Long-term efficacy of a 5-day structured teaching and treatment programme for intensified conventional insulin therapy and risk for severe hypoglycemia

Improvement of glycemic control by re-education in insulin injection technique in patients with diabetes mellitus

INTRODUCTION

The aim of this study was to evaluate the effectiveness of re-education in the insulin injection technique for glycemic control.

METHODS

A preliminary experimental study was performed with 87 insulin-treated diabetic outpatients (11 with type 1 diabetes, 76 with type 2 diabetes; 43 men, 44 women). All patients had been treated with insulin for more than 3 years. After answering questions about the insulin injection technique, the patients' knowledge levels were scored. Correct answers and explanation sheets were subsequently given to all patients. The physicians in charge gave a short lecture and provided 10 min of individual advice. Two, three, and four months after re-education the HbA1c and glycoalbumin levels were measured.

RESULTS

The mean HbA1c levels of almost all patients significantly improved from 7.46 ± 0.09% to 6.73 ± 0.10% (P < 0.01), and the mean glycoalbumin levels significantly improved from 22.76 ± 0.50% to 20.26 ± 0.68% (P < 0.01). Twenty-five patients demonstrated a poor understanding (score of ≤6 points) and showed a significant decrease in the HbA1c level from 7.62 ± 0.20% to 6.71 ± 0.21% (P = 0.02). Forty-three patients demonstrated a moderate understanding (score of 7 or 8 points) and showed a decrease in the HbA1c level from 7.40 ± 0.13% to 6.68 ± 0.07% (P = 0.07). Finally, 19 patients demonstrated a good understanding (score of ≥9 points) and showed a slight decrease in the HbA1c level from 7.38 ± 0.15% to 6.93 ± 0.12% (P = 0.09). Patients with a poor understanding showed the largest decrease in the mean level of HbA1c.

CONCLUSION

Re-education in the insulin injection technique led to an improvement in glycemic control in insulin-treated diabetic patients, especially in those with a poor understanding of the insulin injection technique. More attention should be paid to these strategies for outpatients.

Hypoglycemia, S-ACE and ACE genotypes in a Danish nationwide population of children and adolescents with type 1 diabetes

OBJECTIVE

High S-ACE levels have been shown to predispose to increased risk of hypoglycemia, however; some inconsistency relates to the risk of the ACE genotype. We investigated the association between S-ACE level at diagnosis and ACE genotype to long-term risk of severe hypoglycemia in more than 1000 children and adolescents with type 1 diabetes being part of the Danish Registry of Childhood diabetes over a 10-yr period.

RESEARCH DESIGN AND METHODS

The Registry provided annual registration of clinical data, e.g., HbA1c, blood glucose monitoring, insulin type and dosage and acute diabetic complications (hypoglycemia and DKA). A BioBank coupled to the Registry comprised serum for measuring S-ACE levels and DNA for ACE genotyping.

RESULTS

A total of 1037 individuals were included, aged 9.97 yr (SD 3.84). A total of 622 severe hypoglycemic episodes were observed in 270 individuals. Associations to increased risk of hypoglycemia generated from a negative binominal model were long diabetes duration (p < 0.0001) and high S-ACE level (p = 0.0497) when adjusted for ACE genotype. In the stratified analysis, S-ACE and insulin dosage were associated with hypoglycemia in girls (p = 0.026 and 0.028, respectively). An association of S-ACE level to ACE genotype was identified; however, no difference in the frequency of hypoglycemia, diabetes duration or HbA1c was demonstrated between ACE genotypes.

CONCLUSION

This large nationwide cohort has identified an increased risk for hypoglycemia associated with higher S-ACE level, however only in girls. A strong association was found between ACE genotype and S-ACE levels, but ACE genotype was not related to risk of hypoglycemia.

Training in flexible intensive insulin therapy improves quality of life, decreases the risk of hypoglycaemia and ameliorates poor metabolic control in patients with type 1 diabetes

AIM

Intensified insulin therapy has evolved to be the standard treatment of type 1 diabetes. However, it has been reported to increase significantly the risk of hypoglycaemia. We studied the effect of structured group teaching courses in flexible insulin therapy (FIT) on psychological and metabolic parameters in patients with type 1 diabetes.

