Review of basal-plus insulin regimen options for simpler insulin intensification in people with Type 2 diabetes mellitus.

AIMS: To identify simple insulin regimens for people with Type 2 diabetes mellitus that can be accepted and implemented earlier in primary and specialist care, taking into consideration each individual's needs and capabilities. METHODS: Using randomized clinical trials identified by a search of the PubMed database, as well as systematic reviews, meta-analyses and proof-of-concept studies, this review addresses topics of interest related to the progressive intensification of a basal insulin regimen to a basal-plus regimen (one basal insulin injection plus stepwise addition of one to three preprandial short-acting insulin injections/day) vs a basal-bolus regimen (basal insulin plus three short-acting insulin injections per day) in people with Type 2 diabetes. The review explores approaches that can be used to define the meal for first prandial injection with basal-plus regimens, differences among insulin titration algorithms, and the importance of self-motivation and autonomy in achieving optimum glycaemic control. RESULTS: A basal-plus regimen can provide glycaemic control equivalent to that obtained with a full basal-bolus regimen, with fewer injections of prandial insulin. The first critical step is to optimize basal insulin dosing to reach a fasting glucose concentration of ~6.7 mmol/l; this allows ~40% of patients with baseline HbA1c >75 mmol/mol (9%) to be controlled with only one basal insulin injection per day. CONCLUSIONS: Compared with a basal-bolus regimen, a basal-plus insulin regimen is as effective but more practical, and has the best chance of acceptance and success in the real world.

Effects of melamine in young broiler chicks.

A study was conducted to determine the toxicity of melamine in young broilers fed graded levels of melamine. An additional objective was to determine melamine residual levels in selected tissues. One hundred and seventy-five 1-d-old male Ross broiler chicks were sorted to a randomized block design in stainless steel battery pens. Chicks were assigned to 7 dietary treatments containing 0, 0.5, 1.0, 1.5, 2.0, 2.5, and 3.0% melamine. Each dietary treatment was fed to 5 replicate pens of 5 chicks for 21 d. Mortality increased quadratically (P<0.001) with increasing dietary concentrations of melamine. However, compared with controls, mortality was only higher (P<0.001) in birds fed≥2.5% melamine. Feed intake decreased linearly (P<0.001), whereas BW gain decreased quadratically (P<0.02) with increasing dietary concentrations of melamine. Compared with controls, both feed intake and BW gain were lower (P<0.001) only in birds fed≥1.0% melamine. Relative kidney weights increased linearly (P<0.001), whereas relative liver weights increased quadratically (P<0.05) with increasing dietary concentrations of melamine. Melamine residues in breast muscle and liver tissue increased linearly (P<0.001) with increasing dietary concentrations of melamine, whereas melamine residues in kidney and bile increased quadratically (P<0.02) with increasing dietary concentrations of melamine. Compared with controls, melamine concentrations in liver and kidney were higher (P<0.001) in birds fed all levels of melamine, whereas melamine concentrations in breast muscle and bile were only higher (P<0.001) in birds fed≥1.0% melamine. Serum albumin, total protein, globulin, and calcium increased quadratically (P<0.02) in birds as dietary melamine increased, whereas serum aspartate transaminase and gamma gluatamyltransferase increased linearly (P<0.01) with increasing levels of melamine in the diet. Renal histopathology revealed nonpolarizable melamine crystals in the collecting tubules and ducts of birds fed≥1.5% melamine. In summary, dietary melamine was toxic to broilers at concentrations≥1.0%.

Outcome of post-prostatectomy radiotherapy in one institution.

We present a retrospective study to evaluate the outcome of postoperative radiotherapy for biochemical or clinical recurrent prostate cancer. Twenty-six patients (median age 60 years) underwent radiotherapy after radical prostatectomy between January 1997 and January 2004. Seven patients received adjuvant radiotherapy and 19 received salvage radiotherapy. The median prostate-specific antigen at diagnosis was 8.6 (0.9-89) and most (23 patients) presented with T(3)N(0) disease. The median follow up was 19.5 months (5-84 months). All patients received a dose of 61.2 Gy at 1.8 Gy per fraction, 20 initially receiving 45 Gy to the lesser pelvis. The median dose to the bladder, rectum and left femoral head were 55.6, 57.5 and 33.8 Gy, respectively. All patients were managed radiotherapeutically by the first author. Twenty-four patients are alive. Two patients have died, one from oesophageal cancer and the second from metastatic prostate cancer. Two other patients also developed metastatic disease. Four asymptomatic patients with a rising prostate-specific antigen are under observation. None of the 26 patients has developed a local recurrence. Seven patients have developed grade 1 late bowel effects and three a grade 2 late effect. Eight patients suffer from grade 1 late genitourinary effects and two from grade 2 effects. One patient developed impotence, whereas 23 patients were rendered impotent postoperatively. There were no grade 3/4 late effects. Postoperative radiotherapy is well tolerated and provides effective local control.

