Decreased insulin requirement in relation to GFR in nephropathic Type 1 and insulin-treated Type 2 diabetic patients.

AIMS: In the presence of impaired renal function, patients require less insulin mainly because insulin clearance is prolonged. The aim of this study was to evaluate the insulin requirement related to glomerular filtration rate (GFR) in nephropathic Type 1 and Type 2 diabetic patients. METHODS: In a retrospective study we compared insulin requirement in 20 nephropathic Type 1 diabetic patients and 20 insulin-treated Type 2 diabetic patients from the onset of overt nephropathy until the final stage of renal disease. All patients had proteinuria > 0.5 g/24 h and creatinine clearance >/= 80 ml/min per 1.73 m2 at baseline. Creatinine clearance, urinary protein excretion, glycated haemoglobin and the required insulin doses were determined 3- to 6-monthly, basal C-peptide was measured at the beginning and the end of the observation period. The required insulin doses were evaluated at creatinine clearance rates of 80, 60, 40, 20 and 10 ml/min per 1.73 m2 (or at the initiation of dialysis treatment). RESULTS: The insulin requirement of patients with Type 1 diabetes was reduced from 0.72 +/- 0.16 IU/kg per day at a creatinine clearance rate of 80 ml/min, to 0.45 +/- 0.13 IU/kg per day at a creatinine clearance rate of 10 ml/min (decrement of 38%, P < 0.001). The insulin dose required by Type 2 diabetic patients was reduced from 0.68 +/- 0.28 IU/kg per day at a creatinine clearance rate of 80 ml/min to 0.33 +/- 0.19 IU/kg per day at a clearance rate of 10 ml/min (decrement 51%, P < 0.001). The fall in GFR, urinary protein excretion and glycated haemoglobin levels was similar in the two groups. In patients with Type 2 diabetes, C-peptide levels at the beginning and the end of renal function impairment were 2.2 (0.4-7.3) vs. 2.7 (0.1-4.9) ng/ml (NS). The reduction in insulin requirement was approximately the same in patients with an initial C-peptide level < 1.0 and in those >/= 1.0 ng/ml (decrement 57% vs. 46%). CONCLUSIONS: The reduction in insulin requirement in renal insufficiency is similar in Type 1 and insulin-treated Type 2 diabetic patients. In subjects with Type 2 diabetes, the residual insulin secretion has no impact on the reduction in insulin requirement dependent on the GFR.     

Analgesic dose-response relation in cervical epidural block

The relationship between the age and the spread of analgesia from different epidural anesthetic doses was examined by studying analgesic dose responses in cervical epidural analgesia. Two different anesthetic doses (5ml or 10ml) of 2% mepivacaine were injected into the cervical epidural space at a constant pressure (80mmHg) using an intravenous apparatus, and the spread of analgesia to pinprick was assessed. The significant correlation was found between the patients age and the number of spinal segments blocked (5ml:r = 0.8498, P < 0.01, 10ml:r = 0.5988, P < 0.01). The inverse linear relationship was found between the patients age and the segmental dose requirement (5ml:r = –0.6754, P < 0.01, 10ml:r = –0.5784, P < 0.01). Patients under 39 years of age showed a direct relationship between the dose injected and the number of spinal segments blocked, enabling prediction of the number of segments blocked with a given dose of local anesthetic. Doubling the epidural dose approximately doubled the number of spinal segments blocked. The analgesic dose-response relation in patients over 60 years of age differed from that in patients under 39 years of age and doubling the epidural dose did not double the number of spinal segments blocked. Progressively more extensive analgesia was obtained from a given dose of local anesthetic with advancing age. It was difficult to limit the extent of analgesia by injecting a smaller dose of local anaesthetic in the elderly.(Hirabayashi Y, Matsuda I, Inoue S et al.: Analgesic dose-response relation in cervical epidural block. J Anesth 2: 22–27, 1988)     

虎门镇异位妊娠患者生殖健康状况及其相关知识调查

目的了解异位妊娠患者的生殖健康状况和健康知识需求。方法对虎门镇2家“二甲”医院就诊的496例异位妊娠患者进行生殖健康状况检查和生殖健康知识及需求的问卷调查。结果77.3%的患者合并生殖系统感染,19.0%的患者有过2次以上的人工流产史;影响生殖健康的危险因素依次为:急、慢性宫颈炎,急、慢性盆腔炎/附件炎,多次人流,剖宫产史。生殖系统感染、人工流产与异位妊娠关系及生殖系统感染的预防等方面知识的知晓率低,从不检查治疗者高达58.13%。生殖健康知识需求主要为生殖系统感染的危害、人流危害和避孕知识。期望获取的途径主要为医院咨询门诊和报纸杂志。结论异位妊娠患者存在生殖健康问题,需要进行生殖健康知识教育和提供生殖健康服务。     

