Kyriacou, Loewen, Gibbon, et aI
Gastro-intestinallymphoma in Saudi Arabia
contains a novel population of B lymphocytes which resemble marginal zone cells. Clin Exp Immunol, 1985; 62; 607-612. Tsutsumi Y, Nagura H, Watanbe K. Immune aspects of intestinal metaplasia of the stomach: an immunohistochemical study. Virchows Arch (Pathol Anat), 1984; 403: 345-359.
Shepherd NA, Hall PA, Coates PJ, Levison DA. Primary malignant lymphoma of the colon and rectum. A histopathological and immunochemical analysis of 45 cases with clinicopathological correlations. Histopathology, 1988; 12: 231-252. Spencer J, Finn T, Pulford AF, Mason DY, Isaacson PG. The human gut
Scot Med J 1991; 36: 074-076
0036-9330/91/10190/074$2.00 in USA © 1991 Scottish Medical Journal
METABOLIC CONTROL IN DIABETIC SUBJECTS FOLLOWING MYOCARDIAL INFARCTION: DIFFICULTIES IN IMPROVING BLOOD GLUCOSE LEVELS BY INTRA VENOUS INSULIN INFUSION R.R. Davies, R. W Newton, G.P. McNeill, * R.M. Fisher, tC.M. Kesson,
to.
Pearson
Wards 1 & 2, Ninewells Hospital and Medical School, Dundee; 'Western Infirmary, Glasgow; tVictoria Infirmary, Glasgow; :j:Diabetic Clinic, Aberdeen.
Abstract: Optimal metabolic control during the first twelve hours after myocardial infarction may be associated with improved survival in diabetic subjects. A comparison of an intravenous insulin infusion regimen aimed at improving blood glucose levels (n=35), with 'routine control' (n=34) in the post infarction period has been carried out in diabetic subjects admitted to four Coronary Care Units over a two year period. However, glycaemic control was similar in both groups (intravenous infusion regimen, mean ± SD capillary blood glucose 1O.3± 2.1 mmolll, 'routine control' glucose 10. 7 ± 3.6 mmolll). There were no differences in the rates ofarrhythmias (31% v 32%), heart failure (46% v 47%) or mortality (17% v 18%). Mortality in diabetic subjects was lower than that quoted in previous studies but was higher than in non-diabetic subjects admitted to the Coronary Care Unit during the same period. Attempts to improve glycaemic control by means of intravenous insulin infusion were unsuccessful Key words: Myocardial infarction, insulin infusion. Introduction HE metabolic disturbances observed in diabetic subjects suffering myocardial infarction may adversely affect outcome. Elevation in circulating levels of free fatty acids and potassium imbalance may predispose to cardiac arrhythmias! and increase myocardial oxygen consumption. 2 Reduced metabolic substrate availability and changes in acid-base balance may reduce myocardial contractility. Increased administration of insulin is required to overcome insulin resistance secondary to myocardial infarction to correct these various metabolic abnormalities. Although Gwilt et al found that the introduction of improved metabolic control by means of intravenous insulin had no impact on mortality (33%),3 Clark et al reported a reduction in mortality from 42 to 17% following the introduction of an intravenous insulin infusion regimen. 4 Both of these studies used retrospective historical controls. We describe the results of a randomised prospective controlled study comparing continuous insulin infusion with 'routine therapy' following myocardial infarction in patients with previously diagnosed diabetes mellitus admitted to Coronary Care Units (CCU). The aim of the study was to assess whether improved metabolic control would have any effect on mortality or rates of arrythmia and cardiac failure.
T
Patients and Methods Four hospitals agreed to take part in the study. All patients with suspected myocardial infarction known to have diabetes prior to admission to CCU's were included. Patients with chest pain for more than 12 hours, ketoacidosis, hyperosmolar state, cardiogenic shock or severe cardiac failure were excluded. If informed consent was obtained patients were randomised to receive either continuous Correspondence to: R.R. Davies, Wards 1/2, Ninewells Hospital and Medical School, Dundee DDI9SY.
intravenous insulin, 'infusion regimen', or 'routine therapy'. The infusion regimen consisted of continuous dextrose 5%, 1 litre per 24 hours with potassium added routinely unless serum levels were greater than 5.0 mmol/l, with insulin infused continuously by mechanical pump. This was adjusted according to 2-4 hourly capillary blood glucose measurements using a Glucometer II (Ames Division, Myles Laboratories). CCU staff were instructed to regard Table 1 as a guide to the infusion rate and to adjust the regimen to obtain capillary blood glucose levels between 4 and 8 mmol/l. Routine therapy involved continuing the diabetic therapy present on admission, though metformin was stopped to avoid the theoretical risk of precipitating lactic acidosis. Capillary blood glucose was measured prior to main meals and sleep. Patients clinically judged to have inadequate control (capillary blood glucose consistently> 10 mmol/l) were changed to three times daily subcutaneous soluble insulin prior to meals and evening isophane insulin. Serum potassium levels were measured daily. Blood for glycosylated haemoglobin A l -c (HbA l c ) was taken on admission and measured in a single laboratory (normal
Gastro-intestinallymphoma in Saudi Arabia
contains a novel population of B lymphocytes which resemble marginal zone cells. Clin Exp Immunol, 1985; 62; 607-612. Tsutsumi Y, Nagura H, Watanbe K. Immune aspects of intestinal metaplasia of the stomach: an immunohistochemical study. Virchows Arch (Pathol Anat), 1984; 403: 345-359.
