Brief Answer:
Endocrine care

Detailed Answer:
1 The latest guidelines for BP targets in individuals with diabetes are 140/90. Lower targets can be aimed for without undue treatment or cost burden.

So in this instance, if home monitoring reveals BP readings persistently above target then I generally add a diuretic such as hydrochlorothiazide, to my patients medications. I test for electrolytes in a week or two to ensure there are no side effects from this new medications.

ACE inhibitors or ARB (Angiotensen Receptor blockers) are also an option.

2 Any stress can raise blood glucoses. In Mr JS' case, he has infection and is hospitalized. Both these conditions can elevate blood glucoses.

3 Good glucose control in general , and definitely in the hospital is associated with better outcomes. It is important to keep blood glucoses in the hospital between 110 to 140 before meals with no glucose exceeding 180.

Hypoglycemia is always a risk when tighter glucose control is being attempted.And with Mr JS being on insulin the risk is higher but it can be avoided with scrupulous management

---

Brief Answer:
Follow up

Detailed Answer:

People with diabetes have a higher chance of getting certain infections. This is likely due to:

●High blood sugar – Blood sugar levels that are too high can keep a person’s infection-fighting system (called the “immune system”) from working as well as it should.
●Nerve damage – Over time, diabetes can cause nerve damage. This can lead to problems. For example, nerve damage can make people unable to feel pain in their feet. So if a person gets a cut on the foot or steps on a nail or other sharp object that pierces the skin, he or she might not know it. If a wound isn’t treated right away, it can become an open sore and get infected.
However, in Mr JS' lung infection this mechanism is not a factor
●Blood vessel problems – Over time, diabetes can damage the blood vessels. Then blood can’t flow as well to help heal an infection.

People with diabetes commonly get:

●Skin infections
●Vaginal yeast infections (in women)
●Bladder or kidney infections
●Infections on the feet
●Yeast infections in the mouth
●Lung infections
●Infections after surgery, around the cut from the surgery

Regarding the importance of Mr JS' glucose control in the hospital:

Patients with type 1 or type 2 diabetes mellitus are frequently admitted to a hospital, usually for treatment of conditions other than the diabetes. Glucose control is likely to become unstable in these patients, not only because of the stress of the illness, but also because of the simultaneous changes in food intake and physical activity.

Glucose goals

●Correction and prevention of high blood sugar is beneficial to hospitalized patients. Lower blood glucose levels ('hypoglycemia) may decrease the risk of poor clinical outcomes (such as Mr JS' chances of survival and complications from the infection), but also increase the risk of low blood sugar reactions.. A reasonable target to avoid hypoglycemia is to achieve pre-meal blood glucose concentrations no lower than 90 to 100 mg/dL

Tighter goals may be appropriate for stable patients with previous good diabetes control, and the goal should be set somewhat higher for older patients and those with severe diabetes-related problems (such as heart attacks, strokes, kidney failure, nerve damage, bleeding in retina of the eye) where the heightened risk of hypoglycemia may outweigh any potential benefit.

The best way to control MR JS diabetes in the hospital to use a 'basal-bolus' insulin schedule. This means he would likely benefit from one injection of a long acting insulin and 3 meal time doses of a rapid acting insulin (like the one he is on ie Apidra).
The Novomix type of insulin mixtures are often associated with unstable glucose control

---

Brief Answer:
Second follow up

Detailed Answer:
Since you have asked for professional-level answers in your feedback, here is the medical explanation:

It is widely accepted that diabetics have an increased propensity to develop infections. Despite a number of both systemic and local host factors that can contribute to infections, whether diabetics truly are at greater risk for infection and the magnitude of the effect of diabetes on the risk of infection remain active questions.

Factors making Mr JS vulnerable to infection include the following:

●Hyperglycemia-related impairment of the immune response
●Vascular insufficiency
●Sensory peripheral neuropathy
●Autonomic neuropathy
●Skin and mucosal colonization with pathogens such as Staphylococcus aureus and Candida species

In view of his lung infection, the following is the most likely mechanism:

Hyperglycemia-related impairment of immune response — Neutrophil chemotaxis and adherence to vascular endothelium, phagocytosis, intracellular bactericidal activity, opsonization, and cell-mediated immunity are all depressed in diabetics with hyperglycemia. Investigations to identify the mechanisms of immune impairment have noted the following findings:

●Release of tumor necrosis factor-alpha and interleukin (IL)-1-beta from lipopolysaccharide-stimulated macrophages is reduced in diabetic mice compared with control mice.
●The level of macrophage inflammatory protein 2, a mediator of lung neutrophil recruitment, is significantly decreased in diabetic compared to control mice. The deficiency causes a delay in neutrophil recruitment in the lungs.
●Hyperglycemia impairs opsonophagocytosis by diverting NADPH from superoxide production into the aldose reductase-dependent polyol pathway.
●Diabetic mice with a bacterial infection of the scalp had greater than twofold induction of genes that directly or indirectly induce apoptosis compared with normoglycemic controls. Blocking apoptosis allows for a significant improvement in wound healing and bone growth.
●Methylglyoxal-glycation, which is a major pathway of glycemic damage in diabetics, inhibits production of IL-10 from myeloid cells as well as interferon-gamma and tumor necrosis factor-alpha from T cells; it also reduces MHC class I expression on the surface of myeloid cells.
●High glucose concentrations competitively inhibit binding of oligosaccharides by C-type lectin; such binding is necessary for many functions of the immune system.

---