Pilot study of the SPRINT glycemic control protocol in a Hungarian medical intensive care unit.

Stress-induced hyperglycemia increases morbidity and mortality. Tight control can reduce mortality but has proven difficult to achieve. The SPRINT (Specialized Relative Insulin and Nutrition Tables) protocol is the only protocol that reduced both mortality and hypoglycemia by modulating both insulin and nutrition, but it has not been tested in independent hospitals. SPRINT was used for 12 adult intensive care unit patients (949 h) at Kálmán Pándy Hospital (Gyula, Hungary) as a clinical practice assessment. Insulin recommendations (0-6 U/h) were administered via constant infusion rather than bolus delivery. Nutrition was administered per local standard protocol, weaning parenteral to enteral nutrition, but was modulated per SPRINT recommendations. Measurement was every 1 to 2 h, per protocol. Glycemic performance is assessed by percentage of blood glucose (BG) measurements in glycemic bands for the cohort and per patient. Safety from hypoglycemia is assessed by numbers of patients with BG < 2.2 (severe) and %BG < 3.0 and < 4.0 mmol/liter (moderate and light). Clinical effort is assessed by measurements per day. Results are median (interquartile range). There were 742 measurements over 1088 h of control (16.4 measurements/day), which is similar to clinical SPRINT results (16.2/day). Per-patient hours of control were 65 (50-95) h. Initial per-patient BG was 10.5 (7.9-11.2) mmol/liter. All patients (100%) reached 6.1 mmol/liter. Cohort BG was 6.3 (5.5-7.5) mmol/liter, with 42.2%, 65.1% and 77.6% of BG in the 4.0-6.1, 4.0-7.0, and 4.0-8.0 mmol/liter bands. Per-patient, median percentage time in these bands was 40.2 (26.7-51.5)%, 62.5 (46.0-75.7)%, and 74.7 (61.6.8-87.8)%, respectively. No patients had BG < 2.2 mmol/liter, and the %BG < 4.0 mmol/liter was 1.9%. These results were achieved using 3.0 (3.0-5.0) U/h of insulin with 7.4 (4.4-10.2) g/h of dextrose administration (all sources) for the cohort. Per-patient median insulin administration was 3.0 (3.0-3.0) U/h and 7.1 (3.4-9.6) g/h dextrose. Higher carbohydrate nutrition formulas than were used in SPRINT are offset by slightly higher insulin administration in this study. The glycemic performance shows that using the SPRINT protocol to guide insulin infusions and nutrition administration provided very good glycemic control in initial pilot testing, with no severe hypoglycemia. The overall design of the protocol was able to be generalized with good compliance and outcomes across geographically distinct clinical units, patients, and clinical practice. © 2012 Diabetes Technology Society

SPRINT, STAR: Két Hatékony Kezelési Protokoll Az Intenzív Osztályon Kezelt Betegek Vércukorszintjének Normoglikémiás Tartományban Tartásához

(In Hungarian) Paper P0

Variability of insulin sensitivity during the first 4 days of critical illness

1-pageSafe, effective tight glycaemic control (TGC) can improve outcomes in critical care patients, but is difficult to achieve consistently. Insulin sensitivity defines the metabolic balance between insulin concentration and insulin mediated glucose disposal. Hence, variability of insulin sensitivity can cause variable glycaemia. This study investigates the daily evolution of model-based insulin sensitivity level and variability for critical care patients receiving TGC during the first four days of their ICU stay

Endogenous insulin secretion in critically ill patients

1-pageGlucose-insulin system models can be used for improved glycemic control of critically ill patients. A key component of glucose-insulin models is pancreatic insulin secretion. There is limited data in the literature quantifying insulin secretion in critically ill patients at physiologic levels. This study presents a model pancreatic insulin secretion in critically ill patients based on data from a critically ill population

Linear and non linear response in the aging regime of the 1D trap model

We investigate the behaviour of the response function in the one dimensional trap model using scaling arguments that we confirm by numerical simulations. We study the average position of the random walk at time tw+t given that a small bias h is applied at time tw. Several scaling regimes are found, depending on the relative values of t, tw and h. Comparison with the diffusive motion in the absence of bias allows us to show that the fluctuation dissipation relation is, in this case, valid even in the aging regime.Comment: 5 pages, 3 figures, 3 references adde

Pulmonary embolism diagnostics from the driver function

Ventricular driver functions are not readily measured in the ICU, but can clearly indicate the development of pulmonary embolism (PE) otherwise difficult to diagnose. Recent work has developed accurate methods of measuring these driver functions from readily available ICU measurements. This research tests those methods by assessing the ability of these driver functions to diagnose the evolution of PE

Pilot Proof of Concept Clinical Trials of Stochastic Targeted (STAR) Glycemic Control

