Comparison of low-energy FLACS and conventional cataract surgery: meta-analysis and systematic review.

TOPIC: To systematically compare the effectiveness of conventional phacoemulsification surgery (CPS) and low-energy femtosecond laser-assisted cataract surgery (FLACS) in patients with cataract. CLINICAL RELEVANCE: Cataract surgery is a common procedure, and comparing different techniques such as CPS and low-energy FLACS is crucial for optimizing patient outcomes. METHODS: The PubMed, Web of Science, MEDLINE, EMBASE, and Cochrane library databases were searched for clinical trials. Outcomes of procedure time, effective phacoemulsification time, balanced salt solution usage, cumulative dissipated energy, mean change of corrected distance visual acuity, endothelial cells reduction, central corneal thickness (CCT), and aqueous cytokine level were evaluated. The effect measures were weighted mean differences with 95% CI. The protocol was registered at the Prospective Register for Systematic Reviews (registration number CRD42023420173). RESULTS: 11 studies were included in this meta-analysis, of which 1680 eyes were analyzed (637 eyes in the low-energy FLACS group and 1043 eyes in the CPS group). Low-energy FLACS demonstrated significantly fewer reductions in endothelial cell count at 6 months ( P < .001) compared with CPS. It also exhibited a shorter effective phacoemulsification time ( P < .001) and less balanced salt solution usage ( P < .001). However, there were no differences in cumulative dissipated energy, corrected distance visual acuity, CCT changes, or aqueous cytokine levels between the 2 groups. CONCLUSIONS: Both low-energy FLACS and CPS are effective in treating cataracts, but low-energy FLACS may offer advantages such as reduced phacoemulsification time and less endothelial cell loss.

Identifying and Exploring the Impact Factors for Intraocular Pressure Prediction in Myopic Children with Atropine Control Utilizing Multivariate Adaptive Regression Splines.

PURPOSE: The treatment of childhood myopia often involves the use of topical atropine, which has been demonstrated to be effective in decelerating the progression of myopia. It is crucial to monitor intraocular pressure (IOP) to ensure the safety of topical atropine. This study aims to identify the optimal machine learning IOP-monitoring module and establish a precise baseline IOP as a clinical safety reference for atropine medication. METHODS: Data from 1545 eyes of 1171 children receiving atropine for myopia were retrospectively analyzed. Nineteen variables including patient demographics, medical history, refractive error, and IOP measurements were considered. The data were analyzed using a multivariate adaptive regression spline (MARS) model to analyze the impact of different factors on the End IOP. RESULTS: The MARS model identified age, baseline IOP, End Spherical, duration of previous atropine treatment, and duration of current atropine treatment as the five most significant factors influencing the End IOP. The outcomes revealed that the baseline IOP had the most significant effect on final IOP, exhibiting a notable knot at 14 mmHg. When the baseline IOP was equal to or exceeded 14 mmHg, there was a positive correlation between atropine use and End IOP, suggesting that atropine may increase the End IOP in children with a baseline IOP greater than 14 mmHg. CONCLUSIONS: MARS model demonstrates a better ability to capture nonlinearity than classic multiple linear regression for predicting End IOP. It is crucial to acknowledge that administrating atropine may elevate intraocular pressure when the baseline IOP exceeds 14 mmHg. These findings offer valuable insights into factors affecting IOP in children undergoing atropine treatment for myopia, enabling clinicians to make informed decisions regarding treatment options.

Interaction between glycaemic control and serum insulin-like growth factor 1 on the risk of retinopathy in type 2 diabetes.

