Continuous quality improvement: hypoglycemia prevention in the postoperative surgical population.

A continuous quality improvement project for decreasing hypoglycemia on a surgical unit at a major university medical center in Chicago was successful in reducing hypoglycemic episodes and increasing overall patient safety. A secondary root cause analysis of hypoglycemic episodes is discussed for use in planning future hypoglycemia prevention strategies.

Impact of a subcutaneous insulin protocol in the emergency department: Rush Emergency Department Hyperglycemia Intervention (REDHI).

OBJECTIVE: We evaluated a hyperglycemia treatment protocol for use in the Emergency Department (ED) in patients with diabetes mellitus (DM) before admission to the hospital or discharge home. METHODS: Fifty-four consecutive patients with a history of DM and an ED admission blood glucose (BG) > 200 mg/dL were treated with subcutaneous (SQ) insulin aspart every 2 h until BG was < 200 mg/dL. Point-of-care BG was measured immediately on ED admission and every 2 h until discharge home or hospital admission. The intervention group was compared with 54 historical controls with DM and an ED admission BG > 200 mg/dL. RESULTS: One hundred percent of intervention patients received insulin aspart, whereas only 35% of historical controls received insulin therapy. In the intervention group, mean BG declined from 333 ± 104 mg/dL on ED admission to 158 ± 68 mg/dL on ED discharge. In the historical control group, mean BG decline was significantly less, from 322 ± 126 mg/dL on admission to 242 ± 79 mg/dL on discharge (p < 0.001). Sixty-nine percent of intervention patients and 67% of controls were subsequently admitted to the hospital. Mean hospital length of stay (LOS) in the intervention group was significantly less, 3.8 ± 3.3 days, compared with 5.3 ± 4.1 days in the control group (p < 0.05). Four intervention patients (7.4%) developed a BG < 70 mg/dL. CONCLUSION: A protocol for the treatment of acute hyperglycemia in the ED can be safely implemented. Subsequent inpatient LOS was reduced. Further randomized clinical trials of this intervention are warranted.

Comparison of inpatient insulin regimens with detemir plus aspart versus neutral protamine hagedorn plus regular in medical patients with type 2 diabetes.

BACKGROUND: Studies comparing the use of basal bolus with insulin analogs vs. split-mixed regimens with human insulins in hospitalized patients with type 2 diabetes are lacking. RESEARCH DESIGN AND METHODS: In a controlled multicenter trial, we randomized 130 nonsurgical patients with blood glucose (BG) between 140 and 400 mg/dl to receive detemir once daily and aspart before meals (n = 67) or neutral protamine Hagedorn (NPH) and regular insulin twice daily (n = 63). Insulin dose was started at 0.4 U/kg.d for BG between 140 and 200 mg/dl or 0.5 U/kg.d for BG 201-400 mg/dl. Major study outcomes included differences in mean daily BG levels and frequency of hypoglycemic events between treatment groups. RESULTS: Glycemic control improved similarly in both groups from a mean daily BG of 228 +/- 54 and 223 +/- 58 mg/dl (P = 0.61) to a mean daily BG level after the first day of 160 +/- 38 and 158 +/- 51 mg/dl in the detemir/aspart and NPH/regular insulin groups, respectively (P = 0.80). A BG target below 140 mg/dl before meals was achieved in 45% of patients in the detemir/aspart group and 48% in the NPH/regular group (P = 0.86). During treatment, 22 patients (32.8%) in the detemir/aspart group and 16 patients (25.4%) in the NPH/regular group had at least one episode of hypoglycemia (BG < 60 mg/dl) during the hospital stay (P = 0.34). CONCLUSIONS: Treatment with basal/bolus regimen with detemir once daily and aspart before meals results in equivalent glycemic control and no differences in the frequency of hypoglycemia compared to a split-mixed regimen of NPH and regular insulin in patients with type 2 diabetes.

Cloning and functional characterization of the mouse fructose transporter, GLUT5.

Mouse GLUT5 cDNA and a 7.7-kb genomic fragment have been isolated and characterized. The cDNA sequence suggests mouse GLUT5 is composed of 501 amino acids, and has 69-88% amino acid identity with human, rat, and rabbit GLUT5. Expression of mouse GLUT5 cRNA in Xenopus laevis oocytes showed that GLUT5 mediated fructose transport, with a K(t) of 13 mM. Northern blot studies detected GLUT5 mRNA expression in mouse small intestine, kidney, and testis, with transcript sizes of approximately 2.1, 2.1, and 2.8 kb, respectively. 5'Rapid Amplification of cDNA Ends (5'RACE) determined that the differences in transcript sizes occurred because GLUT5 possessed alternative transcriptional initiation sites in somatic and germ cells. In agreement with studies in rats and rabbits, mouse small intestinal GLUT5 mRNA expression levels were increased following exposure to a 65% fructose-enriched diet. In addition, developmental studies showed a significant increase in GLUT5 mRNA expression levels in adult mouse testis when compared to prepubertal mouse testis. To begin to identify the cis-acting domains responsible for GLUT5 expression characteristics, a 7.7-kb GLUT5 genomic fragment was isolated from a mouse lambda fix11 library and sequenced. The clone contained exons 1-4 and 5' flanking regions. Moreover, caudal homeobox gene (CdxA), upstream stimulatory factor (USF), and sex-determining region of Y (SRY) binding sites were identified in the 5' flanking region that may be responsible for GLUT5's expression characteristics: tissue distribution, sensitivity to dietary fructose in the small intestine, and developmental expression in the testis.

