Improved safety with intravenous insulin therapy for critically ill patients with renal failure

ObjectiveThe aim of this study was to evaluate the safety and efficacy of a new intravenous (IV) regular human insulin infusion (RHI) algorithm for glycemic control in critically ill patients with renal failure.MethodsAdult trauma patients with renal failure who received a new RHI algorithm were compared with those who received the discontinued RHI algorithm (historical control). Target blood glucose (BG) concentration was 70 to 149 mg/dL (3.9–8.3 mmol/L). Patients were evaluated for 7 d while receiving the RHI infusion and continuous enteral or parenteral nutrition.ResultsMean BG was higher for the new RHI algorithm group (n = 25) compared with control (n = 21): 145 ± 10 mg/dL or 8.1 ± 0.6 mmol/L versus 133 ± 14 mg/dL or 7.4 ± 0.8 mmol/L (P = 0.001). The new RHI algorithm resulted in less time within the target BG range (11.9 ± 2.5 h/d versus 16.1 ± 3.3 h/d; P = 0.001); however, BGs were within 70 to 179 mg/dL (or 3.9–10 mmol/L) for 16.3 ± 2.6 h/d. The proportion of patients who experienced an episode of moderate hypoglycemia (BG 40–60 mg/dL or 2.2–3.3 mmol/L) or severe hypoglycemia (BG < 40 mg/dL or 2.2 mmol/L) was decreased (32% versus 76%; P = 0.001) and eliminated (0% versus 29%, P = 0.006), respectively.ConclusionsThe new RHI algorithm improved patient safety by decreasing the prevalence of moderate hypoglycemia and eliminating severe hypoglycemia. The duration of glycemic control within the target BG range was decreased, but acceptable within a higher target BG ceiling.     

Evaluation of nursing adherence to a paper-based graduated continuous intravenous regular human insulin infusion algorithm

ObjectiveThe use of continuous intravenous regular human insulin (RHI) infusion is often necessary to achieve glycemic control in critically ill patients. Because insulin is a high-risk medication owing to the potential for severe hypoglycemia, it is imperative that insulin infusion algorithms are designed to be safe, effective, and instructionally clear. The safety and efficacy of our intravenous RHI infusion algorithm protocol has been previously established (Nutrition 2008;24:536–45); however, the protocol violations by nursing personnel were not examined. The objective of this study was to assess nursing adherence to our RHI infusion algorithm.MethodsContinuous RHI infusion algorithm violations were retrospectively evaluated in adult patients admitted to a trauma intensive care unit who received concurrent continuous enteral and/or parenteral nutrition therapy and our algorithm for at least 3 d. Blood glucose (BG) monitoring was done every 1 to 2 h with the target BG at 70 to 149 mg/dL (3.9 to 8.3 mmol/L). Nursing adherence to the RHI infusion protocol was evaluated for each patient by comparing the adjustments in insulin infusion rates documented by the nursing personnel with the prescribed adjustments per our graduated continuous intravenous RHI infusion algorithm.ResultsA total of 4150 BG measurements necessitating the determination of the appropriate RHI dosage rate by nursing personnel in 40 patients occurred during the observational period. The target BG was achieved for a mean of 20 h/d and none of the patients had an episode of severe hypoglycemia (BG <40 mg/dL or 2.2 mmol/L). The overall rate of algorithm violations was 12.1%. The algorithm violations accounted for a single episode of mild to moderate hypoglycemia (BG 40 to 60 mg/dL or 2.2 to 3.3 mmol/L) in 4 patients and 65 total episodes of hyperglycemia (BG ≥150 mg/dL or 8.3 mmol/L) in 18 patients.ConclusionAn adherence rate of nearly 90% is indicative of excellent nursing adherence compared with other published paper-based algorithms that examined protocol adherence. These data, combined with our previously published glycemic control data, indicate that this RHI infusion algorithm is an effective one for hyperglycemic trauma patients receiving continuous enteral and/or parenteral nutritional therapy.     