METHODS

We prospectively followed 45 type 1 diabetic patients of our outpatient clinic participating in 5 consecutive FIT teaching courses at the University Hospital of Basel. These courses consist of 7 weekly ambulatory evening group sessions. Patients were studied before and 1, 6, and 18 months after the course. Main outcome measures were glycated haemoglobin (HbA1c), severe hypoglycaemic events, quality of life (DQoL), diabetes self-control (IPC-9) and diabetes knowledge (DWT).

RESULTS

Quality of life, self-control and diabetes knowledge improved after the FIT courses (all p<0.001). The frequency of severe hypoglycaemic events decreased ten-fold from 0.33 episodes/6 months at baseline to 0.03 episodes/6 months after 18 months (p<0.05). Baseline HbA1c was 7.2+/-1.1% and decreased in the subgroup with HbA1c > or = 8% from 8.4% to 7.8% (p<0.05).

CONCLUSIONS

In an unselected, but relatively well-controlled population of type 1 diabetes, a structured, but not very time consuming FIT teaching programme in the outpatient setting improves psychological well-being and metabolic parameters.

A prospective study of quality of life in 77 type 1 diabetic patients 12 months after a hospital therapeutic educational programme

AIM

The aim of therapeutic education includes improvement of quality of life (QOL). However, the majority of studies are focused on biomedical or behavioural markers only. We performed a prospective study to assess QOL in adult type 1 diabetic patients for one year following a hospital educational programme.

METHODS

During this prospective single-centre study, QOL was assessed by the DQOL questionnaire in 77 consecutive patients at baseline and three, six and 12 months after a three-day educational programme.

RESULTS

The rate of response was 72.7% (n=55) at three months and 67.5% (n=52) at one year. The overall DQOL score improved at three months from 65.6+/-10.1 to 70.1+/-10.4 (P<0.001), and at one year from 65.1+/-10.4 to 68.5+/-11.7 (P=0.001). Patients exhibited greater satisfaction (66.3+/-15 versus 75.3+/-14.1, P<0.001), a diminished impact of diabetes (61.2+/-10 versus 63.4+/-9.6, P=0.016) as well as of anxiety related to diabetes (67.6+/-18.6 versus 73.6+/-16.2, P=0.009) at three months. This significant improvement was maintained at one year. Improvement in DQOL score at three months was positively correlated with a reduction in HbA(1c) (7.6+/-1.4% versus 7.8+/-1.4%, P=0.032), (r=-0.293, P<0.037). Patients with serious hypoglycaemia before the programme appeared to derive greater benefit from therapeutic education (OR: 9.88, 95% CI: 1.094-89.20).

CONCLUSION

QOL assessed by DQOL improved after therapeutic education and during the following year. The improvement in DQOL score at three months correlated with a reduction in HbA(1c) levels and appeared to particularly benefit to those who had severe hypoglycaemia before the programme.

Diabetes nurse case management: an effective tool

PURPOSE

In March 2000, a large tertiary military medical treatment facility on the east coast implemented a diabetes nurse case management program to coordinate care for patients with diabetes mellitus type 1 or type 2 and a hemoglobin A1c value of 8.0% or greater. Although proven successful for patients while enrolled in the program, there was a lack of research that evaluated how successful patients were at continuing diabetes self-management once discharged. This study evaluated glycosylated hemoglobin A1c (A1c), total cholesterol (TC), triglyceride, and low-density lipoprotein (LDL) levels in patients at admission, discharge, and 6 months following discharge from the program.

DATA SOURCES

A retrospective medical record review of laboratory data was evaluated using descriptive statistics and paired t-test.

CONCLUSIONS

Significant reductions in A1c and TC values from admission to discharge were achieved, which the patients maintained 6 months following discharge. There was also a significant reduction in LDL value from admission to 6 months following discharge.

