Explore the vast range of titles available.

Background Diabetic ketoacidosis (DKA) is an acute, major, life-threatening complication of diabetes that requires immediate treatment. Allergic reaction to insulin is rare, especially when using recombinant human insulin. The clinical presentation of insulin allergy can range from minor local symptoms to a severe generalized allergic reaction such as anaphylaxis. A limited number of cases have been reported on the treatment of severe DKA in patients with type 2 diabetes with insulin allergy. Here, we describe a patient with type 2 diabetes with insulin allergy in which severe DKA resolved after the initiation of continuous intravenous (IV) recombinant human insulin infusion. Case presentation A 58-year-old man with type 2 diabetes initiated subcutaneous insulin administration (SIA) after failure of oral antidiabetic treatment. Symptoms of an allergic reaction developed, including pruritic wheals appearing within 10 min of injection and lasting over 24 h. Both skin prick and intradermal tests were positive with different types of insulin. Two days before admission, he stopped SIA because of allergic symptoms and then experienced weakness and upper abdominal pain. On admission, he was in severe metabolic acidosis with a pH of 6.984 and bicarbonate of 2.5 mmol/litre. The blood glucose level was 20.79 mmol/litre, BUN 4.01 mmol/litre, creatinine 128 μmol/litre, and urinary ketone 11.44 mmol/litre. Over 24 h, metabolic acidosis was refractory to IV fluids, bicarbonate and potassium replacement, as well as haemodialysis. Ultimately, he received continuous IV recombinant human insulin infusion at a rate of 0.1 units/kg/hour, in combination with haemodiafiltration, and no further allergic reactions were observed. On day 5, ketonaemia and metabolic acidosis completely resolved. He had transitioned from IV insulin infusion to SIA on day 14. He was discharged on day 21 with SIA treatment. Three months later, he had good glycaemic control but still had allergic symptoms at the insulin injection sites. Conclusions In this patient, SIA caused an allergic reaction, in contrast to continuous IV insulin infusion for which allergic symptoms did not appear. Continuous IV recombinant human insulin infusion in combination with haemodiafiltration could be an option for the treatment of severe DKA in patients with diabetes with insulin allergy.

ABSTRACT Background Hyperglycemic emergencies are broadly classified into diabetic ketoacidosis and hyperosmotic hyperglycemic state. The purpose of this study was to develop a clinical model for predicting treatment of hyperglycemic emergencies. Methods This study is a multicenter, retrospective cohort study. We used information on patients admitted to four medical institutions for treatment for hyperglycemic emergencies by diabetologists between April 1, 2010, and March 31, 2024, as the machine learning's training data. Multiple regression analysis was performed to find parameters that correlated with the difference between blood glucose levels before and after treatment initiation (ΔGlu), and a gradient boosting decision tree (GBDT) was created to predict ΔGlu. Results Patients with type 1 diabetes (n = 47) and type 2 diabetes (n = 116) were included in the analysis of this study. We created a GBDT model using the following parameters as features: blood glucose level at the start of continuous intravenous insulin therapy, bicarbonate concentration, insulin flow rate, time elapsed since the start of continuous insulin therapy, and drip flow, which are important parameters for continuous intravenous insulin therapy for hyperglycemic emergencies. As a result, the correlation coefficient between predicted ΔGlu and actual ΔGlu was 0.83, showing a strong positive correlation. Conclusions A GBDT model was developed to predict treatment after continuous intravenous insulin therapy using several variables during emergency care of patients with hyperglycemic emergencies. It is hoped that the application of this GBDT will allow appropriate provision of initial treatment, especially in nonspecialized medical facilities. This study developed a clinical model using a gradient boosting decision tree (GBDT) to predict blood glucose reduction (ΔGlu) after continuous intravenous insulin therapy in hyperglycemic emergencies. A multicenter retrospective cohort analysis identified key predictive factors, including initial blood glucose, bicarbonate concentration, insulin flow rate, and elapsed time since therapy initiation. The GBDT model demonstrated strong predictive accuracy (correlation coefficient = 0.83), potentially aiding in optimizing initial treatment, especially in non‐specialized medical facilities.

Background Multiple daily subcutaneous injections (MDSIs) are mainly used for formulating an insulin therapy for diabetic patients; however, they also cause insulin-derived amyloidosis (IDA) and lead to poor glycemic control. In addition, for the continuous subcutaneous insulin infusion system (CSII), precipitation frequently causes catheter occlusion and, if the precipitate in the formulations is amyloid, the injection of the insoluble amyloid into the subcutaneous tissue leads to IDA. The aim of this study was to conduct in vitro experiments and present a situation where insulin formulations cause precipitation and amyloid formation. Methods Humulin®R and NovoRapid® were used as model formulations for MDSIs and CSII, respectively. The generation of the precipitation was evaluated by measuring turbidity, and amyloid formation was evaluated by using Thioflavin T. Humulin®R was mixed with saline buffer solutions and glucose solutions to evaluate the effect of dilution. In addition, we created an experimental system to consider the effect of the time course of condition changes, and investigated the effects of insulin concentration, m -cresol existence, and pH change on the generation of the precipitate and amyloid in the formulation. Results In both the original and diluted formulations, physical stimulation resulted in the formation of a precipitate, which in most cases was an amyloid. The amyloid was likely to be formed at a near neutral pH. On the contrary, although a precipitate formed when the pH was decreased to near the isoelectric point, this precipitate was not an amyloid. Further decreases in pH resulted in the formation of amyloids, suggesting that both the positive and negative charged states of insulin tended to form amyloids. The formulation additive m -cresol suppressed amyloid formation. When additives were removed from the formulation, the amyloid-containing gel was formed in the field of substance exchange. Conclusions To consider changes in conditions that may occur for insulin formulations, the relationship between the formation of precipitates and amyloids was demonstrated in vitro by using insulin formulations. From the in vitro study, m -cresol was shown to have an inhibitory effect on amyloid formation.