Reducing the operative trauma in aortoiliac reconstructions--a prospective study to evaluate the role of video-assisted vascular surgery.

OBJECTIVE: To evaluate the role of the surgical access with regard to the generation of proinflammatory proteins in patients with aortoiliac occlusive disease. DESIGN: Non-random, prospective study of patients undergoing an aortobifemoral bypass procedure. MATERIALS: Twenty-six patients were divided into three groups. In the first group of eight patients, a transperitoneal median laparotomy was used. The second group comprised 10 patients in whom a laparoscopically assisted extraperitoneal minilaparotomy was performed and, in the third group, eight patients were operated on using a retroperitoneal access. METHODS: Biochemical analysis of acute phase proteins and the cytokines interleukin-6 (Il 6), interleukin-8 (Il 8) and tumour necrosis factor (TNF). RESULTS: Aortic cross-clamp and total operative time were significantly longer in the laparoscopic group. After 24 h Il-6 concentrations were significantly higher in the transperitoneal (p < 0.05) and the retroperitoneal group (p < 0.006). After 6 h there was a reduced Il-8 concentration in the laparoscopic group compared to patients with a standard retroperitoneal access. Neither TNF nor acute phase proteins showed any significant alterations. CONCLUSION: Laparoscopic-assisted vascular surgery allows for a smaller incision and reduces the surgical trauma, as it is reflected by interleukin levels.

Developments in the ureteroscopes, techniques and accessories associated with laser lithotripsy.

Two stages in the development of the technique of laser lithotripsy are described. In the first series, spanning 1985-1988, three consecutive groups of patients are compared. In the first 100 patients, 11.5-F ureteroscopes were used. Access on first retrograde attempt was successful in 73%; 3% developed strictures; the ureteric perforation rate was 7%; and 12% required nephrostomy drainage. These results contrast with those of the third group in this series, consisting of 200 patients using a miniaturised ureteroscope. Access on the first retrograde attempt was successful in 99%. There were no strictures, no perforations and no requirements for nephrostomy drainage. (The second group of 100 patients using a range of rigid ureteroscopes was intermediate in its complication rate: 2% developed strictures, the ureteric perforation rate was 3%, and 6% required nephrostomy drainage). In the second series, spanning 1989-1990, the procedures were performed by all grades of urologists using miniaturised endoscopes. An in-depth audit was performed and each patient was followed until completely clear of fragments. The stones were successfully accessed on the first attempt in 213 cases (89%). In group A (139 patients, no basket used) 32 renal units (23%) were cleared of stone fragments immediately following the procedure, rising to 78 units (56%) by 3 months and 99 units (71%) beyond 3 months follow-up. Some fragments remained in 40 renal units and were cleared by further ureteroscopy, ESWL or PCNL, with the exception of 1 patient who had small residual fragments despite ESWL for fragments flushed to the kidney.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of duodenal amino acid infusion on solid gastric emptying in pigs.

The emptying of a 400-g test meal of cubed liver was studied in eight pigs equipped with duodenal cannulas. Gastric effluent was diverted to measure both the rate of emptying and the distribution of particle sizes. The effect of emptying and particle size of infusing normal saline or an isosmolar amino acid solution into the small bowel was studied. Normal saline infusion did not alter the proportion of particles emptied, which were less than 1 mm in diameter. Infusion of the amino acid solution at the same rate significantly decreased the mass of liver emptied from 69.9 to 38.4 g compared with normal saline, and the percentage of particles less than 1 mm in diameter in the gastric effluent increased from 66 to 82%. We conclude that the amino acid solution produced both a reduction in the rate of gastric emptying and an increase in the proportion of small particles in the gastric effluent. We postulate that this may have been due to changes in gastric motility, together with alterations in gastric secretion and digestion, produced by the infusion of the amino acid solution into the small bowel.

Response of porcine lower esophageal sphincter to increasing intraabdominal pressure.

The response of lower esophageal sphincter pressure to increasing intraabdominal pressure was investigated in six anesthetized pigs while measuring the intraabdominal pressure directly with a perfused catheter and recording continuously from the lower esophageal sphincter using a manometric catheter incorporating a constantly perfused sleeve. Studies were conducted both before and after the administration of intravenous atropine. Resting lower esophageal sphincter pressure was 8 mm Hg (3-19 mm Hg). In response to inflation of the peritoneal cavity with carbon dioxide gas, lower esophageal sphincter pressure rose significantly more than intraabdominal pressure whether the stomach was empty or full. In three of the six pigs, phasic lower esophageal sphincter pressure variations occurred as intraabdominal pressure increased. These variations were unrelated to respiration. Resting lower esophageal sphincter pressure was little affected by 75 micrograms/kg intravenous atropine which also had no effect on the lower esophageal sphincter response to increasing intraabdominal pressure. We conclude that, in the pig, the lower esophageal sphincter pressure increases more than the intraabdominal pressure in response to challenge and that excitatory cholinergic fibers do not mediate this response.