Shepherd NA, Hall PA, Coates PJ, Levison DA. Primary malignant lymphoma of the colon and rectum. A histopathological and immunochemical analysis of 45 cases with clinicopathological correlations. Histopathology, 1988; 12: 231-252. Spencer J, Finn T, Pulford AF, Mason DY, Isaacson PG. The human gut
Scot Med J 1991; 36: 074-076
0036-9330/91/10190/074$2.00 in USA © 1991 Scottish Medical Journal
METABOLIC CONTROL IN DIABETIC SUBJECTS FOLLOWING MYOCARDIAL INFARCTION: DIFFICULTIES IN IMPROVING BLOOD GLUCOSE LEVELS BY INTRA VENOUS INSULIN INFUSION R.R. Davies, R. W Newton, G.P. McNeill, * R.M. Fisher, tC.M. Kesson,
to.
Pearson
Wards 1 & 2, Ninewells Hospital and Medical School, Dundee; 'Western Infirmary, Glasgow; tVictoria Infirmary, Glasgow; :j:Diabetic Clinic, Aberdeen.
Abstract: Optimal metabolic control during the first twelve hours after myocardial infarction may be associated with improved survival in diabetic subjects. A comparison of an intravenous insulin infusion regimen aimed at improving blood glucose levels (n=35), with 'routine control' (n=34) in the post infarction period has been carried out in diabetic subjects admitted to four Coronary Care Units over a two year period. However, glycaemic control was similar in both groups (intravenous infusion regimen, mean ± SD capillary blood glucose 1O.3± 2.1 mmolll, 'routine control' glucose 10. 7 ± 3.6 mmolll). There were no differences in the rates ofarrhythmias (31% v 32%), heart failure (46% v 47%) or mortality (17% v 18%). Mortality in diabetic subjects was lower than that quoted in previous studies but was higher than in non-diabetic subjects admitted to the Coronary Care Unit during the same period. Attempts to improve glycaemic control by means of intravenous insulin infusion were unsuccessful Key words: Myocardial infarction, insulin infusion. Introduction HE metabolic disturbances observed in diabetic subjects suffering myocardial infarction may adversely affect outcome. Elevation in circulating levels of free fatty acids and potassium imbalance may predispose to cardiac arrhythmias! and increase myocardial oxygen consumption. 2 Reduced metabolic substrate availability and changes in acid-base balance may reduce myocardial contractility. Increased administration of insulin is required to overcome insulin resistance secondary to myocardial infarction to correct these various metabolic abnormalities. Although Gwilt et al found that the introduction of improved metabolic control by means of intravenous insulin had no impact on mortality (33%),3 Clark et al reported a reduction in mortality from 42 to 17% following the introduction of an intravenous insulin infusion regimen. 4 Both of these studies used retrospective historical controls. We describe the results of a randomised prospective controlled study comparing continuous insulin infusion with 'routine therapy' following myocardial infarction in patients with previously diagnosed diabetes mellitus admitted to Coronary Care Units (CCU). The aim of the study was to assess whether improved metabolic control would have any effect on mortality or rates of arrythmia and cardiac failure.
T
Patients and Methods Four hospitals agreed to take part in the study. All patients with suspected myocardial infarction known to have diabetes prior to admission to CCU's were included. Patients with chest pain for more than 12 hours, ketoacidosis, hyperosmolar state, cardiogenic shock or severe cardiac failure were excluded. If informed consent was obtained patients were randomised to receive either continuous Correspondence to: R.R. Davies, Wards 1/2, Ninewells Hospital and Medical School, Dundee DDI9SY.
intravenous insulin, 'infusion regimen', or 'routine therapy'. The infusion regimen consisted of continuous dextrose 5%, 1 litre per 24 hours with potassium added routinely unless serum levels were greater than 5.0 mmol/l, with insulin infused continuously by mechanical pump. This was adjusted according to 2-4 hourly capillary blood glucose measurements using a Glucometer II (Ames Division, Myles Laboratories). CCU staff were instructed to regard Table 1 as a guide to the infusion rate and to adjust the regimen to obtain capillary blood glucose levels between 4 and 8 mmol/l. Routine therapy involved continuing the diabetic therapy present on admission, though metformin was stopped to avoid the theoretical risk of precipitating lactic acidosis. Capillary blood glucose was measured prior to main meals and sleep. Patients clinically judged to have inadequate control (capillary blood glucose consistently> 10 mmol/l) were changed to three times daily subcutaneous soluble insulin prior to meals and evening isophane insulin. Serum potassium levels were measured daily. Blood for glycosylated haemoglobin A l -c (HbA l c ) was taken on admission and measured in a single laboratory (normal
