Diagnosis and management of pituitary adenomas.

PURPOSE OF REVIEW: Pituitary adenomas are frequently encountered in practice either because of clinical symptoms or as incidental findings. These tumors may alter pituitary function and can therefore have a considerable impact on morbidity, mortality, and quality of life. RECENT FINDINGS: The presentation is variable for each type of tumor, with microadenomas being either silent or manifesting with symptoms of hormonal excess. In contrast, macroadenomas may present with mass effect. The various histologic types include prolactinomas, nonfunctioning adenomas, somatotropinomas, corticotropinomas, and thyrotropinomas. The present article will serve as an update on the diagnosis and treatment of pituitary adenomas. Advances in medical management for each tumor are discussed, highlighting new therapeutic alternatives. The role of surgery is also reviewed. Recommendations on the surveillance and postoperative monitoring of patients are emphasized. SUMMARY: Newer methods in the diagnosis and treatment for pituitary adenomas greatly expand our ability to care for affected patients.

Using the glucometrics website to benchmark ICU glucose control before and after the NICE-SUGAR study.

Prior to 2009, intensive glycemic control was the standard in main intensive care units (ICUs). Glucose targets have been recalibrated after publication of the NICE-SUGAR study in that year, followed by updated guidelines that endorsed more moderated control. We sought to determine if the prevalence of hyperglycemia in US ICUs had increased after the NICE-SUGAR study's results were reported. We used data from hospitals submitted to the Yale Glucometrics™ website to assess mean blood glucose values, percentage of blood glucose within various ranges, and the prevalence of hypo- and hyperglycemic excursions, based on the patient-day method, comparing the pre- to post-NICE-SUGAR time period. Among more than a total of 2 million blood glucose determinations, comprising 408 790 patient-days, median patient-day blood glucose decreased from 144 mg/dL to 141 mg/dL (P < .001) in the pre- versus post-NICE-SUGAR time period. The percentage of patient days with a mean blood glucose of 110-179 mg/dl increased from 58.3 to 63.6%. The percentage of patient-days with either hypoglycemia (<70 mg/dl) or severe hyperglycemia (≥300 mg/dl) decreased during this time. Our results suggest that glycemic control in US ICUs has improved when comparing time periods before versus after publication of the NICE-SUGAR study. We found no evidence that fewer hypoglycemic events were achieved at the expense of more hyperglycemia.

Effects on post-prandial glucose and AGE precursors from two initial insulin strategies in patients with type 2 diabetes uncontrolled by oral agents.

OBJECTIVE: Progressive ß-cell dysfunction in Type 2 diabetes results in the need for insulin therapy in many patients. Yet the best regimen to prescribe to patients transitioning from oral anti-hyperglycemic drugs (OADs) is not clear. We sought to compare the effects of two standard initial insulin strategies (basal insulin alone versus premixed insulin) on post-prandial glucose metabolism and precursors of advanced glycation end-products in patients with type 2 diabetes suboptimally controlled on OADs. RESEARCH DESIGN AND METHODS: This was a 6-month, open-label, single-center study using a cross-over design. 14 subjects were randomized to one of two protocols: once daily insulin glargine or twice-daily 75%/25% neutral protamine lispro/lispro mix. At 12 weeks, the subjects were crossed-over to the opposite protocol. During each period, insulin doses were titrated to target fasting blood glucose of 90-110 mg/dL. At baseline and after the two 12-week treatment periods, subjects were studied in the Clinical Research Center; they consumed three liquid mixed isocaloric meals at 4-h intervals, and glucose, free fatty acids (FFA), lipids, and α-dicarbonyls (3-deoxyglucosone [3-DG] and methylglyoxal [MG]) were measured before and after each meal. Patient data were analyzed in the context of their assigned insulin strategy groups. RESULT: Both insulin regimens led to a significant improvement in glycemic profiles, including fasting glucose and HbA1c, compared to baseline. However, mean post-prandial glucose was lower with lispro mix than with glargine (153 ± 36 vs. 199 ± 49 mg/dL, respectively; P=0.001). Likewise, there was a reduction in both fasting (48 ± 13 vs. 57 ± 19, P=0.047) and post-prandial (53 ± 19 vs. 63 ± 23; P=0.007) 3DG levels with lispro mix as compared to glargine. No differences were noted in MG concentrations. CONCLUSION: In type 2 diabetes patients failing OAD therapy, an initial insulin regimen of twice daily premixed insulin results in significantly improved post-prandial glucose levels as well as a reduction in a precursor of AGEs. The effect of these two initial insulin regimens on long-term diabetic complications requires further study.

Hospital management of hyperglycemia.

PURPOSE OF REVIEW: With the growing prevalence of dysglycemia, the increased frequency of hospitalizations in diabetic patients, and the notable effects of acute stress on glucose metabolism, it is not surprising that hyperglycemia is frequently encountered in the inpatient setting. Hospital hyperglycemia is associated with increased morbidity and mortality, as well as increased length of stay and costs. Accordingly, there has been intense interest in the optimal management of glucose levels in hospitalized patients. However, overly stringent control may result in hypoglycemia, which in itself is a risk factor for adverse clinical outcome. A fine balance in management is obviously important. RECENT FINDINGS: We herein review recent observational studies and randomized clinical trials regarding glycemic management in the hospital, both in the critical care and noncritical care settings. Though results are conflicting, a consensus has recently emerged that although glucose control is important, prior recommendations had become too aggressive. SUMMARY: Newly updated national guidelines call for a blood glucose target for critically ill patients of 140-180 mg/dl, using a continuous insulin infusion if needed. In the noncritically ill, a value less than 140 mg/dl before meals and less than 180 on random checks is recommended. A regimen of basal insulin in conjunction with premeal and supplemental insulin is preferred, as opposed to simple sliding scale insulin. Importantly, these guidelines are merely recommendations and management of the hyperglycemic inpatient must be tailored to suit the individual, considering their other comorbidities, risk factors for hypoglycemia, availability and training of hospital staff, and overall prognosis.