BACKGROUND: There is strong experimental evidence that insulin-like growth factor 1 (IGF-1) plays a role in the development of diabetic retinopathy. We carried out this study to determine the association between serum IGF-1 levels and retinopathy in patients with type 2 diabetes and whether this association is modified by the severity of hyperglycaemia. MATERIALS AND METHODS: A total of 480 consenting patients with type 2 diabetes were enrolled between 1 August 2001 and 31 December 2002. All participants provided a medical history and underwent a physical examination, biochemical assessment and eye fundi examination. These patients were followed up in our clinics according to our national guidelines until 31 December 2009. RESULTS: Compared with the middle tertile, increased levels of IGF-1 did not increase the risk of mild-to-moderate retinopathy (RR, 1·11; 95% CI, 0·63-1·95) and severe retinopathy (RR, 1·84; 95% CI, 0·79-8·57) at baseline. In the longitudinal analysis, increased levels of IGF-1 showed a nonsignificantly increased hazard ratio (HR) for the progression of retinopathy (HR, 1·61; 95% CI, 0·52-4·96) and severe retinopathy (HR, 1·63; 95% CI, 0·65-4·09). However, in patients with relatively good glycaemic control, there was a significantly increased risk of the progression of retinopathy (HR, 2·21; 95% CI, 1·01-5·91) and a cumulative incidence of severe retinopathy (HR, 4·82; 95% CI, 1·10-18·25) in individuals with the highest serum IGF-1 levels. CONCLUSIONS: Our data suggested serum IGF-1 was a contributing factor in severe diabetic retinopathy and this effect may be masked by poor glycaemic control.

Does atropine use increase intraocular pressure in myopic children?

PURPOSE: Because pupillary dilation caused by muscarinic antagonists is a predisposing factor for glaucoma, we examined the effects of long-term atropine treatment for myopia on intraocular pressure (IOP) and studied the risk factors of elevated IOP among myopic children. METHODS: A retrospective chart review was conducted in 621 myopic children (aged 6 to 15 years) whose spherical equivalent refractive error ranged from -1.00 to -6.00 D in each eye and who had received atropine therapy. For all children, we collected their complete ocular examination data and IOP measurements beginning in 2008. We then calculated the cumulative dose and the duration of atropine therapy in the 3 years before the date of recruitment to quantitatively assess the effects of atropine therapy on IOP. RESULTS: Four hundred eighty-nine children who received atropine therapy were classified as the "treatment" group, whereas 132 children who did not receive atropine therapy were classified as "reference" group. Statistical analyses did not find any relation between the dose or duration of atropine therapy and the risk of having elevated IOP. However, the age of the myopic children and the spherical equivalent values were positively associated with the risk of having elevated IOP irrespective of whether they had been treated with atropine or not. CONCLUSIONS: Topical atropine therapy for up to 3 years seemed to be safe in myopic children; neither the cumulative dose nor the duration of atropine therapy was statistically associated with the risk of having elevated IOP. However, the safety of longer atropine therapy still needs more study. Clinicians should be careful to monitor the changes in IOP among older myopic children or myopic children with more severe myopia.

Mean HbA1c and HbA1c variability are associated with differing diabetes-related complications in patients with type 2 diabetes mellitus.

AIMS: To study the different effects of mean HbA1c and HbA1c variability on diabetes-related complications in patients with type 2 diabetes mellitus. METHODS: 1869 patients with type 2 diabetes were followed-up for a median of 9.5 years in a Diabetes Shared Care Program. Mean HbA1c (HbA1c-mean) and standard deviation of HbA1c (HbA1c-SD) were calculated during the first 5 years. The clinical outcomes included nephropathy (urine albumin-to-creatinine ratio [UACR] > 300 mg/g and doubling of serum creatinine), retinopathy (any and advanced), and mortality (due to all-causes, and cardiovascular disease [CVD]). RESULTS: HbA1c-mean was independently associated with UACR > 300 mg/g (Hazard ratio [HR] 1.308 [95% confidence interval {CI}, 1.194-1.433]), any retinopathy (HR 1.274 [1.171-1.385]), and advanced retinopathy (HR 1.237 [1.014-1.509]). HbA1c-SD was independently associated with UACR > 300 mg/g (HR 1.478 [1.189-1.837]), doubling of serum creatinine (HR 2.133 [1.470-3.095]), all-cause mortality (HR 1.880 [1.561-2.266]), and CVD mortality (HR 1.431 [1.069-1.915]). Receiver operating characteristic (ROC) curves showed HbA1c-mean was more associated with any retinopathy, whereas HbA1c-SD was more associated with doubling of serum creatinine, all-cause and CVD mortality. CONCLUSION: Both HbA1c-mean and HbA1c-SD predicted most diabetes-related complications in patients with type 2 diabetes. However, HbA1c-mean was more effective at predicting retinopathy, while HbA1c-SD was more effective at predicting deterioration of renal function and increased mortality.

The role of growth hormone and IGF-1 in retinopathy: a prospective study of retinopathy in patients with acromegaly and impaired fasting glucose.

