Robert Gregory

Closed-loop glycaemic control using an implantable artificial pancreas in diabetic domestic pig (Sus scrofa domesticus).

The performance of a completely implantable peritoneal artificial pancreas (AP) has been demonstrated in principle in a live diabetic domestic pig. The device consists of a smart glucose-sensitive gel that forms a gateway to an insulin reservoir and is designed to both sense glucose and deliver insulin in the peritoneal cavity. It can be refilled with insulin via subcutaneous ports and surgery was developed to insert the AP. Diabetes was induced with streptozotocin (STZ), the device filled with insulin (Humulin(®) R U-500) in situ and the animal observed for several weeks, during which time there was normal access to food and water and several oral glucose challenges. Blood glucose (BG) levels were brought down from >30 mmol/L (540 mg/dL) to non-fasted values between 7 and 13 mmol/L (126-234 mg/dL) about five days after filling the device. Glucose challenge responses improved ultimately so that, starting at 10 mmol/L (180 mg/dL), the BG peak was 18 mmol/L (324 mg/dL) and fell to 7 mmol/L (126 mg/dL) after 30 min, contrasting with intravenous attempts. The reservoir solution was removed after 8 days of blood glucose levels during which they had been increasingly better controlled. A rapid return to diabetic BG levels (30 mmol/L) occurred only after a further 24 days implying some insulin had remained in the device after removal of the reservoir solution. Thus, the closed loop system appeared to have particular influence on the basal and bolus needs for the 8 days in which the reservoir solution was in place and substantial impact for a further 3 weeks. No additional insulin manual adjustment was given during this period.

Insulin pump users would not rule out using an implantable artificial pancreas

The aim of this survey was to establish the limitations of open loop continuous subcutaneous insulin infusion (CSII) as perceived by current users of the technology, and to ascertain their interest in and requirements for a non‐electronic implantable closed loop insulin pump, INSmart, currently under development for the treatment of type 1 diabetes. INSmart has been surgically implanted in the peritoneum in animal models and continuously restored normoglycaemia.

Weight loss and nausea in a patient taking digoxin

In August 2007, a 76 year old white woman was referred because of a two week history of worsening lethargy with loss of appetite and nausea. She had ischaemic heart disease and hypertension and had had a pacemaker inserted in February 2007 for atrial fibrillation with sinus pauses. She had lost 9.3 kg in the past 10 months. When she visited her family doctor two days before hospital admission her symptoms were initially thought to be caused by digoxin toxicity (digoxin concentration 5 nmol/L, therapeutic range 0.9-2.6), so her digoxin dose had been reduced, but a random blood glucose measurement was raised at 29.3 mmol/L (reference range 3.3-6.0) and she was referred to hospital. She had been diagnosed with type 2 diabetes in February 2006 on an oral glucose tolerance test (0 min blood glucose 5.1 mmol/L, 2 hour value 12.3 mmol/L) and had been controlled using diet alone. Her glycated haemoglobin (HbA1c) value had been 6.4% (4.0-6.1%; 46 mmol/mol, 20-43) in February 2007. She was thin, weighing 45 kg, with a body mass index of 17. Her breath smelled “fruity.” Her blood pressure was 148/89 mm Hg. Urinalysis showed 3+ glucose and 3+ ketones. Arterial pH was 7.241 (7.35-7.45), bicarbonate 12 mmol/L (22-29), sodium 129 mmol/L (133-146), potassium 4.9 mmol/L (3.5-5.3), urea 29.3 mmol/L (2.5-7.8), creatinine 213 µmol/L (60-120), and blood glucose 59.3 mmol/L (3.3-6.0). Haemoglobin was 145 g/L (115-165), white cell count was 12.1×109/L (4.0-11.0), and platelets were 251×109/L (140-400). ### 1 What is the diagnosis? #### Short answer Diabetic ketoacidosis (DKA). #### Long answer DKA consists of the biochemical triad of ketonaemia (≥3 mmol/L) or severe ketonuria (more than 2+ on standard urine sticks), hyperglycaemia (blood glucose >11 …