly controlled diabetes in a real-world clinical setting and to define predictors of success. We are the first to present the method of a fasting test as a way to identify the patients at higher risk of failure after treatment de-intensification.

METHODS

The retrospective observational study analyzed data of 62 poorly controlled obese diabetic patients on high-dose insulin therapy, who were subjected to a 72 h fasting test during hospitalization and subsequently switched to liraglutide ± basal insulin therapy. During the fasting, all antidiabetic treatment was discontinued. Patients were classified as responders if they remained on GLP-1RA treatment after 12 months. Non-responders restarted the basal-bolus insulin (BBI) regimen. Development of glycated hemoglobin (HbA1c) and body weight in both groups, alongside with parameters associated with the higher risk of return to the BBI regimen, were analyzed.

RESULTS

A total of 71% of patients were switched successfully (=responders). Responders had more significant improvement in HbA1c (-6.4 ± 19.7 vs. -3.4 ± 22.9 mmol/mol) and weight loss (-4.6 ± 7.1 vs. -2.5 ± 4.0). Statistically significant difference between groups was found in initial HbA1c (75.6 ± 17.9 vs. 90.5 ± 23.6; p = 0.04), total daily dose of insulin (67.6 ± 36.4 vs. 90.8 ± 32.4; p = 0.02), and mean glycaemia during the fasting test (6.9 ± 1.7 vs. 8.6 ± 2.2 mmol/L; p < 0.01).

CONCLUSIONS

This study confirms that therapy de-intensification in poorly controlled patients with a BBI regimen is possible. Higher baseline HbA1c, total daily insulin dose, and mean glucose during fasting test are negative predictive factors of successful therapy de-escalation.

A Federated Learning-Inspired Evolutionary Algorithm: Application to Glucose Prediction

In this paper, we propose an innovative Federated Learning-inspired evolutionary framework. Its main novelty is that this is the first time that an Evolutionary Algorithm is employed on its own to directly perform Federated Learning activity. A further novelty resides in the fact that, differently from the other Federated Learning frameworks in the literature, ours can efficiently deal at the same time with two relevant issues in Machine Learning, i.e., data privacy and interpretability of the solutions. Our framework consists of a master/slave approach in which each slave contains local data, protecting sensible private data, and exploits an evolutionary algorithm to generate prediction models. The master shares through the slaves the locally learned models that emerge on each slave. Sharing these local models results in global models. Being that data privacy and interpretability are very significant in the medical domain, the algorithm is tested to forecast future glucose values for diabetic patients by exploiting a Grammatical Evolution algorithm. The effectiveness of this knowledge-sharing process is assessed experimentally by comparing the proposed framework with another where no exchange of local models occurs. The results show that the performance of the proposed approach is better and demonstrate the validity of its sharing process for the emergence of local models for personal diabetes management, usable as efficient global models. When further subjects not involved in the learning process are considered, the models discovered by our framework show higher generalization capability than those achieved without knowledge sharing: the improvement provided by knowledge sharing is equal to about 3.03% for precision, 1.56% for recall, 3.17% for F1, and 1.56% for accuracy. Moreover, statistical analysis reveals the statistical superiority of model exchange with respect to the case of no exchange taking place.

Comparison of Insulin Dose Adjustments Made by Artificial Intelligence-Based Decision Support Systems and by Physicians in People with Type 1 Diabetes Using Multiple Daily Injections Therapy