Safety and efficacy of a graduated intravenous insulin infusion protocol in critically ill trauma patients receiving specialized nutritional support

OBJECTIVE: The intent of this study was to evaluate the safety and efficacy of our protocol for providing continuous intravenous regular human insulin (RHI) infusion to hyperglycemic critically ill trauma patients receiving specialized nutritional support. METHODS: Capillary blood glucose (BG) concentrations were determined every 1-2 h. Glucose control was defined as a BG concentration in the target range of 70-149 mg/dL (3.9-8.3 mmol/L). Data were recorded for 1 d before the RHI infusion and for a maximum of 8 d thereafter while receiving the RHI infusion. RESULTS: Forty adult critically ill trauma patients received 102 +/- 62 units of RHI daily for 10 +/- 6 d. BG control was achieved within 5 +/- 3 h. BG decreased from 194 +/- 55 mg/dL (10.8 +/- 3.1 mmol/L) to 134 +/- 19 mg/dL (7.4 +/- 1.1 mmol/L) after 1 d of RHI infusion (P < 0.001). Average daily BG ranged from 119 to 124 mg/dL and the target range was maintained for 19.6 +/- 4.7 h/d. None of the patients experienced severe hypoglycemia (<40 mg/dL); 14 patients had asymptomatic hypoglycemia (<60 mg/dL or <3.3 mmol/L) for a total of 23 episodes out of 4140 measurements (0.56%). Estimated creatinine clearance for those with hypoglycemia was 69 +/- 32 mL/min compared with 117 +/- 58 mL/min for the others (P < 0.01). CONCLUSION: Our protocol was safe and effective for the management of hyperglycemia in critically ill trauma patients receiving specialized nutritional support but should be used with caution in patients with renal insufficiency.     

Transitional NPH Insulin Therapy for Critically Ill Patients Receiving Continuous Enteral Nutrition and Intravenous Regular Human Insulin

Background: The intent of this study was to evaluate the efficacy and safety of transitioning from a continuous intravenous (IV) regular human insulin (RHI) or intermittent IV RHI therapy to subcutaneous neutral protamine Hagedorn (NPH) insulin with intermittent corrective IV RHI for critically ill patients receiving continuous enteral nutrition (EN). Methods: Data were obtained from critically ill trauma patients receiving continuous EN during transitional NPH insulin therapy. Target blood glucose concentration (BG) range was 70–149 mg/dL. BG was determined every 1–4 hours. Results: Thirty‐two patients were transitioned from a continuous IV RHI infusion (CIT) to NPH with intermittent corrective IV RHI therapy. Thirty‐four patients had NPH added to their preexisting supplemental intermittent IV RHI therapy (SIT). BG concentrations were maintained in the target range for 18 ± 3 and 15 ± 4 h/d for the CIT and SIT groups, respectively (P < .05). Thirty‐eight percent of patients experienced a BG <60 mg/dL, and 9% had a BG <40 mg/dL. Hypoglycemia was more prevalent for those who were older (P < .01) or exhibited greater daily BG variability (P < .01) or worse HgbA_1C (p < 0.05). Conclusion: Transitional NPH therapy with intermittent corrective IV RHI was effective for achieving BG concentrations within 70–149 mg/dL for the majority of the day. NPH therapy should be implemented with caution for those who are older, have erratic daily BG control, or have poor preadmission glycemic control.     