AIMS: To investigate the effects of the growth hormone (GH)/insulin-like growth factor-1 (IGF-1) axis on the incidence and progression of retinopathy. METHODS: We enrolled 91 patients with acromegaly and 123 subjects with impaired fasting glucose (IFG) between 2008 and 2016 to examine the incidence and prevalence of retinopathy. Patients attended follow-ups in our clinics and underwent examinations according to the national guidelines for diabetes management. Both cohorts attended follow-ups until June 2019. RESULTS: Both groups had similar HbA1c, cholesterol, and blood pressure levels. However, patients with acromegaly had higher GH (8.05 ± 16.18 vs. 0.78 ± 1.25 ng/mL) and IGF-1 (547.0 ± 342.1 vs. 146.7 ± 51.4 ng/mL) levels than in subjects with IFG. During the follow-up period, 8 patients (8.8%) with acromegaly and 12 patients (9.8%) with IFG developed some degree of retinopathy. Three patients with acromegaly and two with IFG progressed to proliferative retinopathy. Patients with acromegaly had the same incidence of non-proliferative retinopathy (odds ratio [OR] 0.830; 95% CI 0.318-2.164) and a non-statistically significantly higher incidence of proliferative retinopathy (OR 2.461; 95% CI 0.404-14.988). CONCLUSION: The data reveals that GH and IGF-1 might play a crucial role in the development of proliferative retinopathy and influence its progression. Therefore, we suggest screening patients with acromegaly should be similar to diabetes patients.

Metronidazole-Induced Irreversible Optic Neuropathy.

Metronidazole-induced optic neuropathy is a rare complication. Most patients have excellent visual recovery. In this study, we report a patient who presented with a sudden onset of severe visual loss after a 1-week course of metronidazole. Myelitis developed simultaneously. The vision and the accompanying neurological deficiency of the patient did not improve even after metronidazole was discontinued immediately and various treatments were given.

Hemoglobin A(1c) and fructosamine for assessing glycemic control in diabetic patients with CKD stages 3 and 4.

BACKGROUND: Hemoglobin A(1c) (HbA(1c)) and fructosamine can be used to monitor glycemic control in diabetic patients with normal kidney function, but their validity in patients with chronic kidney disease (CKD) has not been evaluated. In this study, we evaluated the correlation and accuracy of these 2 measures of glycemic control in type 2 diabetic patients with CKD stages 3-4. STUDY DESIGN: Diagnostic test study. SETTING & PARTICIPANTS: Type 2 diabetic patients with normal (n = 30) and abnormal kidney function (n = 30) were recruited in Taipei Veterans General Hospital, Taiwan. INDEX TESTS: HbA(1c) and fructosamine. REFERENCE TEST: Self-monitoring of blood glucose levels. MEASUREMENTS: Blood glucose measurements consisted of 6 preprandial, 6 postprandial, and 2 bedtime assessments in a week with a cycle of 4-week intervals for 12 weeks. RESULTS: Correlation coefficients between HbA(1c) level or fructosamine-albumin ratio and mean blood glucose levels were 0.836 and 0.645 in participants with normal kidney function and 0.813 and 0.649 in participants with CKD stages 3-4, respectively. In patients with CKD stages 3-4, mean blood glucose levels in weeks 1-12 were 21.9 mg/dL (95% CI, 11.6-32.5) higher than estimated average glucose (eAG) levels calculated from HbA(1c) levels in participants with normal kidney function. In patients with CKD stages 3-4, mean blood glucose levels in weeks 10-12 were 15.5 mg/dL (95% CI, 5.2-30.5) higher than eAG levels calculated from fructosamine levels in participants with normal kidney function, but without statistical significance when eAG calculated from fructosamine level was corrected for serum albumin level (difference of 5.6 mg/dL; 95% CI, -8.6 to 19.8). LIMITATIONS: Relatively small number of participants with limited amount of blood glucose measurement data. CONCLUSION: Our data show that eAG calculated from HbA(1c) and fructosamine levels might underestimate mean blood glucose levels in patients with CKD stages 3-4. References ranges may need to be modified when interpreting results of measurements of glycemic control in type 2 diabetic patients with CKD.

Giant cell (Temporal) arteritis with anterior ischemic optic neuropathy: a biopsy-proven case in Taiwan.

