When intensive insulin therapy (MDi) fails in patients with type 2 diabetes: Switching to GLP-1 receptor agonist versus insulin pump

Treatment with insulin, alone or with oral or injectable hypoglycemic agents, is becoming increasingly common in patients with type 2 diabetes. However, approximately 40% of patients fail to reach their glycemic targets with the initially prescribed regimen and require intensification of insulin therapy, which increases the risks of weight gain and hypoglycemia. Many of these patients eventually reach a state in which further increases in the insulin dosage fail to improve glycemic control while increasing the risks of weight gain and hypoglycemia. The recently completed OpT2mise clinical trial showed that continuous subcutaneous insulin infusion (CSII) is more effective in reducing glycated hemoglobin (HbA1c) than intensification of multiple daily injection (MDI) insulin therapy in patients with type 2 diabetes who do not respond to intensive insulin therapy. CSII therapy may also be useful in patients who do not reach glycemic targets despite multidrug therapy with basal-bolus insulin and other agents, including glucagon-like peptide (GLP)-1 receptor agonists; current guidelines offer no recommendations for the treatment of such patients. Importantly, insulin and GLP-1 receptor agonists have complementary effects on glycemia and, hence, can be used either sequentially or in combination in the initial management of diabetes. Patients who have not previously failed GLP-1 receptor agonist therapy may show reduction in weight and insulin dose, in addition to moderate improvement in HbA1c, when GLP-1 receptor agonist therapy is added to MDI regimens. In subjects with long-standing type 2 diabetes who do not respond to intensive insulin therapies, switching from MDI to CSII and/or the addition of GLP-1 receptor agonists to MDI have the potential to improve glycemic control without increasing the risk of adverse events

anti tnf biosimilars in crohn s disease a patient centric interdisciplinary approach

ABSTRACTIntroduction: The purpose of this review is to highlight the role of biosimilars in early treatment in IBD and introduce ways to facilitate a patient-centric switching process through multi..

Positioning and Smoothing Movement Approaches of a Linear Actuator Dedicated to A Biomedical Application

The movement of linear stepper motors is characterized by a highly oscillatory translation, which is troublesome for the positional accuracy and the speed constant (often required by many industrial applications such as the syringe pump). These oscillations can lead to loss of synchronism and stall risk. Thus, in order to attenuate the amplitudes of these oscillations and to guarantee the positioning of the actuator without errors, solutions exploiting open-loop and closed-loop control techniques are proposed in this paper for the purpose of improve the performance of the actuato

Errors and discrepancies in the administration of intravenous infusions: a mixed methods multihospital observational study

Introduction Intravenous medication administration has traditionally been regarded as error prone, with high potential for harm. A recent US multisite study revealed few potentially harmful errors despite a high overall error rate. However, there is limited evidence about infusion practices in England and how they relate to prevalence and types of error. Objectives To determine the prevalence, types and severity of errors and discrepancies in infusion administration in English hospitals, and to explore sources of variation, including the contribution of smart pumps. Methods We conducted an observational point prevalence study of intravenous infusions in 16 National Health Service hospital trusts. Observers compared each infusion against the medication order and local policy. Deviations were classified as errors or discrepancies based on their potential for patient harm. Contextual issues and reasons for deviations were explored qualitatively during observer debriefs. Results Data were collected from 1326 patients and 2008 infusions. Errors were observed in 231 infusions (11.5%, 95% CI 10.2% to 13.0%). Discrepancies were observed in 1065 infusions (53.0%, 95% CI 50.8% to 55.2%). Twenty-three errors (1.1% of all infusions) were considered potentially harmful; none were judged likely to prolong hospital stay or result in long-term harm. Types and prevalence of errors and discrepancies varied widely among trusts, as did local policies. Deviations from medication orders and local policies were sometimes made for efficiency or patient need. Smart pumps, as currently implemented, had little effect, with similar error rates observed in infusions delivered with and without a smart pump (10.3% vs 10.8%, p=0.8). Conclusion Errors and discrepancies are relatively common in everyday infusion administrations but most have low potential for patient harm. Better understanding of performance variability to strategically manage risk may be a more helpful tactic than striving to eliminate all deviations