Influence of traumatic brain injury on potassium and phosphorus homeostasis in critically ill multiple trauma patients

ObjectiveThe intent of this study was to ascertain whether multiple trauma patients with traumatic brain injury (TBI) had lower serum concentrations of potassium and phosphorus and required more aggressive supplementation than multiple trauma patients without TBI.MethodsVentilator-dependent adult patients without renal impairment who were admitted to the trauma intensive care unit or neurosurgical intensive care unit and who received enteral nutrition were evaluated for the first 14 d after hospital admission. Patients were grouped according to the presence or absence of TBI. Target serum concentrations for potassium and phosphorus were 4 mEq/L and 4 mg/dL, respectively. Electrolyte repletion therapy was given according to the nutritional support service guidelines.ResultsFifty trauma patients (25 with and without TBI) were studied. Daily serum potassium concentrations were consistently lower for those with TBI (P ≤ 0.001), whereas the mean net potassium intake was greater (1.3 ± 0.5 versus 0.7 ± 0.3 mEq · kg^?1 · d^?1, respectively, P ≤ 0.001). Serial serum phosphorus concentrations were similar between groups (P = NS) except for a significantly lower serum phosphorus concentration for trauma patients with TBI on day 3 after hospital admission (2.5 ± 0.5 versus 2.9 ± 0.7 mg/dL, respectively, P ≤ 0.05). However, the mean net phosphorus intake was significantly greater for trauma patients with TBI (0.65 ± 0.25 versus 0.45 ± 0.17 mmol · kg^?1 · d^?1, P ≤ 0.001).ConclusionPotassium and phosphorus requirements are greater for multiple trauma patients with TBI compared with those without TBI.     

A Randomized Controlled Study Comparing a DPP4 Inhibitor (Linagliptin) and Basal Insulin (Glargine) in Patients With Type 2 Diabetes in Long-term Care and Skilled Nursing Facilities: Linagliptin-LTC Trial

Objectives

Safe and easily implemented treatment regimens are needed for the management of patients with type 2 diabetes mellitus (T2DM) in long-term care (LTC) and skilled nursing facilities.

Randomized,double-blind,placebo-controlled trial to evaluate efficacy of ketodiet in predialytic chronic renal failure

ObjectiveTo assess whether a ketodiet, a combination of ketoanalogs of essential amino acids (KAs) and a very low-protein diet, retards progression of chronic renal failure and maintains nutritional status.DesignA prospective, randomized, double-blind, placebo-controlled trial.SettingNephrology outpatient department in Northern Railways Central Hospital, New Delhi, India.PatientsThirty-four patients in predialytic stages of chronic renal failure (CRF), randomized to 2 comparable groups in terms of age, sex distribution, blood pressure control, etiology, use of angiotensin converting enzyme inhibitors, serum creatinine, glomerular filtration rate (GFR), and body mass index (BMI).InterventionSubjects randomly received either 0.6 g/kg/d protein plus placebo (n = 16) or 0.3 g/kg/d protein plus tablets of KAs (Ketosteril; Fresenius Kabi, Germany) (n = 18) for 9 months. A dietician administered the diet as well as the KAs or the placebo to the patients.Outcome measuresChanges in GFR and renal and nutritional parameters were measured.ResultsMean (± SD) GFR measured by the ^99mTc-DTPA (99 m technetium diethylenetri-aminepenta-aceticacid) plasma sample method was unchanged in the ketodiet group: 28.1 ± 8.8 (before) and 27.6 ± 10.1 mL/min/1.73 m² (after the study) (P = .72). However, it significantly decreased from 28.6 ± 17.6 to 22.5 ± 15.9 mL/min/1.73 m² in the placebo group (P = .015). Serum creatinine before and after the study in the ketodiet group was 2.26 ± 1.03 mg/dL and 2.07 ± 0.8 mg/dL (P = .90) and in the placebo group was 2.37 ± 0.85 and 3.52 ± 2.9 mg/dL (P = .066), respectively. In both groups the mean BMI did not change from 25.4 ± 4.2 to 24.5 ± 4.2 kg/m² (P = .46) for ketodiet and from 25.0 ± 6.8 to 23.9 ± 4.1 kg/m² (P = .39) for the placebo group. Serum total proteins decreased significantly (P = .038) in the placebo group, and serum albumin showed a trend (P = .061) toward reduction, whereas both of these parameters were maintained in the ketodiet group.ConclusionOver a 9-month period, very low-protein diet supplemented with ketoanalogs helped CRF patients to preserve GFR and maintain BMI. KAs were safe and efficacious in retarding the progression of renal failure and preserving the nutritional status of CRF patients.     