(open access)Introduction: Tight glycemic control (TGC) has shown benefits but has been difficult to achieve consistently. STAR (Stochastic TARgeted) is a flexible, model-based TGC approach directly accounting for intra- and inter- patient variability with a stochastically derived maximum 5% risk of blood glucose (BG) < 4.0 mmol/L. This research assesses the safety, efficacy, and clinical burden of a STAR TGC controller modulating both insulin and nutrition inputs in pilot trials. Methods: Seven patients covering 660 hours. Insulin and nutrition interventions are given 1-3 hourly as chosen by the nurse to allow them to manage workload. Interventions are calculated by using clinically validated computer models of human metabolism and its variability in critical illness to maximize the overlap of the model-predicted (5-95th percentile) range of BG outcomes with the 4.0-6.5 mmol/L band while ensuring a maximum 5% risk of BG < 4.0 mmol/L. Carbohydrate intake (all sources) was selected to maximize intake up to 100% of SCCM/ACCP goal (25 kg/kcal/h). Maximum insulin doses and dose changes were limited for safety. Measurements were made with glucometers. Results are compared to those for the SPRINT study, which reduced mortality 25-40% for length of stay ≥3 days. Written informed consent was obtained for all patients, and approval was granted by the NZ Upper South A Regional Ethics Committee. Results: A total of 402 measurements were taken over 660 hours (~14/day), because nurses showed a preference for 2-hourly measurements. Median [interquartile range, (IQR)] cohort BG was 5.9 mmol/L [5.2-6.8]. Overall, 63.2%, 75.9%, and 89.8% of measurements were in the 4.0-6.5, 4.0-7.0, and 4.0-8.0 mmol/L bands. There were no hypoglycemic events (BG < 2.2 mmol/L), and the minimum BG was 3.5 mmol/L with 4.5% < 4.4 mmol/L. Per patient, the median [IQR] hours of TGC was 92 h [29-113] using 53 [19-62] measurements (median, ~13/day). Median [IQR] results: BG, 5.9 mmol/L [5.8-6.3]; carbohydrate nutrition, 6.8 g/h [5.5-8.7] (~70% goal feed median); insulin, 2.5 U/h [0.1-5.1]. All patients achieved BG < 6.1 mmol/L. These results match or exceed SPRINT and clinical workload is reduced more than 20%. Conclusions: STAR TGC modulating insulin and nutrition inputs provided very tight control with minimal variability by managing intra- and inter- patient variability. Performance and safety exceed that of SPRINT, which reduced mortality and cost in the Christchurch ICU. The use of glucometers did not appear to impact the quality of TGC. Finally, clinical workload was self-managed and reduced 20% compared with SPRINT

Anomalous diffusion, Localization, Aging and Sub-aging effects in trap models at very low temperature

We study in details the dynamics of the one dimensional symmetric trap model, via a real-space renormalization procedure which becomes exact in the limit of zero temperature. In this limit, the diffusion front in each sample consists in two delta peaks, which are completely out of equilibrium with each other. The statistics of the positions and weights of these delta peaks over the samples allows to obtain explicit results for all observables in the limit $T \to 0$. We first compute disorder averages of one-time observables, such as the diffusion front, the thermal width, the localization parameters, the two-particle correlation function, and the generating function of thermal cumulants of the position. We then study aging and sub-aging effects : our approach reproduces very simply the two different aging exponents and yields explicit forms for scaling functions of the various two-time correlations. We also extend the RSRG method to include systematic corrections to the previous zero temperature procedure via a series expansion in $T$. We then consider the generalized trap model with parameter $\alpha \in [0,1]$ and obtain that the large scale effective model at low temperature does not depend on $\alpha$ in any dimension, so that the only observables sensitive to $\alpha$ are those that measure the `local persistence', such as the probability to remain exactly in the same trap during a time interval. Finally, we extend our approach at a scaling level for the trap model in $d=2$ and obtain the two relevant time scales for aging properties.Comment: 33 pages, 3 eps figure

Young Muslim women's experiences of Islam and physical education in Greece and Britain: a comparative study

Previous research suggests that Muslim women can experience particular problems when taking physical education (PE) lessons, for example with dress codes, mixed-teaching and exercise during Ramadan; and they can face restrictions in extra-curricular activities for cultural and religious reasons. The area is under-researched and there is little evidence of comparative studies that explore similarities and differences in cross-national experiences, which is the aim of this paper. Two studies conducted in Greece and Britain that explored the views of Muslim women on school experiences of physical education are compared. Both studies focused on diaspora communities, Greek Turkish girls and British Asian women, living in predominantly non-Muslim countries. Growing concerns about global divisions between 'Muslims and the West' make this a particularly pertinent study. Qualitative data were collected by interviews with 24 Greek Muslim women, and 20 British Muslim women. \ud <P> \ud Physical education has national curriculum status and a similar rationale in both countries but with different cultures of formality and tradition, which impacted on pupils' experiences. Data suggested that Greek and British groups held positive views towards physical education but were restricted on their participation in extra-curricular activities. For the British women religious identity and consciousness of Islamic requirements were more evident than for the Greek women. Differences in stages of acculturation, historical and socio-cultural contexts contributed to less problematic encounters with physical education for Greek Muslims who appeared more closely assimilated into the dominant culture