IMPLICATIONS FOR PRACTICE

This study supports the value of nurse case management for patients with diabetes.

Fear and other disturbances of severe hypoglycaemia in children and adolescents with type 1 diabetes mellitus

OBJECTIVE

To study perceived occurrence and magnitude of fear and other disturbances of severe hypoglycaemia in children and adolescents with type 1 diabetes mellitus (DM) receiving intensive treatment with active education and psychosocial support.

PATIENTS AND METHODS

Out of a geographic population of 112 patients <19 years of age and their families, with a DM duration >1 year, HbA1c mean+/-SD 6.7+/-0.9 (method 1.15% below DCCT level), 74 responded to a questionnaire. Visual analogue scales, 5-graded Likert scales and open questions were used.

RESULTS

Global quality of life was high, but lower among patients with severe hypoglycaemia within the last year (p = 0.0114). Worse perceived health was correlated to higher HbA1c year mean (r = 0.32, p = 0.0227). Patients and parents regard severe hypoglycaemia more as a problem (p <0.0001) and the risk of it more disturbing than mild hypoglycaemia (p <0.0001), insulin injections (p <0.0001) or blood glucose determinations (p <0.0001). The disturbance is higher during exercise, disco/party and in travel situations. Severe hypoglycaemia with unconsciousness causes more fear than severe hypoglycaemia needing assistance but without unconsciousness (p = 0.0001) or the potential late complications of DM (p = 0.0014). Severe hypoglycaemia needing assistance but without unconsciousness causes more fear than mild hypoglycaemia (p = 0.0001) and diabetic ketoacidosis (p <0.0001) but less than the potential late complications of DM (p = 0.0034).

CONCLUSIONS

Severe hypoglycaemia frequently causes fear and various disturbances in spite of active education and psychosocial support. There is a potential for increased quality of life from interventions targeted at the prevention of severe hypoglycaemia. Further research and improved strategies for the prevention of severe hypoglycaemia are needed.

Exercise-induced and other daytime hypoglycemic events in patients with diabetes: prevention and treatment

Daytime hypoglycemia, like its nocturnal counterpart, is a practical barrier to achieving optimal glycemic control in type 1 diabetes. Daytime hypoglycemia also causes serious social disruptions for people with diabetes because it interferes with daily activities such as working, attending school, or driving. Hypoglycemia during the day may result from missed or delayed meals, or from insulin replacement regimens that do not account for lifestyle patterns, such as glucose utilization due to exercise. Regardless of the cause of hypoglycemia, the severity may be exacerbated when associated with deficient counter-regulatory mechanisms. To lessen the likelihood of daytime hypoglycemia, a three-part approach is recommended: (1) patient education about the relationship between carbohydrate intake and energy expenditure; (2) day-to-day adjustments of meals or snacks and insulin replacements, as needed; and (3) updated insulin replacement regimens, using strategies that more accurately mimic physiological secretory patterns.

Continuous subcutaneous insulin infusion in patients with diabetes mellitus

During the last quarter of a century continuous subcutaneous insulin infusion (CSII) with external portable insulin pumps has been increasingly used in selected type 1 diabetic subjects and also in some patients with type 2 diabetes mellitus. The treatment of diabetes mellitus with insulin pumps has become more and more popular and accepted by diabetic patients as well as by medical professionals worldwide. Published trials have shown that, in most patients, mean blood glucose concentration and glycated hemoglobin (HbA1c) percentages are either slightly lower or similar on CSII versus an optimized therapy with multiple daily insulin injections. Hypoglycemic episodes seem to be less frequent and ketoacidoses occur at a comparable rate to that during intensive injection therapy. Moreover, nocturnal glycemic control can be improved with insulin pumps, and automatic basal rate changes help to minimize a prebreakfast blood glucose increase (often called 'the dawn phenomenon'). For many patients, CSII provides greater flexibility in timing of meals with the result of better quality of life and higher treatment satisfaction. However, despite these promising data, and although many patients with diabetes mellitus with well-defined clinical problems are likely to benefit substantially from CSII, either in respect to glycemic control, acute complications or quality of life and treatment satisfaction, we are still far away from reaching'dream diabetes management', the fully automatic closed-loop system. Presently, the most difficult problem concerns not the design of an 'optimal' insulin pump, but rather the development of a system which is able to provide continuous and reliable blood glucose monitoring. Hence, because this problem has not been solved with maximum satisfaction, the development of a feedback-controlled 'artificial pancreas' is one of the main goals in diabetes management in the new millennium.