Perioperative tight glucose control with hyperinsulinemic-normoglycemic clamp technique in cardiac surgery

ObjectivePrevious attempts to achieve tight glucose control in surgical patients were associated with a significant incidence of hypoglycemia. The purpose of this study was to evaluate the efficacy of perioperative glucose and insulin administration while maintaining normoglycemia using a hyperinsulinemic-normoglycemic clamp technique.MethodsWe studied 70 non-diabetic and 40 diabetic patients undergoing cardiac procedures. Before induction of anesthesia, insulin was administered at 5 mU · kg^?1 · min^?1. Blood glucose (BG) concentrations were determined every 15–30 min. Dextrose 20% was infused at a rate adjusted to maintain BG within 3.5–6.1 mmol/L. At the end of surgery, insulin infusion was decreased to 1 mU · kg^?1 · min^?1 and continued for 24 h. The mean ± standard deviation of BG and the percentage of BG values within the target range were calculated perioperatively. Episodes of severe hypoglycemia, i.e., BG <2.2 mmol/L, were recorded.ResultsThe mean BG remained within target at all times. Normoglycemia in non-diabetic patients was achieved in 92.8% of measurements during and in 83.2% after surgery. In diabetic patients 87.4% of values were within target intraoperatively and 76.7% after surgery. The rate of severe hypoglycemia was 2.7% (three patients). In non-diabetic patients the incidence of severe hypoglycemia was 0.2% of measurements during and 0.1% after surgery. Diabetic patients showed only one episode of severe hypoglycemia after surgery (0.1%).ConclusionPerioperative use of a hyperinsulinemic-normoglycemic clamp technique established and maintained normoglycemia in patients undergoing cardiac surgery with little risk of hypoglycemia.     

Decreased rates of hypoglycemia following implementation of a comprehensive computerized insulin order set and titration algorithm in the inpatient setting

Objectives: More than one-third of hospitalized patients have hyperglycemia. Despite evidence that improving glycemic control leads to better outcomes, achieving recognized targets remains a challenge. The objective of this study was to evaluate the implementation of a computerized insulin order set and titration algorithm on rates of hypoglycemia and overall inpatient glycemic control.

Methods: A prospective observational study evaluating the impact of a glycemic order set and titration algorithm in an academic medical center in non-critical care medical and surgical inpatients. The initial intervention was hospital-wide implementation of a comprehensive insulin order set. The secondary intervention was initiation of an insulin titration algorithm in two pilot medicine inpatient units. Point of care testing blood glucose reports were analyzed. These reports included rates of hypoglycemia (BG < 70 mg/dL) and hyperglycemia (BG >200 mg/dL in phase 1, BG > 180 mg/dL in phase 2).

Results: In the first phase of the study, implementation of the insulin order set was associated with decreased rates of hypoglycemia (1.92% vs 1.61%; p < 0.001) and increased rates of hyperglycemia (24.02% vs 27.27%; p < 0.001) from 2010 to 2011. In the second phase, addition of a titration algorithm was associated with decreased rates of hypoglycemia (2.57% vs 1.82%; p = 0.039) and increased rates of hyperglycemia (31.76% vs 41.33%; p < 0.001) from 2012 to 2013.

Conclusions: A comprehensive computerized insulin order set and titration algorithm significantly decreased rates of hypoglycemia. This significant reduction in hypoglycemia was associated with increased rates of hyperglycemia. Hardwiring the algorithm into the electronic medical record may foster adoption.     

Prevalence,Quality of Care,and Complications in Long Term Care Residents With Diabetes: A Multicenter Observational Study

Background

Few studies have reported on the quality of diabetes care and glycemic control adjusted for medication use in long term care (LTC) facilities.

Methods

This observational study analyzed diabetes prevalence and management and the impact of glycemic control on clinical outcome in elderly subjects admitted to 3 community LTC facilities.