Giant cell arteritis with arteritic anterior ischemic optic neuropathy has rarely been diagnosed in Taiwan. Recently, we encountered a 76-year-old Taiwanese patient who presented with right visual impairment and marked pale swelling of his right disc. He also suffered body weight loss, general malaise and many typical manifestations of giant cell arteritis, such as jaw claudication, a tender, non-pulsating engorgement of his temporal arteries, and a highly elevated erythrocyte sedimentation rate and C-reactive protein level. Biopsy of his right superficial temporal artery revealed a granulomatous inflammation with multinucleated giant cell infiltration. This was a biopsy-proven case of giant cell arteritis with arteritic anterior ischemic optic neuropathy and indicated that although rare, this disease could occur in patients in Taiwan.

Evaluating the Effect of Topical Atropine Use for Myopia Control on Intraocular Pressure by Using Machine Learning.

Atropine is a common treatment used in children with myopia. However, it probably affects intraocular pressure (IOP) under some conditions. Our research aims to analyze clinical data by using machine learning models to evaluate the effect of 19 important factors on intraocular pressure (IOP) in children with myopia treated with topical atropine. The data is collected on 1545 eyes with spherical equivalent (SE) less than -10.0 diopters (D) treated with atropine for myopia control. Four machine learning models, namely multivariate adaptive regression splines (MARS), classification and regression tree (CART), random forest (RF), and eXtreme gradient boosting (XGBoost), were used. Linear regression (LR) was used for benchmarking. The 10-fold cross-validation method was used to estimate the performance of the five methods. The main outcome measure is that the 19 important factors associated with atropine use that may affect IOP are evaluated using machine learning models. Endpoint IOP at the last visit was set as the target variable. The results show that the top five significant variables, including baseline IOP, recruitment duration, age, total duration and previous cumulative dosage, were identified as most significant for evaluating the effect of atropine use for treating myopia on IOP. We can conclude that the use of machine learning methods to evaluate factors that affect IOP in children with myopia treated with topical atropine is promising. XGBoost is the best predictive model, and baseline IOP is the most accurate predictive factor for endpoint IOP among all machine learning approaches.

A STROBE-compliant case-control study: Effects of cumulative doses of topical atropine on intraocular pressure and myopia progression.

Topical atropine has become a mainstream treatment of myopia throughout East and Southeast Asia, but it is uncertain whether long-term topical atropine therapy induces intraocular pressure (IOP) elevation and subsequent development of glaucoma. We then prospectively examined the effects of long-term atropine treatment on IOP.Our case series collected 186 myopic children who were younger than 16 years of age. Complete ocular examination data, IOP and refractive status measurements beginning in 2008 were collected for all participants. Participants were divided into two groups: 121 children who received atropine therapy at various concentrations were classified as the treated group, whereas 65 children who did not receive atropine therapy were classified as the untreated (reference) group. In the treated group, clinicians prescribed different concentrations of atropine eye drops according to their discretion with regard to the severity of myopia on each visit of the patient. We then calculated the cumulative dose of atropine therapy from 2008 to the patients' last follow-up in 2009. Furthermore, the treated group was then further divided into low- and high-refractive-error groups of nearly equal size for further analysis.There were no significant differences for the baseline refractive errors and IOPs between the treated and untreated groups. Both the low- and high-cumulative atropine dosage subgroups showed significantly lower myopic progression than the untreated group, but there was no significant difference between the two subgroups in terms of different cumulative dosages. All groups, including the untreated group, showed an increase of mean IOP at the last follow-up, but both low- and high-cumulative atropine dosage subgroups experienced a smaller increase of IOP. The mean IOP of all atropine-treated groups showed no significant increase in either low- or high-refractive-error eyes.This study revealed that topical atropine eye drops do not induce ocular hypertension and are effective for slowing the progression of myopia. The treatment effects are not correlated with the cumulative atropine dosages.

Increased prevalence of proliferative retinopathy in patients with acromegaly.