Objective: Artificial intelligence-based decision support systems (DSS) need to provide decisions that are not inferior to those given by experts in the field. Recommended insulin dose adjustments on the same individual data set were compared among multinational physicians, and with recommendations made by automated Endo.Digital DSS (ED-DSS). Research Design and Methods: This was a noninterventional study surveying 20 physicians from multinational academic centers. The survey included 17 data cases of individuals with type 1 diabetes who are treated with multiple daily insulin injections. Participating physicians were asked to recommend insulin dose adjustments based on glucose and insulin data. Insulin dose adjustments recommendations were compared among physicians and with the automated ED-DSS. The primary endpoints were the percentage of comparison points for which there was agreement on the trend of insulin dose adjustments. Results: The proportion of agreement and disagreement in the direction of insulin dose adjustment among physicians was statistically noninferior to the proportion of agreement and disagreement observed between ED-DSS and physicians for basal rate, carbohydrate-to insulin ratio, and correction factor (P < 0.001 and P ≤ 0.004 for all three parameters for agreement and disagreement, respectively). The ED-DSS magnitude of insulin dose change was consistently lower than that proposed by the physicians. Conclusions: Recommendations for insulin dose adjustments made by automatization did not differ significantly from recommendations given by expert physicians regarding the direction of change. These results highlight the potential utilization of ED-DSS as a useful clinical tool to manage insulin titration and dose adjustments.

Adjustment of Insulin Pump Settings in Type 1 Diabetes Management: Advisor Pro Device Compared to Physicians' Recommendations

AIMS

To compare insulin dose adjustments made by physicians to those made by an artificial intelligence-based decision support system, the Advisor Pro, in people with type 1 diabetes (T1D) using an insulin pump and self-monitoring blood glucose (SMBG).

METHODS

This was a multinational, non-interventional study surveying 17 physicians from 11 countries. Each physician was asked to provide insulin dose adjustments for the settings of the pump including basal rate, carbohydrate-to-insulin ratios (CRs), and correction factors (CFs) for 15 data sets of pumps and SMBG of people with T1D (mean age 18.4 ± 4.8 years; eight females; mean glycated hemoglobin 8.2% ± 1.4% [66 ± 11mmol/mol]). The recommendations were compared among the physicians and between the physicians and the Advisor Pro. The study endpoint was the percentage of comparison points for which there was an agreement on the direction of insulin dose adjustments.

RESULTS

The percentage (mean ± SD) of agreement among the physicians on the direction of insulin pump dose adjustments was 51.8% ± 9.2%, 54.2% ± 6.4%, and 49.8% ± 11.6% for the basal, CR, and CF, respectively. The automated recommendations of the Advisor Pro on the direction of insulin dose adjustments were comparable )49.5% ± 6.4%, 55.3% ± 8.7%, and 47.6% ± 14.4% for the basal rate, CR, and CF, respectively( and noninferior to those provided by physicians. The mean absolute difference in magnitude of change between physicians was 17.1% ± 13.1%, 14.6% ± 8.4%, and 23.9% ± 18.6% for the basal, CR, and CF, respectively, and comparable to the Advisor Pro 11.7% ± 9.7%, 10.1% ± 4.5%, and 25.5% ± 19.5%, respectively, significant for basal and CR.

CONCLUSIONS

Considerable differences in the recommendations for changes in insulin dosing were observed among physicians. Since automated recommendations by the Advisor Pro were similar to those given by physicians, it could be considered a useful tool to manage T1D.

Risk of anal incontinence in women with inflammatory bowel diseases after delivery

AIM

The aim of our prospective study was to evaluate the development of postpartum anal incontinence in patients with inflammatory bowel disease (IBD) compared to healthy women.

MATERIAL AND METHODS

Patients with IBD and healthy controls enrolled in the study from January 1st 2013 to November 30th 2016 and filled in the anal incontinence questionnaire in the beginning of pregnancy and after vaginal delivery. The results were statistically processed using suitable tests.

RESULTS

A total of 57 women were enrolled, 17 (29.8 %) with ulcerative colitis, 23 (40.4 %) with Crohn's disease, and 17 (29.8 %) healthy controls. Incidence of postpartum anal incontinence is comparable across all groups; there was no statistically significant difference between the IBD and control groups (Kruskal-Wallis test by ranks with Dunn correction, non-significant). Postpartum anal incontinence was strongly correlated with the extent of perineal injury (r = 0.80; p < 0.0001; Pearson's linear correlation).