Results

Among 1409 LTC residents (age 79.7 ± 12 years), the prevalence of diabetes was 34.2%. Subjects with diabetes were either on no pharmacological agents (10%) or were treated with sliding scale regular insulin (SSI, 25%), oral antidiabetic drugs (OAD, 5%), insulin (34%), or with combination of OAD and insulin (26%). Patients with diabetes had a mean daily BG of 156 ± 39 mg/dL and a mean admission HbA1c of 6.7% ± 1.1%. Compared with nondiabetes, residents with diabetes had higher number of complications (54% vs 45%, P < .001), infections (26% vs 21%, P = .036), emergency room (ER) and hospital transfers (37% vs 30%, P = .003), but similar mortality (15% vs 14%, P = .56). A total of 43% of residents with diabetes had a BG less than 70 mg/dL, and those with hypoglycemia had longer median length of stay (LOS, 52 vs 29 days, P < .001), more ER or hospital transfers (56% vs 69%, P = .005), and mortality (20% vs 10%, P = .002) compared with residents without hypoglycemia.

Conclusion

Diabetes is common in LTC residents and is associated with higher resource utilization and complications. Hypoglycemia is common and is associated with increased need of emergency room visits and hospitalization and higher mortality. Our findings emphasize the need for randomized trials evaluating the impact of different approaches to glycemic management on clinical outcome in LTC residents with diabetes.     

Effect of a soy protein diet on serum lipids of renal transplant patients

ObjectiveThe aim of the present study was to evaluate the effect of a soy-protein diet on plasma lipid levels of renal transplant recipients with moderate hypercholesterolemia.DesignDietary intervention case-control observational study.SettingRenal transplantation outpatient clinic.PatientsFifteen stable patients who had renal transplantation (serum creatinine < 2 mg/dL) with moderate hypercholesterolemia (low-density lipoprotein [LDL] cholesterol > 140 mg/dL).InterventionAfter a baseline dietary interview, dietary counseling was given individually with the goal of substituting 25 g of animal protein with 25 g of soy protein for a 5-week period, using commercially available soy foods, according to each patient’s own preference.Main outcome measuresBefore and after the soy-diet period, plasma lipid profiles including total, LDL, and high-density lipoprotein (HDL) cholesterol, triglycerides, apolipoprotein A1 and B were determined. Protein catabolic rate was assumed as a measure of dietary protein intake.ResultsTwo patients dropped out. After the soy diet, total cholesterol (254 ± 22 to 231 ± 31 mg/dL, P < .05) and LDL cholesterol (165 ± 20 versus 143 ± 20 mg/dL, P < .01) decreased significantly. No significant changes were observed regarding HDL cholesterol and triglycerides. Dietary protein intake did not differ at baseline (73.2 ± 22.9 g/day) and during the soy diet (72.6 ± 15.6 g/day), when the reported actual soy protein intake resulted 26 ± 8 g/day.ConclusionsThis study shows that soy proteins given as part of the daily protein intake have beneficial effects on serum LDL cholesterol levels of renal transplant recipients with moderate hypercholesterolemia. Soy proteins could be of use in the nutritional management of renal transplant recipients.     

Ejercicio moderado y consumo de alimentos de alto y bajo índice glucémico en mujeres sedentarias