Delayed graft function requiring more than one‐time dialysis treatment is associated with inferior clinical outcomes

Delayed graft function (DGF) is a common complication of deceased donor kidney transplantation with negative impact on clinical outcomes. In a single‐center retrospective analysis, we compared patient and kidney survival, early renal function, and the incidence of acute rejection during the first year among all adult deceased donor kidney transplant patients without DGF, with DGF requiring one‐time and/or more than one‐time dialysis treatment between January 1, 2000, and December 31, 2008. Of 831 adult kidney transplant patients, 74 (8.9%) required one‐time and 134 (16.1%) more than one‐time dialysis treatment post‐transplantation, respectively. While DGF patients with one‐time dialysis treatment had comparable clinical outcomes to that of patients without DGF, patients with DGF requiring more than one‐time dialysis treatment had a 45% increased risk for death (HR 1.45, 95% CI 1.02, 2.05, p = 0.04) after adjustment for the differences in demographic and baseline characteristics. Furthermore, DGF patients with more than one‐time dialysis requirement displayed significantly lower renal function after recovery (OR 0.32, 95% CI 0.21, 0.49, p < 0.001, for eGFR ≥ 60 mL/min) and higher incidence of acute rejection during the first year (OR 1.66, 95% CI 1.11, 2.49, p = 0.015). Additional studies of therapeutic approaches to manage patients with prolonged DGF are needed.     

Surfactant protein-A in bronchoalveolar lavage fluid from neonates with RDS on conventional and high-frequency oscillatory ventilation

Surfactant protein-A (SP-A) was measured in bronchoalveolar lavage (BAL) samples from ventilated neonates in order to study the concentration of SP-A with regard to: 1) high-frequency oscillatory ventilation (HFOV) vs. conventional mechanical ventilation (CMV); 2) the postnatal course and ontogeny of SP-A; and 3) the correlation with measurements of pulmonary function. Patients on HFOV had markedly lower BAL SP-A concentrations on days 1 and 2 compared to those on CMV, which may indicate influence of mode of ventilation on surfactant metabolism. The SP-A concentrations increased postnatally concurrent with resolution of acute respiratory distress syndrome. Finally, there were only weak correlations between BAL SP-A concentration and dynamic lung compliance and oxygen requirement.     

Energy needs in the treatment of uncomplicated severe acute malnutrition: Secondary analysis to optimize delivery of ready‐to‐use therapeutic foods

Outpatient therapeutic feeding protocols for the treatment of uncomplicated severe acute malnutrition in children were initially based on weight gain data from inpatient settings and expert knowledge of the physiological requirements during recovery. However, weight gain and energy requirements from historic inpatient settings may differ from modern outpatient settings and therefore may not be appropriate to guide current therapeutic feeding protocols. We calculated the weight gain and average estimated total daily energy requirement of children successfully treated for uncomplicated severe acute malnutrition as outpatients in Niger (n = 790). Mean energy provided by six therapeutic feeding protocols was calculated and compared with average estimated energy requirements in the study population. Overall weight gain was 5.5 g·kg^?1·day^?1 among recovered children. Average energy requirements ranged from 92 to 110 kcal·kg^?1·day^?1 depending on the estimation approach. Two current therapeutic feeding protocols were found to provide an excess of energy after the first week of treatment in our study population, whereas four research protocols tended to provide less energy than the estimated requirement after the first week of treatment. Alternative feeding protocols have the potential to simplify and lead to important savings for programmes but should be evaluated to show adequacy to meet the energy needs of children under treatment, as well as feasibility and cost efficiency. Our findings rely on theoretical calculations based on several assumptions and should be confirmed in field studies.     

如何估算烧伤病人热能需要量

采用血气分析仪测定氧耗量、ＣＯ２排量及用Ｗｅｉｒ公式计算ＲＥＥ（静息能量消耗）的方法测算烧伤病人需要量，并提出了我国第一个烧伤病人热卡计算公式（第三军医大学烧伤营养公式）：ＫＪ／ｄ＝４１８４×体表面积ｍ２＋１０５×烧伤面积％，其前半部为病人基础需要量，每平方米１０００千卡（４１８４千焦）；后半部为烧伤需要量，对每烧伤面积％需增加１０５千焦的由来作了说明。介绍了体表面积的简化公式：体表面积ｍ２＝（身高ｍ－０．６）×１．５，总能量消耗除ＲＥＥ外，还应包括食物生热及活动耗能，烧伤病人在ＲＥＥ值基础上再增加多少作为每天热能供应总量，这仍是需要探讨的课题。