The challenge of perioperative pain management in opioid-tolerant patients

The increasing number of opioid users among chronic pain patients, and opioid abusers among the general population, makes perioperative pain management challenging for health care professionals. Anesthesiologists, surgeons, and nurses should be familiar with some pharmacological phenomena which are typical of opioid users and abusers, such as tolerance, physical dependence, hyperalgesia, and addiction. Inadequate pain management is very common in these patients, due to common prejudices and fears. The target of preoperative evaluation is to identify comorbidities and risk factors and recognize signs and symptoms of opioid abuse and opioid withdrawal. Clinicians are encouraged to plan perioperative pain medications and to refer these patients to psychiatrists and addiction specialists for their evaluation. The aim of this review was to give practical suggestions for perioperative management of surgical opioid-tolerant patients, together with schemes of opioid conversion for chronic pain patients assuming oral or transdermal opioids, and patients under maintenance programs with methadone, buprenorphine, or naltrexone

Closed-loop control of anesthesia : survey on actual trends, challenges and perspectives

Automation empowers self-sustainable adaptive processes and personalized services in many industries. The implementation of the integrated healthcare paradigm built on Health 4.0 is expected to transform any area in medicine due to the lightning-speed advances in control, robotics, artificial intelligence, sensors etc. The two objectives of this article, as addressed to different entities, are: i) to raise awareness throughout the anesthesiologists about the usefulness of integrating automation and data exchange in their clinical practice for providing increased attention to alarming situations, ii) to provide the actualized insights of drug-delivery research in order to create an opening horizon towards precision medicine with significantly improved human outcomes. This article presents a concise overview on the recent evolution of closed-loop anesthesia delivery control systems by means of control strategies, depth of anesthesia monitors, patient modelling, safety systems, and validation in clinical trials. For decades, anesthesia control has been in the midst of transformative changes, going from simple controllers to integrative strategies of two or more components, but not achieving yet the breakthrough of an integrated system. However, the scientific advances that happen at high speed need a modern review to identify the current technological gaps, societal implications, and implementation barriers. This article provides a good basis for control research in clinical anesthesia to endorse new challenges for intelligent systems towards individualized patient care. At this connection point of clinical and engineering frameworks through (semi-) automation, the following can be granted: patient safety, economical efficiency, and clinicians' efficacy

Attentional dysfunction in Parkinson’s disease : the role of central amygdala dopamine and possible treatment options

While it is known that Parkinson’s disease (PD) results in motor dysfunction, there exist many cognitive symptoms including impairments in attention. PD patients demonstrate impaired ability to switch attention between tasks, rules, or stimuli, ignore irrelevant stimuli, and sustain attention to stimuli or tasks. Dysfunction of the mesocortical system is suggested to be responsible for these attentional deficits. However, attentional impairments surface in the early stages of the disease and cortical areas are among the last regions to show pathology. Further, it is not well understood how effective common dopamine replacement therapy (L-dopa) is in restoring attentional dysfunction. Recent work suggests that L-dopa may only improve some aspects of attentional function in PD, thus making further examination of the effects of L-dopa on attentional function important. And as L-dopa also has many other limitations (e.g. possible development of unwanted motor side effects), it is also necessary to investigate other possible treatments for these dysfunctions. In this dissertation, I first examined the role of dopaminergic function in the central amygdala (CeA) in the regulation of attentional processes in rodents. I found that dopaminergic input into the CeA mediated by D1 receptors is necessary for attention switching (i.e. disengagement behavior) and selective and sustained attention in rodents. Then I investigated the effects of L-dopa on these two different types of attentional deficits in a rodent model of PD in which dopamine is depleted unilaterally using the neurotoxin, 6-hydroxydopamine. While L-dopa was able to recover basic attentional switching, more complex attentional processes (i.e. selective and sustained attention) were not recovered. In an attempt to find a better treatment for these deficits, I used methylene blue (MB), a metabolic enhancer and antioxidant, to target mitochondrial dysfunction, a characteristic of all compromised dopamine cells. While MB was able to provide moderate neuroprotection in this model of PD, it was unable to recover attentional function. Taken together, my dissertation work demonstrates that attentional function is partly regulated by sub-cortical CeA dopamine mechanisms and that PD-related attentional dysfunction may require a multi-faceted treatment approach.Psycholog