Du LZ, Liu PY, Ge CY, et al. Neuropsychiatr Dis Treat. 2022;18:13091314. The authors have advised the affiliation on page 1309 is incorrect. The correct affiliation should read \"Department of Clinical Pharmacy, Nanjing First Hospital, Nanjing Medical University, Nanjing, People's Republic of China\". The authors apologize for this error.

Background: Continuous intravenous infusion (IV) or subcutaneous injection (SC) of insulin was widely applied to control hyperglycemia after ischemic stroke. However, the impact of different administration modes on glycemic variability was unknown. Methods: Consecutive stroke patients treated with intravenous thrombolysis were screened. Subjects who received insulin treatment were included and entered into the IV or SC group according to the respective administration mode. Blood glucose was closely monitored within the first 72 hours, and the target range of glucose was from 7.7 to 10.0 mmol/L for all patients. The variabilities of glucose, assessed using standard deviation of the mean, variable coefficient and range from the maximum to the minimum value, were compared between the two groups. Results: A total of 130 patients were enrolled with 66 in the IV groups and 64 in the SC group. Compared with the SC group, the IV group had higher glycemic variability evaluated as either standard deviation (2.7 [+ or -] 0.7 mmol/L vs 2.2 [+ or -] 0.9 mmol/L, p = 0.002), variable coefficient (0.26 [+ or -] 0.06 vs 0.23 [+ or -] 0.08, p = 0.011) or range (10.0 [+ or -] 3.6 mmol/L vs 8.1 [+ or -] 3.1 mmol/L, p = 0.001). Multivariate logistic regression analyses found that continuous intravenous infusion was associated with higher level of the standard deviation (adjusted OR 3.01, 95% CI 1.29-7.28, p = 0.011), variable coefficient (adjusted OR 5.97, 95% CI 2.55-13.96, p < 0.001) and range (adjusted OR 6.08, 95% CI 2.63-14.05, p < 0.001). Conclusion: Continuous intravenous infusion of insulin was associated with higher glycemic variability than subcutaneous injection in acute stroke patients receiving thrombolysis. Keywords: acute ischemic stroke, insulin, continuous intravenous infusion, subcutaneous injection, administration mode

A 71-year-old man without previous history of diabetes was hospitalized after suffering polyuria for 1 month and involuntary movement of the left arm for 1 week. His random serum glucose was 42.05 mmol/l and his hemoglobin A1C was 14% (129 mmol/mol). His serum osmolarity was normal and his urine ketone was negative. Cerebral CT revealed hyperdensity in the right basal ganglia. The patient was diagnosed with diabetic hemiballism-hemichorea (HH). Intravenous insulin was given and later shifted to continuous subcutaneous insulin infusion. During the hospital stay, insulin titration was guided mainly by flash glucose monitoring (FGM). Finger-prick glucose was occasionally checked to verify the accuracy of the FGM. Rapid correction of severe hyperglycemia was achieved without hypoglycemia. HH resolved within 1 week after euglycemia was achieved. This case emphasized the importance of being alert for HH as the initial presentation of diabetes and neuroimaging negative diabetic HH. In addition, interstitial glucose-monitoring technologies including continuous glucose monitoring and FGM can facilitate inpatient intensive insulin therapy in diabetic HH by avoiding hypoglycemia.

This study was set up to assess whether postoperative suppression of gluconeogenesis by dextrose infusion would be influenced by continuous peripheral nerve block (CPNB) with local anesthetics, in comparison with epidural and with intravenous analgesia. Twenty-seven patients, undergoing elective primary total knee arthroplasty for osteoarthritis, were randomly allocated to one of the three groups of 9 patients each: patient controlled analgesia (PCA) with i.v. morphine, epidural with bupivacaine 0.1% and fentanyl 3μg/ml, or continuous femoral and sciatic blocks with ropivacaine 0.2%. Endogenous glucose production, an index of gluconeogenesis, and glucose clearance, an index of whole body glucose uptake, were assessed on the second postoperative day by measuring [6,6- 2H 2]glucose kinetics after an overnight fast (fasted state), and during a 3-h period infusion of dextrose at 4 mg/kg/min (fed state). Visual analog scale (VAS) at rest and at knee flexion, use of morphine, mobilization, nutritional intake, and bowel function were also collected. Endogenous glucose production was totally suppressed by 3 h of dextrose infusion in all 3 groups ( P < .001) while glucose clearance was unchanged. Blood glucose and insulin increased ( P < .001), while glucagon decreased, with the greatest change in the epidural group ( P < .05). VAS at rest and at knee flexion was significantly lower in patients receiving epidural and CPNB compared to i.v. morphine ( P < .05). Restoration of bowel function, assessed as return of bowel movements, was faster in the CPNB group ( P < .05). Excellent analgesia was achieved in the epidural and continuous nerve block groups. Postoperative gluconeogenesis was totally suppressed by dextrose infusion independent of the analgesia technique with no change in glucose utilization.