ObjectiveTo analyze changes in blood glucose, insulin and triglyceride concentrations in relation to a moderate aerobic exercise in sedentary women of different body weight, exposed to either a high or low glycemic index carbohydrates diet.DiseñoCross-over type.SiteResearch was performed in the Exercise Physiology Laboratory at Facultad de Ciencias de la Cultura Física, Universidad Autónoma de Chihuahua, México.ParticipantsTwenty-six young sedentary women who did not exercise in the last year participated in the study. Four of adequate weight (AW) and 2 with obesity (OB) were excluded for not consuming the suggested carbohydrates (1 gr/kg of weight) nor completed the programed exercise. There were n = 10 in each group (AW/OB).InterventionTwo treatments of 55 minutes of aerobic exercise each were applied one day after consuming either high or low glycemic index carbohydrates.Main measurementsPlasmatic glucose, insulin, and triglycerides were determined before and after the scheduled exercise.ResultsGlucose, insulin, and triglycerides were higher in OB than in AW at baseline. Glucose was normalized in OB from 5.8 ± 0.35 to 5.3 ± 0.23 mmol/L (P = .001), only by eating foods with low glycemic index; triglycerides increased from 139.5 ± 66.0 to 150.8 ± 67.2 mg/dl (P = .004) at the end of the exercise, after consumption of low glycemic index carbohydrates.ConclusionElevation of triglycerides secondary to exercise after consumption of low glycemic index seems to indicate an increase of lipid oxidation in OB.     

Skim milk as a recovery beverage after exercise is superior to a sports drink for reducing next-day postprandial blood glucose and increasing postprandial fat oxidation

We determined the effect of consuming low–glycemic index (LGI) skim milk compared to a high–glycemic index (HGI) sports drink following evening exercise on fat oxidation and blood lipids after a subsequent high-energy breakfast. We hypothesized that postexercise skim milk consumption, compared to sports drink, would increase fat oxidation and lower harmful blood lipid and glucose concentrations after a next-day high-energy breakfast. In this randomized counterbalanced crossover trial, 20 overweight-obese participants (body mass index ≥ 25 kg/m²) underwent 4 conditions: 90-minute exercise (50% Vo_2peak) followed by sports drink (EX-HGI), exercise followed by isoenergetic skim milk (EX-LGI), exercise followed by water (Exercise), and a control condition (Control). The amount of the sports drink or milk consumed postexercise was based on the energy used during exercise plus 10%. Blood lipids, glucose, and fat oxidation were assessed before and for 6 hours after a high-energy breakfast the next morning. Fat oxidation was highest for EX-LGI (6.7 ± 2.7 g/h) and lowest for EX-HGI (6.0 ± 1.8 g/h) (condition main effect; P = .042). Triglyceride concentration and total area under the curve were higher with EX-HGI than Exercise (1.7 ± 1.6 vs 1.3 ± 1.0 mmol/L, P = .037, and 11.7 ± 9.4 vs 8.6 ± 6.0 mmol L⁻¹ h, P = .005, respectively). Glucose concentration was lower with EX-LGI than EX-HGI (4.1 ± 1.1 vs 4.4 ± 1.1 mmol/L, P = .027). Homeostatic model assessment of insulin resistance was higher with EX-HGI than Control (2.32 ± 1.15 vs 1.86 ± 0.97, P = .005). In conclusion, evening postexercise skim milk consumption, compared with a high-GI sports drink, significantly reduced blood glucose and possibly increased fat oxidation after a high-energy breakfast the next morning.     

Refractory hypoglycemia and subsequent cardiogenic shock in starvation and refeeding: Report of three cases

ObjectiveAlthough starvation is associated with high in-hospital mortality, its related cardiac complications are not sufficiently understood. The aim of this study was to determine the clinical course and pathogenesis of cardiac complications in malnourished patients.MethodsWe reviewed three cases of hypoglycemia and hypotriglyceridemia with cardiac complications in starvation.ResultsThis report concerns three patients, respectively suffering from anorexia nervosa, esophageal carcinoma, and Parkinson's disease. Their ages ranged from 18 to 70 y, body mass index was 11.5 ± 1.5 kg/m² (mean ± SD), and the main symptom was coma. The average blood glucose level was 15.7 ± 7.8 mg/dL without any history of insulin use or diabetes mellitus. In all cases, hypoglycemia was refractory and repetitive so that continuous glucose administration was required to maintain euglycemia. Serum triglyceride and non-esterified fatty acid levels were also very low (7 ± 4 mg/dL and 10 ± 9.1 μEq/L, respectively). Levels of serum potassium, phosphate, and magnesium were almost normal at admission. The main cardiac complications included Takotsubo cardiomyopathy and cardiac arrest. All patients survived as a result of intensive treatment.ConclusionsRepetitive severe hypoglycemia without known background causes should be viewed as an important sign. Once this occurs, the administration of a much higher caloric input than usual accompanied by intensive monitoring will be required to maintain appropriate glucose levels. The early identification of such patients seems to be essential to reduce the high risk for cardiac complications during starvation and refeeding.     