Serum ACE predicts severe hypoglycemia in children and adolescents with type 1 diabetes

OBJECTIVE

To investigate whether risk of severe hypoglycemia is related to serum (S) ACE level during intensive treatment in type 1 diabetic children.

RESEARCH DESIGN AND METHODS

A cohort of 86 intensively treated type 1 diabetic patients was studied during 1999-2000. In 1999, the age range was 7-19 years (median 12.8), diabetes duration was 1.2-14.7 years (5.3), insulin dose was 0.4-1.7 units x kg(-1) x 24 h(-1) (1.0), and the HbA(1c) year mean was 4.7-10.2% (6.8). HbA(1c), insulin doses, and events of severe hypoglycemia (needing assistance from another person) were prospectively registered at regular visits, scheduled quarterly. S-ACE was determined once.

RESULTS

Severe hypoglycemia was correlated to S-ACE (r = 0.22, 95% CI 0.01-0.41, P = 0.0093). The square root of severe hypoglycemia was correlated to S-ACE (r = 0.27, 95% CI 0.06-0.45, P = 0.0093). Patients with S-ACE at the median level or above (n = 44) reported a mean of 3.0 yearly events of severe hypoglycemia compared with 0.5 events in patients with S-ACE lower than the median (n = 42) (P = 0.0079). Of the patients with an S-ACE at the median level or above, 27 (61%) reported severe hypoglycemia, compared with 17 (40%) patients with an S-ACE lower than the median (P = 0.0527). Insulin dose, HbA(1c), age, onset age, duration, C-peptide, and sex did not differ between these two groups. S-ACE was negatively correlated with age (r = -0.27, 95% CI -0.46 to 0.07, P = 0.0265) but not with HbA(1c), duration, or blood pressure.

CONCLUSIONS

The elevated rate of severe hypoglycemia among patients with higher S-ACE suggests, among other factors, that a genetic determinant for severe hypoglycemia exists. Further evaluation is needed before the clinical usefulness of this test can be elucidated.

Screening for people with diabetes mellitus for poor blood glucose control in an ophthalmological laser clinic

PURPOSE

The study was performed to test the effect of a structured intervention in diabetic patients with poor glycaemic control in an ophthalmological department.

PATIENTS AND METHODS

All the patients attending the ophthalmological out-patient department with the need for laser therapy due to diabetic retinopathy were investigated from January to March 1998 (Type 1: n=20, Type 2: n=144). If an HbA(1c)-level higher than 9.0% was found the patient was informed within 1 week and a standardised letter was sent to the primary care physician and the local ophthalmologist. Over the first 3 months of 1999 the effect was evaluated.

RESULTS

HbA(1c) values higher than 9.0% were found in eight/20 of the patients (40%) with Type 1 diabetes and in 61/144 of the patients (54%) with Type 2 diabetes. In 55% this new information in the context of the need for laser therapy resulted in the acceptance of a structured intervention by the patient. This led to an improvement of the HbA(1c) in the people with Type 1 diabetes.

CONCLUSION

Patients with poor blood glucose control can be identified in an ophthalmological department. The need for laser therapy can be used to motivate the patients for a significant improvement of the quality of blood glucose control.