CONCLUSIONS

Women with inflammatory bowel disease in remission do not exhibit higher incidence of postpartum anal incontinence (PPAI) compared to healthy controls; the key correlate of PPAI appears to be the extent of obstetric injury, consistently across all study groups. These results suggest that concerns about postpartum anal incontinence development should not be an indication for Caesarean section in IBD patients (Tab. 6, Fig. 1, Ref. 34).

Diagnosing celiac disease in patients with a history of lymphoma: factors that matter

OBJECTIVE

The aim of this study was to identify pitfalls in establishing the diagnosis of celiac disease (CD) in patients with a history of lymphoma.

METHODS

A total of 103 patients with a history of lymphoma had anti-tissue transglutaminase antibodies (atTGA) and their class A, G, and M immunoglobulin (IgA, IgG) levels determined. Patients with atTGA positivity underwent enterobiopsy and CD-associated HLA locus testing.

RESULTS

The mean age of patients was 55 ( ± 13.5) years. The predominant lymphoma types included B-type non-Hodgkin's lymphoma (B-NHL, 66 %), T-type NHL (8 %), and Hodgkin's lymphoma (26 %). Serological positivity was documented in 3.9 % of cases; one patient had the diagnosis of CD confirmed by enterobiopsy. In 11 patients (10.7 %), IgA levels were decreased to a various extent; of these patients, 10 were shown to have also their IgG levels decreased. The median time from follow-up to blood collection was 58 (32-104) months. The decrease in immunoglobulin levels correlated with a more advanced stage of the tumor (Ann Arbor III-IV) at the time of diagnosis [1.4 (0.9-2.0) g/l versus 2.4 (1.5-3.0) g/l for IgA, p = 0.0001; and 9.4 (7.2-11.5) g/l versus 11.2 (10.3-12.3) g/l for IgG, p = 0.001] and older age [65 (54-72) years versus 55 (44-61) years for IgA, p = 0.04; and 69 (59-74) years versus 53 (43-61) years for IgG, p = 0.0001]. Rituximab therapy in B-NHL patients had no effect on the subsequent incidence of decreased IgA levels.

CONCLUSION

Reduced IgA and IgG levels represent important factors contributing to the low detection rate of serological screening for CD in patients with a history of lymphoma.

Influence of physical activity on metabolic state within a 3-h interruption of continuous subcutaneous insulin infusion in patients with type 1 diabetes

BACKGROUND

The aim of this study was to evaluate the influence of physical activity on blood glucose, insulinemia, and ketone bodies level during interruption of insulin delivery.

METHODS

We enrolled 12 patients with type 1 diabetes (men with an average age of 33.4±8.66 years, body mass index of 25.7±3.75 mg/m(2), and glycated hemoglobin of 8.4±0.95%). The test was performed after overnight fasting at the usual insulin dosage. The delivery of insulin by the pump was stopped for 3 h, and blood samples were obtained in 30-min intervals for determination of blood glucose, insulinemia, β-hydroxybutyrate, non-esterified fatty acids, and acid-base balance parameters. A test with (EXE) or without (CON) physical exercise (moderate aerobic exercise) was performed in each patient at random in the course of 2 weeks. Results are presented as median (first quartile; third quartile).

RESULTS

Groups CON and EXE did not differ in blood levels of insulin during the test. Regarding time course of glycemia, we found differences only in min 270 for CON versus EXE of 15.2 (13.6; 16.7) and 13.9 (9.1;16.5) mmol/L, respectively (P=0.038). Concerning blood levels of β-hydroxybutyrate, we found significant differences in min 180-300 of the test: CON of 419 (354; 541), 485 (344; 580), and 107 (63; 156) μmol/L versus EXE of 690 (631; 723), 703 (562; 871), and 241 (113; 507) μmol/L (P<0.01). Comparable results were found in values of total ketone bodies and free fatty acids.