A Study Examining the Effect of a Short Bout of Postprandial Walking on the Glycemic Effect of a Meal: Type 1 Diabetes

Objective: The purpose of this pilot study was to determine whether 15 minutes of postprandial walking has an effect on the glycemic response to a breakfast beverage in individuals with type 1 diabetes (T1DM).

Methods: Seven participants, aged 22.3 ± 4.3 years, with T1DM using intensive insulin therapy completed 2 days of data collection. On day 1, participants measured baseline fasting blood glucose (BG) with a glucometer, consumed an 8-ounce Boost® beverage (41 grams carbohydrate), administered a bolus of insulin according to the carbohydrate load and fasting BG, and sat quietly, repeating BG measurements 15, 30, 60, 90, and 120 minutes after consumption. On day 2, participants repeated the protocol, but walked 15 minutes at 50% to 60% maximum heart rate immediately after beverage consumption.

Results: The difference between peak and baseline (peak – baseline) BG and incremental glucose area under the curve (iAUC) were lower in all but one participant on the walking compared to the sedentary day. Mean peak – baseline BG was significantly lower on the walking day compared to the sedentary day (6.4 ± 1.2 vs 14.4 ± 3.4 mmol/L, respectively, p = 0.016) as was the iAUC, (241.1 ± 155.8 vs 468.6 ± 94.5 mmol/L/120 min, respectively, p = 0.031).

Conclusions: Fifteen minutes of postprandial walking can blunt the spike in BG and overall glycemic response to a breakfast beverage in young adults with T1DM and may be an effective and realistic component in the management of T1DM.     

An Unusual Microcephaly

Abstract

Hyperglycemia occurs frequently in hospitalized patients and affects patient outcomes, including mortality, inpatient complications, hospital length of stay, and overall hospital costs. Various degrees of glycemic control have been studied and consensus statements from the American Diabetes Association/American Association of Clinical Endocrinologists and The Endocrine Society recommend a target blood glucose range of 140 to 180 mg/dL in most hospitalized patients. Insulin is the preferred modality for treating all hospitalized patients with hyperglycemia, as it is adaptable to changing patient physiology over the course of hospitalization. Critically ill patients should receive intravenous insulin infusion, and all noncritically ill patients with hyperglycemia (individuals with and without diabetes) should be managed using a subcutaneous insulin algorithm with basal, nutritional, and correctional dose components. Hypoglycemia remains a limiting factor to achieving optimal glycemic targets. Similar to hyperglycemia, hypoglycemia is an independent risk factor for poor outcomes in hospitalized patients. Improvement in glycemic control throughout the hospital includes efforts from all health care providers. Institutions can encourage safe insulin use by using insulin algorithms, preprinted order sets, and hypoglycemia protocols, as well as by supporting patient and health care provider education.     

Hypocaloric,High‐Protein Nutrition Therapy in Older vs Younger Critically Ill Patients With Obesity

