Closed-loop insulin delivery for glycaemic control in hospitalised and perioperative adults: A systematic review and meta-analysis of randomised controlled trials.

Comparative Efficacy of Insulin Delivery Modalities on Glycaemic Control in Adults With Type 2 Diabetes: A Systematic Review and Network Meta-Analysis.

AIMS To compare insulin delivery modalities for glycaemic control, body weight and insulin dose in adults with insulin-treated Type 2 diabetes. MATERIALS AND METHODS We searched eight databases and two trial registries until 27 April 2026 for parallel-group randomised trials comparing pre-specified insulin delivery modalities. The primary network meta-analysis excluded the clinically heterogeneous residual Other node. Outcomes were changes in HbA1c, time in range (TIR), time above range (TAR), time below range (TBR), body weight and insulin dose; certainty was assessed with CINeMA. RESULTS Thirty-seven reports describing 36 independent trials with 4157 participants were included. Median follow-up was 12 weeks. In the primary no-Other analysis, hybrid closed-loop (HCL) reduced HbA1c versus multiple daily injections (MDI; MD -0.79%, 95% CI -1.33 to -0.25), increased TIR (MD +16.00 percentage points, 95% CI +8.77 to +23.22), reduced TAR (MD -13.48 percentage points, 95% CI -23.05 to -3.91) and reduced insulin dose (MD -15.69 U/day, 95% CI -31.33 to -0.06). Continuous subcutaneous insulin infusion also reduced HbA1c (MD -0.47%, 95% CI -0.74 to -0.20) and insulin dose. Fully closed-loop yielded larger TIR/TAR estimates, but from one short trial only and should be considered hypothesis-generating. HCL increased body weight (MD +1.58 kg, 95% CI +0.75 to +2.40). Most trials had risk-of-bias concerns and low-risk sensitivity analysis was infeasible. CONCLUSIONS HCL showed the most consistent glycaemic benefit, but body-weight and sparse safety evidence warrant caution. FCL findings require larger, longer confirmation. TRIAL REGISTRATION PROSPERO registration: CRD420261381231.

Benefits and Risks of Intensive Glucose Control in Intensive Care Units: A Meta-Analysis of Randomized Controlled Trials.

BACKGROUND Hyperglycaemia is common among intensive care unit (ICU) patients and is associated with increased mortality. However, whether intensive or liberal glucose control is more beneficial remains controversial. AIM To compare the benefits and risks of intensive versus liberal glucose control in ICU patients. STUDY DESIGN A Meta analysis of randomized controlled trials. METHODS Systematic review and meta-analysis of randomized controlled trials (RCTs). We systematically searched PubMed, Cochrane Library, Embase and Web of Science from inception to October 30, 2024. The review was conducted according to PRISMA guidelines. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. Data were independently screened and extracted by four reviewers. Relative risks (RRs) were pooled using a random effects model, and trial sequential analysis was performed for the primary outcome. RESULTS Seventy RCTs were included, comprising 36 502 patients, of which 64 RCTs (32 491 patients, 89%) were conducted in adults and 6 RCTs (4011 patients, 11%) in children. The RR of all-cause mortality after intensive and liberal glucose control was 0.99 (95% CI, 0.93-1.05) in adults. Comparable findings were observed for all-cause mortality in children. Intensive glucose control had a statistically significantly higher risk of severe hypoglycaemia in both children (RR 5.70; 95% CI 2.60-12.51) and adults (RR 3.55; 95% CI 2.49-5.07). However, intensive glucose control had a statistically lower risk of infection in both children (RR 0.83; 95% CI 0.70-0.98) and adults (RR 0.78; 95% CI 0.63-0.97). In the subgroup analysis of adults, a lower risk of infection was observed in all surgical groups, but not in the medical group. There was no statistically significant difference in other complications, including sepsis, acute renal injury, new need for dialysis and need for blood transfusion. CONCLUSIONS Intensive and liberal glucose control had similar effects on all-cause mortality in adults and children, though paediatric data are limited and should be interpreted cautiously. Intensive glucose control reduced infection risk, especially in surgical ICUs, but increased the risk of severe hypoglycaemia. RELEVANCE TO CLINICAL PRACTICE These findings suggest that routine intensive glucose control does not improve survival and should be applied cautiously due to increased hypoglycaemia risk, although it may reduce infection risk, particularly in surgical ICU patients.

Contemporary automated insulin delivery systems in older adults with type 1 diabetes: A systematic review and meta-analysis.