CONCLUSIONS

The influence of physical activity during a 3-h interruption of insulin pump treatment is evident, especially in the increase in plasma levels of non-esterified fatty acids and ketone bodies. Correction bolus leads to a rapid increase in insulinemia; however, normalization of blood glucose and ketone bodies is achieved within another 90 min.

Analysis of continuous patient data from the Czech National Register of patients with type 1 and type 2 diabetes using insulin pump therapy

AIM

Patient data from the Czech National Register of patients treated with Continuous Subcutaneous Insulin Infusion (CSII) were evaluated to compare treatment indication, efficacy and safety with specific regard to the type of diabetes (T1 vs. T2).

METHODS

Evaluation was done on complete data sets of at least 3 years from patients with either T1 diabetes (n=730, 93.1%) or T2 diabetes (n=54, 6.9%) between 1995 and 2006.

RESULTS

HbA(1c) decreased from 9.65 (+/-0.07) and 9.66 (+/-0.05) for T1 and T2 respectively to 8.24 (+/-0.07) for T1 and 8.52 (+/-0.27) for T2 after 1 year of treatment, 8.34 (+/-0.07) and 8.54 (+/-0.26) after 2 years and 8.44 (+/-0.07) and 8.71 (+/-0.25) after 3 years (adjusted mean values, +/-SEM). This reduction is significant for both diabetes types. Results gathered from the safety analysis revealed almost comparable results for both patient groups (rates of adverse events of 42.5 and 34.8 for T1 and T2, per 100 patients and year).

CONCLUSION

Both patient groups achieved substantial reduction of HbA(1c). Safety evaluation showed that fewer patients with T2 diabetes were affected by adverse events. According to that CSII treatment for patients with T2 diabetes is similarly effective with a slightly better safety profile.

[Long-term evaluation of patients with type 1 diabetes mellitus treated with insulin glargine]

AIMS OF THE STUDY

To evaluate long-term effects of treatment with insulin analogue glargine in patients with type 1 diabetes mellitus and to follow up their further course of life.

PATIENT SAMPLE AND METHODOLOGY

Retrospective evaluation of 114 patients who, from September 2004, had their basal insulin changed from NPH insulin to insulin glargine. Treatment was changed again in patients in whom a year-long treatment with insulin glargine did not bring improvement in diabetes control. The original sample was divided into 3 groups and the results compared. Compensation of diabetes (HbA1c) after 1, 2 and 3 years and changes to basal and bolus daily insulin dose and body weight were evaluated.

RESULTS

The results are presented as median and 25th and 75th percentile. Group A--75 patients (65%) treated for the entire evaluation period with insulin glargine. Initial HbA1c was 7.3 (6.4-8.2)%, 6.9 (6.0-8.4)% after 1 year, 7.1 (5.9-7.9)% after 2 years and 6.6 (5.5-7.7)% after 3 years (p < 0.001). We did not identify any statistically significant changes to total, basal or bolus daily dose of insulin or statistically significant body weight increase over the evaluation period. Group B--19 patients (17%). Switch from insulin glargine to detemir twice daily. Initial HbA1c was 7.3 (6.9-8.5)%, 7.4 (6.8-8.7)% after 1 year of treatment with insulin glargine, 7.7 (7.2-8.1)% before the treatment switch and 7.8 (6.7-8.5)% (NS) after 3 years of treatment. Daily dose of total, basal and bolus insulin did not change and, similarly, no statistically significant change to patients' bodyweight was identified. Group C--17 patients (15%). Switch from insulin glargine to an insulin pump. This group had better initial compensation with HbA1c 6.7(5.7-8.6)%, HbA1c after 1 year was 6.2 (5.6-8.1)%, 7.0 (6.0-7.4)% before the treatment switch and 6.3 (5.2-7.7)% after 3 years of treatment. Total daily insulin dose: 48 (34-60)-38 (25-49) IU/day (NS). Basal daily insulin dose: 17.5 (13-28) IU/day-23 (12-32) IU/day (NS). Bolus daily dose decreased significantly: from 25.5 (21-33) to 15.5 (12-22) IU/day (p < 0.01). Body weight: 76 (71-97) kg-73 (72-99) kg (NS). Only 3% of patients went back to NPH insulin.