BACKGROUND: This pilot study was carried to determine the prevalence of retinopathy, especially proliferative retinopathy, in patients with acromegaly. METHODS: We analyzed 43 acromegalic patients and 129 age- and gender-matched patients with type 2 diabetes. The retinopathy status was determined from the medical records based on the ophthalmologist consultations of patients with acromegaly. Color photographs of the macula- and disc-centered views were obtained at an angle of 45° with a fundus camera after pharmacologic-induced mydriasis in patients with type 2 diabetes. RESULTS: Compared with age- and gender-matched patients with type 2 diabetes, the acromegalic patients had lower fasting plasma glucose levels and lower systolic and diastolic blood pressures, but were taller and had higher IGF-1 levels. Any degree of retinopathy was present in 9.3% (4 of 43) of patients with acromegaly and 34.9% (45 of 129) of patients with type 2 diabetes (odds ratio [OR] = 0.191; 95% confidence interval [CI] = 0.064-0.570). Proliferative retinopathy was present in 9.3% (4 of 43) of patients with acromegaly and 9.3% (12 of 129) of patients with type 2 diabetes (OR = 1.000; 95% CI = 0.305-3.281). Non-proliferative retinopathy was absent in patients with acromegaly, but present in 25.9% (33 of 129) of patients with type 2 diabetes. CONCLUSION: The high proliferative, but absence of non-proliferative retinopathy in our patients with acromegaly may reflect the pathogenic effect of IGF-1 on neovascularization. IGF-1 may play an important role in proliferative retinopathy, but may play no role in non-proliferative retinopathy.

Decrease heart rate variability but preserve postural blood pressure change in type 2 diabetes with microalbuminuria.

BACKGROUND: This study compares the cardiovascular autonomic function in type 2 diabetes with and without microalbuminuria, in order to identify the possible links between early nephropathy and diabetic autonomic neuropathy (DAN). METHODS: Cardiovascular reflex tests were performed to determine the cardiovascular autonomic function. Thirty cases of type 2 diabetes with microalbuminuria were studied for evidence of DAN to compare with a normoalbuminuric group of 56 diabetic patients. RESULTS: There was an increased prevalence of autonomic dysfunction in patients with microalbuminuria (63.3% in the microalbuminuria group vs. 40.0% in the normoalbuminuric controls, p = 0.001). These patients had lower heart rate variability during single breathing tests (6.9 +/- 4.3 vs. 9.6 +/- 3.6 beats/minute, p = 0.005), during 6 consecutive breathings (5.8 +/- 3.6 vs. 8.2 +/- 3.3 beats/minute, p = 0.005), after standing up (12.2 +/- 4.6 vs. 15.0 +/- 5.2 beats/ minute, p = 0.012), and during the Valsalva maneuver (11.3 +/- 3.5 vs. 13.2 +/- 3.6 beats/minute, p = 0.022). The heart rate variability with these stresses was revealed to be less favorable in subjects with microalbuminuria. However, blood pressure (BP) changes from the sitting to standing position were not significantly different for systolic BP (11.5 +/- 10.7 vs. 10.7 +/- 7.8 mmHg, p = 0.741) and diastolic BP (5.2 +/- 4.4 vs. 5.9 +/- 4.0 mmHg, p = 0.451) between the 2 groups. CONCLUSION: Type 2 diabetic patients with microalbuminuria have diminished heart rate variability in response to deep breathing, change of position and the Valsalva maneuver, but they preserve BP response to postural change. Therefore, microalbuminuria seems to be associated with early DAN, but not with advanced DAN.

Severe strabismus after scleral buckling: multiple mechanisms revealed by high-resolution magnetic resonance imaging.

PURPOSE: Strabismus occurring after scleral buckling for retinal detachment typically is attributed to scarring, but this is not the only mechanism. We investigated use of magnetic resonance imaging (MRI) to identify a spectrum of mechanisms of strabismus occurring after scleral buckling. DESIGN: Prospective, noncomparative, observational case series in an academic referral setting. PARTICIPANTS: Six patients with long-standing, large-angle strabismus after monocular or binocular scleral buckling. Horizontal and vertical preoperative deviations, present from 8 to 120 months, ranged from 25 prism diopters to more than 90 prism diopters. METHODS: Multipositional high-resolution MRI of both orbits was performed using surface coils in multiple, controlled gaze positions. Coronal, sagittal, and axial images were obtained as clinically appropriate. MAIN OUTCOME MEASURES: Different mechanisms of pathologic characteristics of the extraocular muscles (EOMs) in complicated strabismus after scleral buckling. RESULTS: Magnetic resonance imaging readily demonstrated EOM size and contractility, as well as features of scleral buckle hardware such as grooves and junctions and relationships of EOMs to the buckle and sclera. Imaging demonstrated that 5 rectus EOMs were disinserted from the globe at the buckle: 2 superior rectus, 2 medial rectus, and 1 lateral rectus. One patient with suspected inferior rectus muscle disinsertion had restrictive strabismus as a result of interference by a meridional explant and myopic staphyloma. Magnetic resonance imaging demonstrated anterior migration and transection by the silicone element through rectus EOMs in 3 patients. Disinserted EOMs were retrieved successfully by transconjunctival surgery in 4 patients and by orbitotomy in 1 patient, markedly improving alignment even as long as 5 years after EOM disinsertion. CONCLUSIONS: Multipositional high-resolution MRI provides valuable information such as location and contractile potential of disinserted EOMs, as well as mass effect from the scleral buckle. Preoperative orbital MRI may be a useful tool to distinguish multiple mechanisms of persistent severe strabismus after scleral buckling and is helpful in surgical planning.

