The Joint British Diabetes Societies guidelines for the management of diabetic ketoacidosis (these do not cover Hyperosmolar Hyperglycaemic Syndrome) are available in full at: This article summarizes the main changes from previous guidelines and discusses the rationale for the new recommendations. The key points are: Monitoring of the response to treatment (i) The method of choice for monitoring the response to treatment is bedside measurement of capillary blood ketones using a ketone meter.(ii) If blood ketone measurement is not available, venous pH and bicarbonate should be used in conjunction with bedside blood glucose monitoring to assess treatment response.(iii) Venous blood should be used rather than arterial (unless respiratory problems dictate otherwise) in blood gas analysers.(iv) Intermittent laboratory confirmation of pH, bicarbonate and electrolytes only.Insulin administration (i) Insulin should be infused intravenously at a weight-based fixed rate until the ketosis has resolved.(ii) When the blood glucose falls below 14 mmol ⁄ l, 10% glucose should be added to allow the fixed-rate insulin to be continued.(iii) If already taking, long-acting insulin analogues such as insulin glargine (Lantus Ò

Low-dose corticotropin test was superior to standard-dose test for diagnosing chronic HPAI, although it has technical limitations.

Cellular and tissue defects associated with insulin resistance are coincident with transcriptional abnormalities and are improved after insulin sensitization with thiazolidinedione (TZD) PPAR␥ ligands. We characterized 72 human subjects by relating their clinical phenotypes with functional pathway alterations. We transcriptionally profiled 364 biopsies harvested before and after hyperinsulinemic-euglycemic clamp studies, at baseline and after 3-month TZD treatment. We have identified molecular and functional characteristics of insulin resistant subjects and distinctions between TZD treatment responder and nonresponder subjects. Insulin resistant subjects exhibited alterations in skeletal muscle (e.g., glycolytic flux and intramuscular adipocytes) and adipose tissue (e.g., mitochondrial metabolism and inflammation) that improved relative to TZD-induced insulin sensitization. Pre-TZD treatment expression of MLXIP in muscle and HLA-DRB1 in adipose tissue from insulin resistant subjects was linearly predictive of post-TZD insulin sensitization. We have uniquely characterized coordinated cellular and tissue functional pathways that are characteristic of insulin resistance, TZD-induced insulin sensitization, and potential TZD responsiveness. muscle and adipose tissue ͉ transcriptional mechanisms ͉ diabetes ͉ branched chain amino acid (BCAA) ͉ inflammation I nsulin resistance is a pathological state in which insulin action is impaired in target tissues including liver, skeletal muscle, and adipose tissue. Insulin resistance is a defining feature of the metabolic syndrome and the primary defect leading to type 2 diabetes (1, 2). Impaired insulin-stimulated glucose uptake in skeletal muscle and lipid metabolism in adipocytes are central characteristics of insulin-resistance. Other manifestations of the condition include elevated intramuscular fat content (3), dysregulation of adipokine secretion, and chronic lowgrade inflammation in adipose tissue (4). Macrophage infiltration in adipose tissue activates inflammatory pathways that induce insulin resistance and modulate the effects of adipose tissue on whole-body metabolism (5). Several studies have shown that decreased mitochondrial protein and oxidative phosphorylation (OXPHOS) in skeletal muscle and adipocytes are also underlying factors of insulin resistance (6, 7).Thiazolidinediones (TZDs) are insulin-sensitizing drugs used to treat type 2 diabetes. TZDs enhance insulin sensitivity by improving glucose and lipid metabolism, altering adipokine secretion, and reducing adipose tissue inflammation (4, 8). Although TZDs improve insulin sensitivity and the glycemic, lipid, and inflammatory profiles of most patients, approximately 30% of diabetic subjects do not respond to TZD treatment, as gauged by fasting plasma glucose or HbA1c levels (9, 10). TZDs are ligands of peroxisome proliferator-activated receptor gamma (PPAR␥) through which they alter the expression of hundreds of genes in skeletal muscle, adipocytes, and macrophages. PPAR␥-mediated gene regulation is the predom...

A 0900 h serum cortisol < 100 nmol/l (24 h off replacement hydrocortisone) indicated ACTH deficiency and need for lifelong steroid replacement. A 0900 h serum cortisol > 450 nmol/l one week after pituitary surgery is highly suggestive of a normal cortisol response to hypoglycaemia. A 0900 h serum cortisol between 250 and 450 nmol/l one week after pituitary surgery permits safe withdrawal of steroid therapy pending an insulin hypoglycaemia test 1 month after surgery. Patients with 0900 h serum cortisol between 100 and 250 nmol/l should continue replacement steroids until definitive testing. Low dose and standard dose Synacthen tests 1 week after pituitary surgery are unreliable and should not be used.

PRL exists in different forms in human serum. The predominant form is little PRL (molecular mass 23 kDa) with smaller amounts of big PRL (molecular mass 50--60 kDa) and at times big big or macroprolactin (molecular mass 150--170 kDa). The frequency and clinical consequences of macroprolactinemia have not been clearly established, mainly because of difficulty in identifying these patients biochemically. This previously required the use of gel filtration chromatography, which could not be used routinely. Recently, a screening test using polyethylene glycol (PEG) has been used to identify macroprolactin in serum. Consequently, this study was designed to examine the use of PEG precipitation in the identification of patients with a predominance of macroprolactin and to establish the clinical characteristics of such a cohort. Over 12 months, 18,258 requests for serum PRL were received and of these 1225 patients had a serum PRL more than 700 mU/L. A total of 322 of these patients (26%) had a percentage recovery after PEG precipitation of less than 40%, thus indicating the presence of a predominance of macroprolactin. Fifty-five of these patients were referred for detailed clinical assessment. Symptoms typical of hyperprolactinemia were not common in this cohort. None had sustained amenorrhea and eight have had oligomenorrhea at age less than 40 yr. One had galactorrhea. All had pituitary imaging, and four had a microadenoma with none having a macroadenoma. PEG precipitation allows easy identification of macroprolactin in routine clinical practice. As the clinical consequences of this entity at this stage seem relatively benign, referral and intensive investigation of these patients may not be necessary. However, follow-up of a large cohort is required to ensure that the long-term outlook is likewise benign. This would have important implications for both patients and healthcare systems.