CONCLUSION

Insulin glargine brings improved control of diabetes. The dose of insulin glargine did not differ from NPH insulin. No statistically significant body weight increase was observed during the evaluation period.

Influence of cardiovascular autonomic neuropathy on atherogenesis and heart function in patients with type 1 diabetes

AIM

Cardiovascular autonomic neuropathy (CAN) increases mortality of patients with type 1 diabetes (Type 1 DM). We set out to find out whether the presence of CAN in asymptomatic, normotensive Type 1 DM affects endothelial function (marker of atherogenesis) and left ventricle function (marker of cardiomyopathy).

METHODS

Twenty-one Type 1 DM with CAN (Group A) and 35 Type 1 DM without CAN (Group B) were enrolled in the study. None of them suffered from any cardiovascular disease nor advanced chronic complications of diabetes. Both groups were comparable in age, glycemic control, BMI, and blood pressure. Markers of endothelial dysfunction and chronic inflammation were used as indicators of incipient atherogenesis. Left ventricle function was evaluated using echocardiography.

RESULTS

Both groups did not differ in any parameter of atherogenesis. However we found a statistically significant difference in values characterizing systolic and diastolic left ventricle functions between the groups.

CONCLUSIONS

CAN is not associated with elevation of markers of endothelial dysfunction and chronic inflammation in normotensive asymptomatic Type 1 DM. However CAN is associated with the impairment of systolic and diastolic left ventricle function and can thus be regarded as one of the risk factors of diabetic cardiomyopathy.

Effect of mild increase of physical activity on microvasculary reactivity in obese subjects with diabetes mellitus type 2

Microangiopathy, well known in diabetic patients as a cause of late complications, develops mainly due to chronic exposition to elevated glucose and triglyceride level. Physical training acts as a protective factor even if no changes in metabolic parameters are observed. It's supposed, that lifestyle modification leads to the improvement of endothelial dysfunction and microvasculary reactivity, in healthy subjects it has already been proven experimentally.

AIM

Determine if mild, short time and metabolically indifferent increase of physical activity changes microvasculary reactivity in obese diabetic patients and how long these findings persist after return to habitual lifestyle. In 8 patients with type 2 diabetes mellitus was measured microvasculary reactivity and perfusion of skin in lower limbs by laser-doppler flowmetry and transcutaneous oximetry. First before the study, second after 3-week's period of habitual physical activity, third after 3-week's period of mild increased physical activity and finally after next 3-week's period of habitual activity. Training intensity was objectified (non sport-practiced subjects) by pedometers. Results were evaluated by Friedman and pair Wilcoxon test. After mild aerobic activity (walk about 800 [560-1400] meters/day) microvasculary reactivity was increased in both tests (increase after heating from 4,9x [4,4 D 5,4] to 6,1x [5,7 D 6,8], p<0.01, shorten half time to reach maximum perfusion from 4,1 [2,7 D 5,4] s to 3,1 [2,4 D 4,0] s, p<0.05. The increased perfusion lasted after following four weeks of habitual activity in smaller extent (microvascular reactivity increase after heating 5.2 [4.8 D 6.1] s, half time to reach maximum perfusion 3.8 [2.7 D 5.0], this increase was not significant in comparison with habitual activity in the first period). Metabolic and anthropometric parameters and transcutaneous oxygen tension didn't change significantly.

[Glycated haemoglobin--is it its exclusive position in diabetology under threat?]

