The American journal of medicine
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Review
Treatment of patients with severe insulin deficiency; what we have learned over the past 2 years.
The initial injection in 1922 of a pancreatic extract, or insulin as it came to be known, into a patient with diabetes mellitus has since been followed by the successive introduction of longer-acting insulins, more highly purified insulins, and insulins that have been modified to more closely match insulin activity to patients' physiologic requirements. The recently introduced rapid-acting insulin analogues lispro and aspart and the long-acting analogue glargine are further refinements of insulin therapy. Current treatment strategies for severe insulin deficiency are based on the need to provide 2 components of insulin replacement: basal and postprandial. ⋯ Experience and observations since 2001 indicate that insulin therapy should be introduced earlier in patients with type 2 diabetes to control blood glucose levels. More importantly, the greatest benefit of insulin glargine has been to change positively the way physicians and patients think about insulin therapy. Newer insulin analogues, improved devices for home glucose monitoring, and pulmonary inhaled insulin are other innovations that promise improvement of hemoglobin A(1c) levels.
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The burden of type 2 diabetes mellitus will become even greater in coming decades as more young people present with the disease and patients live longer with the devastating complications of chronic hyperglycemia. Conventional and largely ineffectual treatment strategies consisting of lifestyle measures and long-term oral therapy are being challenged by studies showing that the early addition of insulin to oral agents can significantly improve glycemic control in patients with type 2 diabetes. ⋯ This simple treat-to-target strategy may be readily adopted in general practice through a widely translatable algorithm moving from oral pharmacotherapy to early addition of basal insulin glargine if glycemic targets are not met. The once-daily flexible dosing of insulin glargine and its smooth, flat profile, associated with fewer episodes of nocturnal hypoglycemia, make it among the safest and most practical tools to date for transforming the paradigm of type 2 diabetes management.
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Letter Case Reports
Aspergillus rib and vertebral osteomyelitis in a former intravenous drug user.
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In 2000, the Business Roundtable published its Leapfrog report, which contained suggestions for improving administration of critical care. The Leapfrog Group intends to influence health care policy by pressuring insurers and hospitals to implement its guidelines, and both internists and intensivists are likely to be affected if these recommendations are realized. ⋯ Aside from the guideline that all critically ill patients should be cared for by intensivists, Leapfrog's standards for critical care are based either on weak or no scientific evidence. Rather, most of the guidelines are grounded in common sense and rational extrapolation of the data; as such, they are a reasonable starting point for debate by physicians and policymakers about optimal methods of achieving intensivist-guided care of critically ill patients.