Combined metformin and insulin therapy for patients with type 2 diabetes mellitus.

OBJECTIVE: This study was undertaken to assess the effects of combined treatment with insulin and metformin in patients with type 2 diabetes mellitus in whom dietary measures, weight control, and oral antihyperglycemic therapy had failed. BACKGROUND: Insulin resistance in peripheral tissues, increased hepatic gluconeogenesis, and impaired insulin secretion are the underlying factors in the development of type 2 diabetes. Metformin is a biguanide antihyperglycemic agent that increases peripheral insulin sensitivity, reduces hepatic gluconeogenesis, and decreases intestinal glucose absorption. METHODS: Thirty-one patients (24 women, 7 men; mean age, 61.8 years; mean body mass index [BMI], 28.0 kg/m2) were enrolled in this randomized, double-blind, 2-way, crossover, placebo-controlled study. Patients with type 2 diabetes who were treated previously with insulin or oral hypoglycemic agents and who had a glycosylated hemoglobin (HbA1c) level >9% or a fasting blood glucose level >8 mmol/L were included. Patients who were being treated with oral agents were switched to insulin therapy and required to maintain stable blood glucose control for 2 months prior to randomization. Patients received insulin plus either metformin 1,700 mg/d or placebo for 5 months, followed by a 2-month washout period, and were then crossed over to the other treatment arm for 5 months of additional treatment (total treatment period: 12 months). RESULTS: Thirty patients completed the study; 1 patient withdrew early because of hypoglycemia. Compared with placebo, metformin produced significant reductions from overall baseline in mean daily insulin dose requirement (-8.69 units (17.2%], P < 0.001), HbA1c level (-0.74 [9.9%], P = 0.005), serum fructosamine level (-44.40 micromol/L, P = 0.026), 24-hour blood glucose profile (P = 0.008), and total cholesterol level (-0.42 mmol/L, P = 0.005). No treatment effects were observed on body weight, blood pressure, serum high-density lipoprotein cholesterol levels, or serum triglyceride levels. There was no correlation between BMI and reduction in HbA1C. No major side effects were reported. CONCLUSIONS: Combination therapy with metformin and insulin improves glycemic control and reduces insulin requirements. with no major side effects, in patients with type 2 diabetes and may improve the risk profile in this patient population.

Ventricular fibrillation in hypercalcaemic crisis due to primary hyperparathyroidism.

We report the case of a 64-year-old man who presented with severe hypercalcaemia secondary to primary hyperparathyroidism. Soon after admission he developed ventricular fibrillation with no other cause than this severe hypercalcaemia. Although the occurrence of cardiac arrhythmias in hypercalcaemia is widely known, ventricular fibrillation has never been described before.

Methemoglobinemia as an uncommon cause of cyanosis.

Cyanosis is usually caused by decreased arterial oxygen saturation due to pulmonary or cardiac diseases. Methemoglobinemia is a rare cause, sometimes with lethal outcome. Two patients are described, both with an unremarkable cardiopulmonary history, presented with severe cyanosis due to aniline-induced methemoglobinemia that developed at work. The symptoms and the treatment of methemoglobinemia are discussed.

Aerosolized prostacyclin in acute respiratory distress syndrome caused by Chlamydiaceae spp. pneumonia.

Management of respiratory failure in acute respiratory distress syndrome (ARDS) typically requires ventilatory assistance. If traditional approaches to mechanical ventilation and adjunctive measures fail to succeed in achieving adequate oxygenation, alternative measures should be considered. We describe an ARDS patient with respiratory failure caused by a severe Chlamydiaceae species community-acquired pneumonia (CAP). Aerosolized prostacyclin (PGI(2)) treatment was successfully instituted for refractory hypoxemia.

An unusual case of multiple endocrine neoplasia type 1 and the role of 111In-pentetreotide scintigraphy.

A 50-year-old woman is described with a very unusual combination of MEN-1 syndrome with a negative family history. At first she had been treated because of a clinically non-functioning pituitary adenoma in the maxillary sinus. Six years later a carcinoid tumour was discovered by means of 111In-pentreotide scintigraphy.

[Antipsychotic medication as a cause of deep hypothermia]. / Antipsychotica als oorzaak van diepe hypothermie.

Two patients were presented at our hospital with hypothermia following dose adjustment of antipsychotic medication. The first patient, a mentally retarded 45-year-old man developed a temperature of 31.7 degrees C several days after starting of levomepromazine. The second patient, an 41-year-old schizophrenic man, whose risperidone dose had been increased following a psychotic crisis, developed deep hypothermia (temperature 29.7 degrees C) and severe respiratory insufficiency requiring pressure support ventilation. Both patients were admitted to the ICU and recovered completely. Antipsychotics influence hypothalamic thermoregulation and may induce hypothermia by stimulating dopamine (mainly D2) receptors and blocking 5-HT2 receptors. Furthermore, antipsychotics may reduce the shivering capability and can cause peripheral vasodilatation and reduced shunting by blocking skin alpha 1 receptors. Hypothermia can be a lethal condition. When a patient's clinical condition deteriorates following the start of antipsychotic medication, the presence of hypothermia should be excluded.

Intermittent versus continuous treatment for acute renal failure: where do we stand?

Despite impressive advances in the field of general intensive care and in the techniques available for the treatment of acute renal failure (ARF), particularly the development of continuous renal replacement therapies (CRRT), it is suggested that outcome of ARF patients has remained similar to that observed 2 or more decades ago. This article focuses on the impact of several factors, including the dialysis regimen, on outcome in ARF patients in a recent time period compared with an earlier period to assess whether a change has occurred in the patient population, dialysis regimen, or renal and patient outcome. Critical differences between intermittent hemodialysis (IHD) and CRRT and the authors' preference for continuous venovenous hemofiltration (CWH) are explained. However, using the APACHE II score and more specifically use of the ratio between this score at 2 different time points (ICU admission v time of start of dialysis), the need for an easy-to-use and reliable severity-of-illness score to allow adequate comparison of patient groups or treatment strategies is emphasized. Using data from a recent survey, attention is also given to the implementation of acute dialytic support, particularly CRRT, in the Netherlands.

Treatment of life-threatening lithium toxicity with high-volume continuous venovenous hemofiltration.

There is still debate as to the preferred extracorporeal treatment modality for severe lithium intoxication. Because lithium is readily diffusable, intermittent hemodialysis is usually performed. However, this bares the risk of a post-dialysis rebound concentration and, in the case of severe lithium poisoning collapse, aggravation of hemodynamic instability. Because of the relatively slow but continuous solute removal, continuous renal replacement therapy (CRRT) may be advantageous. We report the first case in the literature of severe lithium intoxication treated effectively with high-volume continuous venovenous hemofiltration (HV-CVVH). Results compared favorably to other forms of CRRT in terms of lithium clearance. Ease of implementation, the excellent tolerability and the superior lithium clearance without rebound phenomenon may make HV-CVVH the preferred treatment modality for severe lithium poisoning.