Hyperglycaemia is the common characteristic for diabetes patients. Prolonged hyperglycaemia due to absolute or relative lack of insulin is the cause of microangiopathy. Glucose reacts with both blood vessel wall proteins and plasmatic proteins and erythrocyte haemoglobin. This characteristic of glucose is used to monitor the level of diabetes compensation. The level of glycated haemoglobin reflects glycaemia for the last 2 to 3 months. It began to be used in diabetology in the 1980's. This outline paper deals with some of the pitfalls with which glycated haemoglobin has been recently associated. The first part is dedicated to factors influencing haemoglobin glycation. The second, methodological part focuses on factors influencing its assessment and interpretation. The third part concentrates on the options for the substitution ofglycated haemoglobin by other diabetes compensation markers.

Could we predict asymptomatic cardiovascular autonomic neuropathy in type 1 diabetic patients attending out-patients clinics?

BACKGROUND AND AIMS

Diabetic cardiovascular autonomic neuropathy (CAN) is associated with increased morbidity and mortality. This complication may be asymptomatic for a long time. The aim of this study was to assess the prevalence, severity and predictors of asymptomatic CAN in patients with type 1 diabetes mellitus (DM1).

PATIENTS AND METHODS

107 patients with DM1 were enrolled: 52 men and 55 women aged 39.8 +/- 12.4 years (18-72), duration of DM 16.6 +/- 9.5 years (0.5-43), age at DM manifestation 23.5 +/- 12.8 years (1-54) and BMI 25.1 +/- 3.2 (18.9-33.91). CAN was assessed using standard cardiovascular reflex tests (Ewing battery) and the patients were divided into three groups according to the results: Group 0, without CAN; Group I, 1(st) degree CAN; Group II, 2(nd) degree CAN. We assessed the most frequent relationships between CAN and chronic complications, episodes of severe hypoglycemia, time-related parameters (age of patients, duration of diabetes, age at manifestation), glycosylated hemoglobin (HbA(1)c), BMI, cardiovascular diseases and blood pressure, and determined the predictability of CAN on the basis of these relationships.

RESULTS

Only 50 of the 107 patients (46%) showed no CAN. We found 1(st) degree CAN in 38 patients (36%) and 2(nd) degree CAN in 19 (18%). CAN correlated more significantly with the duration of diabetes (p < 0.001) than with age (p < 0.05). The relationship between CAN and HbA(1)c was on the borderline of statistical significance (p = 0.053). We found a positive correlation between CAN and the presence of chronic complications [peripheral neuropathy (p < 0.001), retinopathy (p < 0.001), and some markers of nephropathy: creatinine (p < 0.03), albuminuria (p < 0.01)]. Although blood pressure was within the physiological range (124.2/74.5 +/- 11.5/7.8 mmHg) in all patients, a positive correlation with CAN was confirmed (p < 0.05). No relationship with occurrence of severe hypoglycemia was found.

CONCLUSIONS

According to our results, asymptomatic CAN is very frequent in patients with DM1. By using multifactorial logistic regression (step-wise) analysis we demonstrated that if albuminuria, peripheral neuropathy and elevated systolic BP are present simultaneously, there is a high probability that the patient also has CAN (84.9% of initial group correctly predicted, p < 0.001).

The relationship between glycemia, insulin and oxidative stress in hereditary hypertriglyceridemic rat