Older adults with type 1 diabetes are clinically heterogeneous, with variable cognition, dexterity, comorbidity burden, caregiver support, and prior technology experience. Evidence on automated insulin delivery systems (AIDs) in this population remains limited and largely observational. We performed a systematic review and meta-analysis of contemporary AIDs in adults aged ≥60 years with type 1 diabetes. We searched PubMed, Embase, Web of Science, Cochrane Library, and ClinicalTrials.gov through February 2026. Nine studies (7 observational studies and 2 randomized crossover trials; 8,765 participants) were included. We pooled outcomes during AID use using single-arm random-effects meta-analyses. When baseline data were available, we performed change-from-baseline analyses. With AIDs, pooled mean time in range (TIR) was 77.95% (95% CI 75.31-80.59), HbA1c was 6.95% (52 mmol/mol) (95% CI 6.67-7.24), and time below range (TBR) < 70 mg/dL was 1.35% (95% CI 1.12-1.57). From baseline, AID use was associated with higher TIR, lower hyperglycemia, lower HbA1c (MD - 0.36%; 95% CI - 0.63 to - 0.09), and lower diabetes distress, without increased hypoglycemia. Findings were consistent in direction with broader AID literature. Older age alone should not preclude individualized AID use.

Closed-loop vasopressor systems for hemodynamic control in perioperative and critical care settings: a systematic review and meta-analysis.

Maintaining mean arterial pressure (MAP) within a predefined target is central to haemodynamic management in surgical and critically ill adults receiving vasopressors. Closed-loop vasopressor (CLV) systems automate titration to optimise blood pressure control, but their clinical effectiveness remains uncertain. We performed a systematic review and meta-analysis comparing CLV with manual titration. This PRISMA 2020-compliant review was prospectively registered in PROSPERO (CRD420250655697). MEDLINE, Embase, Scopus, Web of Science, CENTRAL, and the Cochrane Library were searched (January 2000-June 2025). Randomised controlled trials enrolling adults receiving vasopressors in perioperative or intensive care settings were included. Primary outcomes were time within the MAP target range and time spent in hypotension or hypertension. Risk of bias was assessed using RoB 2.0 and certainty of evidence using GRADE. Random- or fixed-effects models were selected according to heterogeneity. Six randomized controlled trials (215 patients) were included in the systematic review, whereas five perioperative trials contributed to the meta-analysis of haemodynamic control outcomes, and one ICU-based study was summarized narratively because it did not report comparable MAP control endpoints. CLV increased time within the MAP target range (mean difference [MD] 33.94%, 95% CI 20.41-47.46; I2 = 77%) and reduced time in hypotension (MD - 18.24%, 95% CI - 28.95 to - 7.53; I2 = 73%). There was no significant difference in time in hypertension, cumulative norepinephrine dose, or major/minor adverse events. ICU length of stay was not pooled because of clinical and methodological heterogeneity. Certainty of evidence ranged from low to high (moderate for haemodynamic control outcomes). CLV systems improved haemodynamic control, primarily in perioperative settings, but heterogeneity and small samples limit confidence in effect size and generalisability. Evidence in critically ill populations remains limited, and larger trials are needed to determine whether improvements in these physiological surrogate endpoints translate into meaningful patient-centred outcomes.

Safety and Glycemic Efficacy of Perioperative Liraglutide in Cardiac Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Perioperative hyperglycemia in cardiac surgery is associated with wound infection, acute kidney injury, and death, yet the intravenous insulin used to treat it is itself coupled to hypoglycemia. Glucagon-like peptide-1 receptor agonists lower glucose only when glucose is elevated and might therefore separate glycemic control from hypoglycemic risk. We searched PubMed/MEDLINE, Scopus, Web of Science, and CENTRAL through September 2025 for randomized controlled trials of perioperative subcutaneous liraglutide versus placebo or insulin-based usual care in adults undergoing cardiac surgery. Two reviewers screened, extracted data, and applied the Cochrane Risk of Bias 2 tool independently; certainty was graded using GRADE. Effects were pooled by inverse variance, fixed-effect when I2 was below 50%. Seven reports of 4 trials, enrolling 446 randomized patients, were eligible. Liraglutide did not alter 30-day mortality (1/161 vs 3/160; risk ratio [RR] 0.42, 95% confidence interval [CI], 0.06-2.81), the composite of any postoperative complication (68/129 vs 76/132; RR 0.92; 95% CI, 0.74-1.14), cardiac adverse events (RR 1.08; 95% CI, 0.83-1.40), hypoglycemia (8/165 vs 9/166; RR 0.85; 95% CI, 0.34-2.13), or postoperative nausea and vomiting (RR 3.01; 95% CI, 0.26-35.27).

Automated oxygen control versus manual titration in preterm infants: A systematic review and meta-analysis.