Prognostic factors of mortality among patients with severe hyperglycemia.

OBJECTIVES: Severe hyperglycemia is associated with increased morbidity and mortality in a variety of patients. We undertook this study to identify prognostic factors of mortality among patients experiencing severe hyperglycemia in the emergency department (ED). STUDY DESIGN: Longitudinal observation study. METHODS: We recruited patients who visited the ED with blood glucose levels higher than 500 mg/dL between July 2008 and September 2010. The primary outcome was death from any cause within 90 days. Outcome analysis was first performed with Pearson's χ(2) test. Any characteristic with suspected significance (P < .1) was then used in a univariate Cox regression model. The variables found to be statistically significant were then subjected to multivariate analysis for further investigation. RESULTS: Among 733 patients with severe hyperglycemia, the 90-day mortality rate was 14.6% (n = 107). Independent prognostic factors for increasing 90-day mortality included elevated absolute neutrophil count (hazard ratio [HR], 7.34), elevated C-reactive protein (HR, 4.48), elevated blood urea nitrogen (HR, 3.04), elevated respiratory rate (HR, 2.91), decreasing body temperature (HR, 2.68), decreasing systolic blood pressure (HR, 2.65), elevated potassium (HR, 2.54), decreasing blood glucose (HR, 2.46), elevated creatinine (HR, 2.40), elevated white blood cell count (HR, 2.30), and elevated ratio of blood urea nitrogen to creatinine (HR, 2.23). CONCLUSIONS: The 90-day mortality rate among patients with severe hyperglycemia in the ED was 14.6%. Sepsis, renal impairment with electrolyte imbalance, and lower blood pressure were independent prognostic factors.

Easy-to-prepare autologous platelet-rich plasma in the treatment of refractory corneal ulcers.

As platelets are rich in growth factors for tissue regeneration, autologous platelet-rich plasma (PRP) has been used to treat some refractory corneal defects. Although PRP is effective, the cost of its preparation is very high. This article presents three cases of refractory corneal ulcer under the prescription of autologous PRP. The autologous PRP used in these cases was easily prepared in the blood bank laboratory. In this paper, we collected three patients with refractory corneal ulcer who were unresponsive to conventional treatment. The patients presented with neurotrophic ulcer, exposure corneal ulcer, and limbal deciency with corneal ulcer after hepatitic keratitis. Although we easily prepared autologous PRP eye drops using simple laboratory centrifugation, this preparation still had a clinical effect on corneal defect. The mean intervention time was 24 ± 6.9 days. The case with exposure corneal ulcer had significant wound healing and the other two cases felt subjective symptom relief. There were some clinical improvements of refractory corneal ulcers in our three cases. We present the clinical results of three cases and report an easy procedure for the preparation of autologous PRP. Autologous PRP prepared simply in the laboratory, it may be an alternative option for treating refractory corneal ulcer.

Long-term glycemic control after 6 months of basal insulin therapy.