Background: Older patients require more protein than younger patients to achieve anabolism, but age‐associated renal dysfunction may limit the amount of protein that can be safely provided. This study examined whether older, critically ill trauma patients with obesity can safely achieve nitrogen equilibrium and have positive clinical outcomes similar to younger obese patients during hypocaloric, high‐protein nutrition therapy. Methods: Adult patients with traumatic injury and obesity (body mass index [BMI] >30 kg/m²), admitted to the Presley Trauma Center from January 2009 to April 2011, were evaluated. Patients were targeted to receive hypocaloric, high‐protein nutrition therapy (<25 kcal/kg ideal body weight [IBW]/d and >2 g/kg IBW/d of protein) for >10 days. Patients were stratified as older (≥60 years) or younger (18–59 years). Results: Seventy‐four patients (33 older, 41 younger) were studied. Older and younger patients were similar in BMI and injury severity. When given isonitrogenous regimens (2.3 ± 0.2 g/kg IBW/d), nitrogen balance was similar between older and younger patients (?3.2 ± 5.7 g/d vs ?4.9 ± 9.0 g/d; P = .363). Older patients experienced a greater mean serum urea nitrogen concentration than younger patients (30 ± 14 mg/dL vs 20 ± 9 mg/dL; P = .001) during nutrition therapy. Clinical outcomes were not different between groups. Conclusions: Older critically ill trauma patients exhibited an equivalent net protein response as younger patients during hypocaloric, high‐protein nutrition therapy. Older patients are at greater risk for developing azotemia. Close monitoring is warranted.     

The Effect of Added Peanut Butter on the Glycemic Response to a High–Glycemic Index Meal: A Pilot Study

Objective: The purpose of this pilot study was to determine whether supplementation of a high–glycemic index breakfast meal with peanut butter attenuates the glycemic response.

Methods: Sixteen healthy adults, aged 24.1?±?3.5 years, reported in the morning to a nutrition assessment laboratory for two days of data collection, having fasted 8 to 12?hours. On day 1 (control), fasting blood glucose (BG) was measured using glucometers, then participants consumed two slices of white bread and 250 mL apple juice (60?g carbohydrate) within 15?minutes. BG was measured again at 15, 30, 60, 90, and 120?minutes after the first bite of the meal. On day 2, the protocol was repeated, except 32?g (2 tbsp) of peanut butter was added to the meal (treatment).

Results: The spike in BG was significantly lower on the treatment versus control day (35.8?±?16.4 vs. 51.0?±?20.8?mg/dL, respectively; p?<?0.01), and BG was significantly lower on the treatment day at 15, 30, and 60?minutes post–meal consumption (p?<?0.05).

Conclusions: This study indicates that supplementation with 32 g (2 tbsp) peanut butter attenuates the magnitude of BG spike and overall glycemic response to high–glycemic index meal and may be a practical, beneficial strategy to prevent undesirable elevations in BG.     

Antidiabetic Effect of Rosella-Stevia Tea on Prediabetic Women in Yogyakarta,Indonesia

Background: Rosella tea (Hibiscuss sabdariffa. Linn) with stevia sweetener (Stevia rebaudiana Bertoni) is a combined herbal drink that is expected to have antidiabetic effect by lowering glucose levels in people with diabetes and prediabetes. This research investigates the effect of rosella-stevia tea to decrease fasting blood glucose (FBG) and 2 hours postprandial blood glucose (2-hour postprandial BG) level in prediabetic women.

Method: This is quasi-experimental research with control and treatment (rosella-stevia tea) group. Each group consists of 12 prediabetic women aged 30–60 years. Rosella-stevia tea (5 g rosella powder, 125 mg stevia sweetener) was administered to the treatment group twice a day for 14 days.

Result: Rosella-stevia tea consumption affects blood glucose levels. Rosella-stevia tea consumption significantly lowered the FBG level (from 111.25 ± 7.20 mg/dL to 88.58 ± 13.19 mg/dL; p < 0.01) but not the 2-hour postprandial BG level (from 123.25 ± 37.61 mg/dL to 106.92 ± 18.82 mg/dL). There are no significant differences in the control group (FBG level from 106.00 ± 5.27 mg/dL to 102.08 ± 8.36, and 2-hour postprandial BG level from 119.83 ± 16.43 mg/dL to 128.00 ± 23.54 mg/dL).

Conclusion: Rosella-stevia tea consumption can lower the FBG level but not the 2-hour postprandial BG level in prediabetic women.