A randomized trial of two weight-based doses of insulin glargine and glulisine in hospitalized subjects with type 2 diabetes and renal insufficiency.

OBJECTIVE: Renal insufficiency may increase the risk of hypoglycemia in hospitalized patients with diabetes who are treated with insulin. We randomized inpatients with type 2 diabetes and chronic renal failure to treatment with two different dose levels of insulin glargine and glulisine and studied control of hyperglycemia and the frequency of hypoglycemia. RESEARCH DESIGN AND METHODS: We conducted a multicenter, prospective, randomized trial to compare the efficacy of once-daily glargine and three-times daily glulisine at 0.5 vs. 0.25 units/kg/day. A total of 107 subjects had type 2 diabetes for >1 year, had a glomerular filtration rate <45 mL/min but did not require dialysis, and had an initial blood glucose (BG) >180 mg/dL. Doses were adjusted based on four-times daily BG measurements for 6 days. RESULTS: Mean BG on the first day was 196 ± 71 mg/dL in the group receiving 0.5 units/kg (0.5 group) and 197 ± 55 mg/dL in the group receiving 0.25 units/kg (0.25 group; P = 0.94). On days 2 to 6, mean BG was 174 ± 52 mg/dL in the 0.5 group and 174 ± 46 mg/dL in the 0.25 group (P = 0.96). There were no significant differences between groups in the percentage of BG values within the target range of 100 to 180 mg/dL on any of the 6 study days. In the 0.5 group, 30% experienced hypoglycemia (BG <70 mg/dL) compared with 15.8% of the 0.25 group (P = 0.08). CONCLUSIONS: Reduction of initial glargine/glulisine insulin weight-based dosing in hospitalized patients with diabetes and renal insufficiency reduced the frequency of hypoglycemia by 50% without compromising the control of hyperglycemia.

Treatment of inpatient hyperglycemia beginning in the emergency department: a randomized trial using insulins aspart and detemir compared with usual care.

OBJECTIVE: We examined the impact of an aspart insulin protocol for treatment of hyperglycemia in the emergency department (ED) coupled with rapid initiation of a detemir-aspart insulin protocol for patients admitted to the hospital. RESEARCH DESIGN AND METHODS: ED patients with type 2 diabetes mellitus and a blood glucose (BG) ≥ 200 mg/dL were randomized to intervention (INT) or usual care (UC). INT patients (n = 87) received aspart every 2 hours when BG > 200 mg/dL, and if admitted, began daily detemir in the ED. UC patients (n = 89) were treated per hospital physicians. RESULTS: The initial ED BG was 304 ± 76 mg/dL. The final ED BG differed: 217 ± 71 mg/dL for INT patients versus 257 ± 89 mg/dL for UC patients (P < .01). No INT patients and 3 UC patients had a BG < 50 mg/dL (P = .5). ED length of stay (LOS) was similar: 5.4 ± 1.8 hours for INT patients versus 4.9 ± 1.9 hours for UC patients (P = .06). Sixty-nine percent from each group were admitted. Admission BG was 184 ± 74 mg/dL for INT patients versus 224 ± 93 mg/dL for UC patients (P < .01). Patient-day weighted mean glucose was 163 ± 39 mg/dL for INT patients versus 202 ± 39 mg/dL for UC patients (P < .01). One INT patient and 6 UC patients had a BG < 50 mg/dL (P = .11). Hospital LOS was similar: 2.7 ± 2.0 versus 3.1 ± 1.9 days, respectively (P = .58). CONCLUSIONS: An aspart insulin protocol safely lowers BG levels in the ED without prolonging LOS. During hospitalization, a detemir-aspart protocol achieves significantly better glycemic control compared with guideline-driven use of NPH-aspart or glargine/detemir-aspart (usual care) without increasing hypoglycemia. Standardization of insulin protocols in the ED and hospital settings leads to improvement in overall glycemic control with greater safety and efficacy than usual care.

On dioxin formation in iron ore sintering.

Iron ore sintering is an important source of "dioxins", polychlorinated dibenzo-p-dioxins and dibenzofurans (PCDD/Fs). This paper reports on attempts to identify materials, conditions, and mechanisms responsible for PCDD/F formation (i) by investigating salient properties of ores (viz., with respect to oxidation, condensation, and chlorination of model organics) and (ii) by mimicking the industrial process on a microscale with real-life materials. Principles of Design of Experiments (DOE) are employed. The reactivities of iron ores differ greatly. Limonite/goethite "soft" ore is a very active oxidation catalyst (e.g., for benzene and phenol), a property that may be useful in cleaning up crude sintering process offgases, whereas hematite/magnetite "hard" ore is not. The latter, however strongly promotes condensation of phenol to dibenzofuran. A newly built lab-microscale sintering facility could satisfactorily imitate the large-scale process, in part or as a whole. Results obtained with realistic feed mixtures point at dioxin formation in the sinter bed at levels significant enough to explain a major part of the outputs observed in the real-life process. With approximately 8 ppm (wt) of chloride added as NaCl, the PCDD/F output doubled, but with the same proportion of chlorine administered as C2Cl4, the dioxin output was over 2 orders of magnitude larger. The use of process reverts, etc. containing chlorinated organics should therefore be avoided. PCDD/F congener patterns are also reported and compared with those observed in practice.