OBJECTIVES: To compare the effects of a 6-month course of insulin therapy versus oral antidiabetic drugs (OADs) on long-term (5-year) glycemic control in patients newly diagnosed with type 2 diabetes mellitus (T2DM) with severe hyperglycemia. STUDY DESIGN: 5 years' follow-up of a randomized controlled trial. METHODS: Newly diagnosed patients with T2DM and severe hyperglycemia were hospitalized and treated with intensive insulin injections for 10 to 14 days. Fifty patients were randomized to receive either insulin injections or OADs for an additional 6 months. Subjects were followed for 5 years to evaluate long-term glycemic control. We compared the glycated hemoglobin (A1C) levels of the treatment groups and the proportion of patients in each group who reached the treatment targets. We also examined the remission rate (A1C ≤6.5% without antidiabetic medication) at the end of the 5 years. The mechanisms of improved glycemic control and possible mechanism of remission were also investigated. RESULTS: At 5 years, A1C levels remained lower in the insulin group than in the OAD group (6.49 ± 0.72% vs 7.72 ± 1.06%; P = .012). The proportion of subjects with A1C levels ≤6.5% was significantly higher in the insulin group than in the OAD group (63.6% vs 23.5%; P = .013). The remission rate was 27.3% in the insulin group and 5.9% in the OAD group (P = .048). CONCLUSIONS: This randomized trial demonstrated that a 6-month course of insulin therapy led to better 5-year glycemic control, reflected by lower A1C levels, than did oral antidiabetic agent therapy. Moreover, the insulin-treated group had a significantly higher rate of remission from diabetes.

Effects of glucose and blood pressure control on diabetic kidney disease in old patients with type 2 diabetes.

AIMS: We determined the influence of age on the effects of glucose and blood pressure control on diabetic kidney disease in patients with type 2 diabetes. METHODS: A total of 721 patients with type 2 diabetes, aged 41-85 years and with an estimated glomerular filtration rate (eGFR) ≥30 mL/ [min · 1.73 m(2)], were enrolled in this study between August 2001 and December 2002. All participants were followed up at our clinics until December 31, 2010. Primary outcomes were the development of end-stage renal disease (ESRD) and all-cause mortality. Secondary outcomes were the development of clinical albuminuria and a severe decline in eGFR. RESULTS: During the follow-up period (median: 8.3 years), 27 (3.7%) patients developed ESRD, 130 (18.0%) patients died without developing ESRD, and 16 (2.2%) patients died after developing ESRD. Mortality rate increased with age, but the incidence rate of ESRD did not. Poor glucose and blood pressure control was associated with the development of clinical albuminuria and with a severe decline in eGFR in younger patients with diabetes, but not in older patients. The development of severe decline in eGFR and ESRD was significantly lower in the middle tertile of blood pressure (i.e., SBP of 128-141 mm Hg) in older patients. CONCLUSIONS: Adequate glucose and blood pressure control did not reduce the risk of ESRD; however, it may have delayed the onset of clinical albuminuria as well as eGFR decline in younger patients with type 2 diabetes.

The role of insulin-like growth factor-1 and growth hormone in the mortality of patients with acromegaly after trans-sphenoidal surgery.

CONTEXT: Acromegaly is associated with a significant increase in mortality. With the development of new modalities of treatment, it has become important to identify prognostic factors relating to mortality. OBJECTIVE: This study aimed to determine the all-cause mortality of patients with acromegaly after trans-sphenoidal surgery, and assess the impact of biochemical markers on survival. DESIGN: Two hundred thirty-four patients were admitted to the Taipei Veterans General Hospital for acromegaly between 1979 and 2007. Of the 163 patients who underwent trans-sphenoidal surgery, 142 had data available for insulin-like growth factor-1 (IGF-1), and their survival status was analyzed. Serial data for fasting growth hormone (GH) and IGF-1 were collected. This study also used the last follow-up data for mortality analysis. The patients with acromegaly were grouped according to the last follow-up GH level (≤2 or >2 µg/L) and IGF-1 SD score (≤2 or >2). All-cause mortality was followed to the end of 2007 and compared to the general Taiwanese population by standardized mortality ratios. RESULTS: Serial GH and IGF-1 data revealed that the GH levels in the first 3 years after surgery were important predictors of mortality in acromegaly. However, there are insufficient IGF-1 data for deceased patients to determine the significance of a raised IGF-1 immediately following treatment. Comparison of crude death rates suggests that a fasting GH level of 2 µg/L and normalization of the IGF-1 level are appropriate targets. After subgroup analysis to assess the impact of discordant GH and IGF-1 levels on survival, the data showed that the elevated GH group had a trend toward a higher mortality than the elevated IGF-1 group. CONCLUSIONS: An elevated GH value in the first 3 years after surgery may be the best predictor of mortality. Thus, the follow-up of patients with acromegaly at relatively frequent intervals after trans-sphenoidal surgery should be routine.