Mixed insulin can improve control of prednisolone-induced hyperglycaemia.

BACKGROUND: Hyperglycaemia is a common side effect of prednisolone, although there are no widely accepted guidelines for the management of glucocorticoid-induced hyperglycaemia (GIH). Our institution uses mixed insulin in a pre-breakfast or pre-breakfast and pre-lunch regimen, with the rationale that this profile of insulin action matches the physiological effect of prednisolone on blood glucose levels (BGLs). AIM: Evaluate the use of the mixed insulin (NovoMix30) in a pre-breakfast or pre-breakfast and pre-lunch regimen as management for GIH in a tertiary hospital setting. METHOD: We retrospectively evaluated all inpatients coprescribed prednisolone ≥7.5 mg and NovoMix30 for at least 48 hours over a 19-month period. BGLs were evaluated with repeated-measures analysis within four time periods across the day, beginning from the day prior to NovoMix30 administration. RESULTS: A total of 53 patients were identified. NovoMix30 significantly reduced BGLs in the morning (mean 12.7 ± 4.5 vs. 9.2 ± 3.9 mmol/L, P < 0.001), afternoon (mean 13.6 ± 3.8 vs. 11.9 ± 3.8 mmol/L, P = 0.001) and evening (12.1 ± 3.8 vs. 10.8 ± 3.8 mmol/L, P = 0.01). With uptitration of insulin over 3 days, 43% of all BGLs were within the target range, compared with 23% on day 0 (P < 0.001). The final median dose of NovoMix30 was 0.15 (0.10-0.22) units/kg bodyweight, or 0.40 (0.23-0.69) units/mg of prednisolone, which is lower than our hospital guideline recommends. One overnight hypoglycaemic event was observed. CONCLUSION: Mixed insulin as a pre-breakfast or pre-breakfast and pre-lunch regimen can target the hyperglycaemic pattern induced by prednisolone and minimise overnight hypoglycaemia. However, higher doses of insulin than those used in our study are likely required for optimal BGL control.

Protein-energy malnutrition in older Australians: A narrative review of the prevalence, causes and consequences of malnutrition, and strategies for prevention.

ISSUE ADDRESSED: Protein-energy malnutrition (PEM) is a condition of involuntary weight and muscle loss caused by inadequate nutritional intake. In Australia, it is predominantly associated with chronic diseases, as are common in the older population. Given the ageing population of Australia, and the poor outcomes associated with PEM, there is a need to identify the contributing factors, and to explore strategies to prevent PEM. METHODS: Two databases were searched for pertinent keywords, including malnutrition, Australia and elderly, with relevant articles selected for inclusion. The citations and references of these articles were also searched for further articles. RESULTS: PEM is associated with increasing age and institutionalisation. The contributing factors are multifactorial, and include physiological, pathophysiological and structural causes. PEM is a significant public health issue for Australia, in terms of its consequences on both quality of life for older adults, and the burden on the healthcare system. However, there are strategies that can be implemented at the community, organisation and policy level to prevent PEM. CONCLUSION: PEM is a common problem for older Australians, and this has important physiological and public health consequences, especially in the context of the ageing Australian population. However, there is significant scope for preventing PEM. SO WHAT?: Readers can be advised that PEM is a significant public health issue that will increase in importance as the population continues to age. It is important that communities, organisations and governments develop strategies to prevent PEM.

Problematic alcohol consumption in homeless Australians: A narrative review of the causes, barriers to receiving help and possible solutions.

ISSUE ADDRESSED: Problematic alcohol consumption (PAC) affects one-third of homeless Australians, and it is expected that the rates will increase as the population ages. However, current policy does not recognise the importance of this problem. The aim of this narrative review was to examine the social determinants and other risk factors contributing to PAC in homeless Australians, the barriers to receiving help and possible solutions for the Australian context. METHODS: PubMed and PsycINFO databases and Australian government websites were examined for the keywords "alcohol" and "homeless," and pertinent articles were selected for inclusion and for citation tracking of further relevant articles. RESULTS: The causes of PAC in homeless Australians are multifactorial, and multidirectional, and include risk factors such as low socio-economic status, mental illness and having experienced trauma. There is significant stigma associated with both homelessness and PAC, which further isolates this group. Current policies to address PAC in the homeless are inadequate; however, there are a range of possible programs to reduce PAC in this group, and international harm reduction strategies have also shown success in improving outcomes for this group. CONCLUSION: There are numerous social risk factors that influence the development of PAC in the homeless. The introduction of harm reduction strategies, programs to enhance motivation and personal skills, as well as better mental health treatment, would all fill important gaps in services for homeless Australians with PAC. SO WHAT?: Health professionals can be advised that there are many social determinants that influence PAC in homeless Australians. There are important structural barriers to providing this marginalised group with the services they require; however, there is scope for the introduction of new programs, including harm reduction strategies, to meet the fundamental needs of this group.

Altered in utero kidney development in newborns with congenital heart disease.

BACKGROUND: It is known that the heart is not the only organ affected in congenital heart disease (CHD); there is growth restriction of both the brain and the whole body. The protective mechanism of "the brain-sparing phenomenon" re-directs blood flow toward the growing brain in fetuses with CHD. We hypothesized that these changes would result in impaired fetal kidney growth. METHODS: The preoperative ultrasound measurements of kidney length were obtained retrospectively from 452 neonates requiring surgery for CHD. Percentiles were generated based on regression analysis of normative kidney length from three datasets according to both corrected gestational age and to birthweight. RESULTS: As a cohort, neonates with CHD have significantly enlarged kidneys, with a mean percentile ranging from 54.1-72.7 (p < 0.001), depending on the three normal population datasets used for comparison. The kidneys of neonates with left heart obstruction were consistently demonstrated to be greater than normal, unlike those with cyanotic heart disease which were shown to have either normal or enlarged kidneys, depending on the reference population used. CONCLUSIONS: The kidneys of newborns with CHD are not reduced in size, and on average are larger than normal. The nature of this size discrepancy and its subsequent clinical significance is unknown.