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

ObjectiveProgressive β-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 MethodsThis 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 90–110mg/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.ResultBoth 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.ConclusionIn 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.     

False-positive pregnancy test after passive transfusion of beta-human chorionic gonadotropin from donor red blood cells during erythrocytapheresis

BACKGROUND: Patients transfused with blood products may passively receive soluble antibodies, proteins, and other analytes that persist during the collection, processing, and transfusion of the blood product. In this report, a female patient who received transfusion of five red blood cell (RBC) units during erythrocytapheresis later demonstrated an unexpected positive result in assays for the beta-subunit of human chorionic gonadotropin (bHCG), a screening test for pregnancy. The result caused postponement of an elective surgical procedure. A follow-up test 1 week later was negative. STUDY DESIGN AND METHODS: To investigate the possibility of passive transfusion of the hormone from a donor RBC unit, a sample from each of the units transfused was assayed for the level of bHCG. RESULTS: One of the 5 units transfused to the patient had a high level of bHCG. The observed bHCG level in the recipient was found to be comparable to the predicted level, given the donor's plasma bHCG level and accounting for the dilution factors in the preparation of the RBC unit and the erythrocytapheresis procedure and the in vivo t((1/2)) of the hormone. CONCLUSION: The donor, who was unaware of her pregnancy status at the time of donation, harbored a high bHCG level that caused the positive test result in the recipient patient's serum and urine. If an unexpected analyte or serology is detected in a recipient of a blood transfusion, it is important to consider the possibility of passive transfusion of the analyte.     

Issues in Design and Implementation in an Urban Birth Cohort Study: The Syracuse AUDIT Project

The Syracuse AUDIT (Assessment of Urban Dwellings for Indoor Toxics) project is a birth cohort study of wheezing in the first year of life in a low-income urban setting. Such studies are important because of the documented serious risks to children's health and the lack of attention and published work on asthma development and intervention in communities of this size. We studied 103 infants of mothers with asthma, living predominantly in inner-city households. Our study combines measurements of a large panel of indoor environmental agents, in-home infant assessments, and review of all prenatal and postnatal medical records through the first year of life. We found multiple environmental pollution sources and potential health risks in study homes including high infant exposure to tobacco smoke. The prevalence of maternal smoking during pregnancy was 54%; postnatal environmental tobacco smoke (ETS) exposure was nearly 90%. The majority (73%) of homes showed signs of dampness. Participants' lives were complicated by poverty, unemployment and single-parenthood. Thirty-three percent of fathers were not involved with their children, and 62% of subjects moved at least once during the study period. These socioeconomic issues had an impact on project implementation and led to modification of study eligibility criteria. Extensive outreach, follow up, and relationship-building were required in order to recruit and retain families and resulted in considerable work overload for study staff. Our experiences implementing the project will inform further studies on this and other similar populations. Future reports on this cohort will address the role of multiple environmental variables and their effects on wheezing outcome during the first year of life.Crawford, Hargrave, Liu, Anbar, Hall, Naishadham, Czerwinski, Webster, Lane, and Abraham are with the Department of Pathology, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY 13210, USA; Hunt is with the UNYSPEC Ltd., Baldwinsville, NY, USA.     

Assessing and managing medically fragile children: tracheostomy and ventilatory support

Over the past decade, there has been an increase in premature births. Children born prematurely often present with complex medical conditions; some require a tracheostomy. Although many children with tracheostomies require assistance to achieve effective communication, speech-language pathologists may have limited information with respect to the medical issues and communication needs of this population. The purpose of this article is twofold. First, a review of basic information on tracheostomy and ventilatory support in the pediatric population is provided. Second, information on the assessment of communication skills and intervention specific to voice for the child with a tracheostomy is detailed. Two case studies are presented. The case studies illustrate the diversity and medical complexity common to this population and provide practical information for the clinician working with a child with a tracheostomy.