The aim of this study was to determine the effects of insulin infusion on oxidative stress induced by acute changes in glycemia in non-stressed hereditary hypertriglyceridemic rats (hHTG) and Wistar (control) rats. Rats were treated with glucose and either insulin or normal saline infusion for 3 hours followed by 90 min of hyperglycemic (12 mmol/l) and 90 min of euglycemic (6 mmol/l) clamp. Levels of total glutathione (GSH), oxidized glutathione (GSSG) and total antioxidant capacity (AOC) were determined to assess oxidative stress. In steady states of each clamp, glucose infusion rate (GIR) was calculated for evaluation of insulin sensitivity. GIR (mg.kg(-1).min(-1)) was significantly lower in hHTG in comparison with Wistar rats; 25.46 (23.41 - 28.45) vs. 36.30 (27.49 - 50.42) on glycemia 6 mmol/l and 57.18 (50.78 - 60.63) vs. 68.00 (63.61 - 85.92) on glycemia 12 mmol/l. GSH/GSSG ratios were significantly higher in hHTG rats at basal conditions. Further results showed that, unlike in Wistar rats, insulin infusion significantly increases GSH/GSSG ratios in hHTG rats: 10.02 (9.90 - 11.42) vs. 6.01 (5.83 - 6.43) on glycemia 6 mmol/l and 7.42 (7.15 - 7.89) vs. 6.16 (5.74 - 7.05) on glycemia 12 mmol/l. Insulin infusion thus positively influences GSH/GSSG ratio and that way reduces intracellular oxidative stress in insulin-resistant animals.

[Clinical experience in treatment with the long-term insulin analogue glargin in a diabetes centre]

OBJECTIVE

To assess the experience obtained by a diabetes centre in the treatment of patients with type 1 diabetes with the long-term insulin analogue glargin.

PATIENT SAMPLE AND METHOD

136 patients with type 1 diabetes mellitus (DM) were evaluated on a retrospective basis for the period from March 2004 to march 2005. We monitored HbA(1c) before the treatment with glargin, after 3 months, again after 6 months, and finally after 1 year of therapy. We evaluated the effectiveness of treatment with glargin insulin based upon diabetes compensation at the start of treatment. We also compared glycaemia variability in the 6 months prior to treatment initiation and the 6 months after the application of glargin insulin, this was done using the standard glycaemia deviation obtained from the patients' glucometers. In addition we evaluated the changes in total, basal and bolus daily dose of insulin after the change in therapy.

RESULTS

The results were evaluated in the form of a median and the percentile of 25 and 75. Before the glargin therapy started, HbA(1c) was 7.4 (6.5-8.5)%. It decreased dramatically to 7.0 (6.2-8.1)% after 3 months of therapy (p < 0.01), to 7.2 (6.3-8.2)% after 6 months of therapy (p < 0.05), and reached the level of 7.1 (6.1-8.2)% after one year (p < 0.01). Analysis of glycemic profiles during the 6 months before and 6 months after transfer to glargin insulin therapy showed a significant decrease in the variability as evaluated by the decrease in standard deviations from the original 4.9 (4.3-5.6) mmol/l to 4.5 (3.9-5.1) mmol/l (p < 0.001). The total daily dose of insulin prior to treatment and after 6 months of therapy with glargin decreased from 44 (35-56) IU/day to 42 (34-53) IU/day (p = 0.01). There was no change in the basal dose of insulin after the change in therapy--it remained at 20 (12-28), (16-26) IU/day. The dose of bolus administered insulin decreased from 24 (18-32) to 21 (17-29) IU/day (p < 0.01).

CONCLUSION

A dramatic improvement in HbA(lC) and a dramatic decrease in glycaemia variability are associated with glargin insulin treatment. The dose ofglargin insulin does not differ from that of NPH.

[Effects of insulin on glucose metabolism in sepsis]

The study surveys potential effects of hyperglycemia on prognosis, complications and mortality of critical patients. Normalization of glycemia seems to be an effective therapeutic approach that influences morbidity and mortality of critical patients. Although insulin therapy has many positive effects, it is rather a way how to achieve normoglycemia. Authors present their own research of the impact of plasmatic insulin levels on glucose metabolism. It seems that the ability of critical patients to utilise and store glucose is significantly decreased due to their insulin resistance. Glucose oxidation is decreased only slightly. Glucose utilisation and oxidation in sepsis can be enhanced by administration of insulin.