The Journal of clinical endocrinology and metabolism
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J. Clin. Endocrinol. Metab. · Sep 2009
ReviewClinical review: Intensive insulin therapy in critically ill patients: NICE-SUGAR or Leuven blood glucose target?
Hyper- and hypoglycemia are associated with increased mortality of critically ill patients, but whether this association is causal remains unclear. Early randomized-controlled studies compared insulin infusion targeting "age-normal" blood glucose levels, labeled intensive insulin therapy, with an approach that considered hyperglycemia as a beneficial adaptation. These studies found benefits with maintaining normoglycemia. A recent large multicenter study, NICE-SUGAR, compared a similar age-normal with an intermediate glucose target and found the intermediate target superior. These results require explanation. ⋯ These differences do not permit confident recommendations for a single optimal glucose target in variable ICU settings. Respecting the "primum non nocere" principle, it appears safe not to embark on targeting age-normal levels in ICUs that are not equipped to accurately and frequently measure blood glucose and have not acquired extensive experience with iv insulin administration using a customized guideline. A simple overall fall-back position could be to maintain blood glucose levels as close to normal as possible without evoking unacceptable fluctuations, hypoglycemia, and hypokalemia.
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J. Clin. Endocrinol. Metab. · May 2008
ReviewThirty years of personal experience in hyperglycemic crises: diabetic ketoacidosis and hyperglycemic hyperosmolar state.
Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) cause major morbidity and significant mortality in patients with diabetes mellitus. For more than 30 yr, our group, in a series of prospective, randomized clinical studies, has investigated the pathogenesis and evolving strategies of the treatment of hyperglycemic crises. This paper summarizes the results of these prospective studies on the management and pathophysiology of DKA. ⋯ Areas of future research include prospective randomized studies to do the following: 1) establish the efficacy of bicarbonate therapy in DKA for a pH less than 6.9; 2) establish the need for a bolus insulin dose in the initial therapy of DKA; 3) determine the pathophysiological mechanisms for the absence of ketosis in HHS; 4) investigate the reasons for elevated proinflammatory cytokines and cardiovascular risk factors; and 5) evaluate the efficacy and cost benefit of using sc regular insulin vs. more expensive insulin analogs on the general ward for the treatment of DKA.
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J. Clin. Endocrinol. Metab. · Oct 2006
ReviewHypothalamic pituitary adrenal function during critical illness: limitations of current assessment methods.
Activation of the hypothalamic-pituitary-adrenal (HPA) axis represents one of several important responses to stressful events and critical illnesses. Despite a large volume of published data, several controversies continue to be debated, such as the definition of normal adrenal response, the concept of relative adrenal insufficiency, and the use of glucocorticoids in the setting of critical illness. ⋯ The routine use of glucocorticoids during critical illness is not justified except in patients in whom adrenal insufficiency was properly diagnosed or others who are hypotensive, septic, and unresponsive to standard therapy. When glucocorticoids are used, hydrocortisone should be the drug of choice and should be given at the lowest dose and for the shortest duration possible. The hydrocortisone dose (50 mg every 6 h) that is mistakenly labeled as low-dose hydrocortisone leads to excessive elevation in serum cortisol to values severalfold greater than those achieved in patients with documented normal adrenal function. The latter data should call into question the current practice of using such doses of hydrocortisone even in the adrenally insufficient subjects.
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J. Clin. Endocrinol. Metab. · Jul 2006
Review Comparative StudyClinical review: Thyrotoxic periodic paralysis: a diagnostic challenge.
The aim of this article was to review the clinical presentation, pathogenesis, and management of thyrotoxic periodic paralysis (TPP). ⋯ Due to population mobility, TPP is increasingly common in Western countries. Early diagnosis and prompt treatment prevent life-threatening complications associated with hypokalemia and muscle weakness. Assaying of thyroid function in patients with hypokalemic paralysis distinguishes TPP from other forms of hypokalemic periodic paralysis.
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J. Clin. Endocrinol. Metab. · Mar 2006
ReviewControversy in clinical endocrinology: diagnosis of polycystic ovarian syndrome: in defense of the Rotterdam criteria.
Polycystic ovary syndrome (PCOS) is a very common endocrinopathy with a heterogeneous presentation whose etiology is still uncertain. Not surprisingly, therefore, the definition of, and diagnostic criteria for, PCOS remain controversial. ⋯ These new diagnostic criteria for PCOS reflect the significant advances, particularly from studies of familial PCOS, in understanding of the etiology of the syndrome and the basis for its heterogeneity. Under the revised diagnostic criteria, the inclusion of women with hyperandrogenism and regular cycles has met with general agreement. The inclusion of women with oligomenorrhea and polycystic ovaries who do not have clear evidence of androgen excess is, in the opinion of this author, also justified but remains a contentious issue and one that requires further investigation.