Acute and chronic hyperglycemia are proinflammatory states, but the status of proinflammatory cytokines and markers of oxidative stress and cardiovascular risks is not known in hyperglycemic crises of diabetic ketoacidosis (DKA) and nonketotic hyperglycemia (NKH). We studied 20 lean and 28 obese patients with DKA, 10 patients with NKH, and 12 lean and 12 obese nondiabetic control subjects. We measured 1) proinflammatory cytokines ( , and 4) cortisol, growth hormone (GH), and free fatty acids (FFAs) on admission (before insulin therapy) and after insulin therapy and resolution of hyperglycemia and/or ketoacidosis. Results were compared with lean and obese control subjects. Circulating levels of cytokines, TBA, DCF, PAI-1, FFAs, cortisol, and GH on admission were significantly increased two-to fourfold in patients with hyperglycemic crises compared with control subjects, and they returned to normal levels after insulin treatment and resolution of hyperglycemic crises. Changes in CRP and homocysteine in response to insulin therapy did not reach control levels after resolution of hyperglycemia. We conclude that DKA and NKH are associated with elevation of proinflammatory cytokines, ROS, and cardiovascular risk factors in the absence of obvious infection or cardiovascular pathology. Return of these values to normal levels with insulin therapy demonstrates a robust anti-inflammatory effect of insulin. Diabetes
OBJECTIVE—In this prospective, randomized, open trial, we compared the efficacy and safety of aspart insulin given subcutaneously at different time intervals to a standard low-dose intravenous (IV) infusion protocol of regular insulin in patients with uncomplicated diabetic ketoacidosis (DKA). RESEARCH DESIGN AND METHODS—A total of 45 consecutive patients admitted with DKA were randomly assigned to receive subcutaneous (SC) aspart insulin every hour (SC-1h, n = 15) or every 2 h (SC-2h, n = 15) or to receive IV infusion of regular insulin (n = 15). Response to medical therapy was evaluated by assessing the duration of treatment until resolution of hyperglycemia and ketoacidosis. Additional end points included total length of hospitalization, amount of insulin administration until resolution of hyperglycemia and ketoacidosis, and number of hypoglycemic events. RESULTS—Admission biochemical parameters in patients treated with SC-1h (glucose: 44 ± 21 mmol/l [means ± SD], bicarbonate: 7.1 ± 3 mmol/l, pH: 7.14 ± 0.09) were similar to those treated with SC-2h (glucose: 42 ± 21 mmol/l, bicarbonate: 7.6 ± 4 mmol/l, pH: 7.15 ± 0.12) and IV regular insulin (glucose: 40 ± 13 mmol/l, bicarbonate 7.1 ± 4 mmol/l, pH: 7.11 ± 0.17). There were no statistical differences in the mean duration of treatment until correction of hyperglycemia (6.9 ± 4, 6.1 ± 4, and 7.1 ± 5 h) or until resolution of ketoacidosis (10 ± 3, 10.7 ± 3, and 11 ± 3 h) among patients treated with SC-1h and SC-2h or with IV insulin, respectively (NS). There was no mortality and no differences in the length of hospital stay, total amount of insulin administration until resolution of hyperglycemia or ketoacidosis, or the number of hypoglycemic events among treatment groups. CONCLUSIONS—Our results indicate that the use of subcutaneous insulin aspart every 1 or 2 h represents a safe and effective alternative to the use of intravenous regular insulin in the management of patients with uncomplicated DKA.
. Impaired expression and insulin-stimulated phosphorylation of Akt-2 in muscle of obese patients with atypical diabetes. Am J Physiol Endocrinol Metab
Current models of diabetes care delivery fall short of producing excellent glycemic control, perhaps due to the brevity of clinical interaction. The goal of our Comprehensive Diabetes Improvement Program (CDIP) is to utilize the "downtime " between clinic visits. CDIP utilizes a structured telephone intervention (STI) delivered by a peer motivator (PM) to 5 fellow patients with diabetes at weekly intervals for 6 months. The STI focused on multimodality diabetes self-management, stressing the roles of monitoring, diabetes education, diet, exercise, and medication adherence. In this report, we present our initial experience with 24 diabetes patients (4 PMs and 20 motivatees). The patients' mean age was 51.9 6 2.2 yr, BMI 35.3 6 1.2 kg/m2, duration of diabetes 8.6 6 1.4 yr; 55% were African American. The control group comprised diabetes patients not receiving structured phone calls. Based on a targeted 24 phone calls in 6 months, the mean percent phone calls received by patients in the 4 PM groups (PM-1 to PM-4) were 81.9 6 3.7%, 75.0 6 3.8%, 70.8 6 4.5%, and 58.3 6 2.3%, respectively. In a questionnaire study, the subjects overwhelmingly agreed that weekly telephone calls from fellow diabetes patients were acceptable (92.9%), helpful (80%), or improved self-management behavior (93%). No subject indicated that the calls interfered with home life. The mean changes in HbA1c (%) in the 4 groups (PM-1 to PM-4) from baseline to 6 months were 0.46 (NS), 21.6 (p < .02), 21.2 (p = .02), and 20.13 (NS), respectively. The corresponding mean changes in weight (kg) were 0.58, 22.03, 22.02, and 2.7 kg, respectively. There was an inverse correlation between the percentage of phone calls received and the change in HbA1c (r = 2.372) or weight (r = 2.42). These results indicate that a structured patient-to-patient telephone intervention improves diabetes self-management activities, which translates into improved glycemic control.
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