Therapeutic plasma exchange and cyclosporine in the treatment of systemic lupus erythematosus

Despite treatment with intensive immunosuppressive drug regimens, often the prognosis of patients suffering from systemic lupus erythematosus (SLE) is poor. Side effects such as infections and malignant tumors often occur. In the present trial, 21 patients (4 male and 17 female, aged 37.9 +/- 12.8 years) suffering from SLE for 9.4 +/- 2.6 years, were treated for 2.3 +/- 1.8 years with drug regimens of corticosteroids, azathioprine and/or cyclophosphamide. Then, over a period of up to 8 years, in addition to conventional therapies, especially in active stages of the disease with extremely high concentrations of anti-DNA-, antinuclear antibodies and circulating immunocomplexes, therapeutic plasma exchange (TPE) sessions were carried out depending on symptomatology. In addition patients received 2.5 +/- 0.6 mg cyclosporine/kg body weight/day. Compared to previous treatment modalities, clinical symptoms improved more quickly and more effectively (p = 0.046). After 5 to 48 (17.5 +/- 13.8) months, cyclosporine was established as a monotherapy for 8 of 21 patients. In the other cases, corticosteroids, azathioprine and cyclophosphamide were reduced by 40 to 100%. No severe side effects were seen. In acute stages of SLE and in forms with persistently high antibody levels, the addition of TPE sessions and cyclosporine as the basic immunosuppressive drug is usually very effective with regard to improving clinical symptomatology.

Prevalence of sexual disorders in a selection-free diabetic population (JEVIN)

There is an extensive literature on sexual disorders among diabetic patients, but a shortage of studies on their prevalence in selection-free populations. In the present trial (JEVIN), 90% of all insulin-treated diabetic patients (IDDM/NIDDM, n = 127/117) aged 16-60 years and living in the city of Jena (100247 inhabitants) were studied. Each subject underwent a structured interview followed by a clinical and laboratory examination. The prevalence of sexual disorders was 32% in IDDM and 46% in NIDDM male patients. Patients with sexual disorders were older (IDDM 47.5 +/- 9.8 vs. 37.7 +/- 11.6, P = 0.0004; NIDDM 53.4 +/- 4.3 vs. 49.5 +/- 8.2 years, P = 0.04) and had longer diabetes duration (IDDM 23.1 +/- 13.8 vs. 13.5 +/- 11.1, P = 0.001; NIDDM 12.4 +/- 7.5 vs. 8.4 +/- 5.8 years, P = 0.03) than patients without sexual disorders. There were no significant differences (P < 0.05) between the groups as regards HbA1c, body-mass index and insulin dose/kg body weight. The prevalence of diabetes long-term complications in men with versus men without sexual disorders (IDDM/NIDDM): retinopathy, 65/53% vs. 50/18% (P = 0.34/0.03); neuropathy, 58/48% vs. 9/34% (P = 0.001/0.47); nephropathy, 65/50% vs. 12/36% (P = 0.001/0.45). In addition, all the patients completed standardized questionnaires according to Bradley et al. and Lewis et al. to assess quality of life and treatment satisfaction, and one question concerning sexual disorders. The quality of life of IDDM patients with sexual disorders was lower than that of patients without sexual disorders (42.2 +/- 11.4 vs. 54.2 +/- 8.5, P = 0.0005), but there were no differences (P < 0.05) in NIDDM patients. In women, the prevalence of sexual disorders was 18/42% in IDDM and NIDDM. Comparing these data with the literature and with reports from healthy controls, mostly there is clearly an underestimation of the prevalence of sexual disorders in diabetic populations. Physicians must make more efforts to detect and treat sexual disorders, which may result in an improvement of patients' quality of life.

[Quality of care of patients with diabetes mellitus living in a rural area of Germany]

PATIENTS AND METHOD

In a population based study the quality of diabetes care of insulin-treated diabetic patients aged 16 to 60 years and living in a rural area was studied. The parameters of metabolic control as well as the incidence of acute complications (severe hypoglycemia with the need of glucose or glucagon injection, ketoacidosis with hospital admission) were assessed by examination and with a standardized questionnaire in 81% of the target population (type-1/type-2-diabetic patients: n = 25/33). Also, in all the patients diabetic long-term complications (retinopathy, nephropathy, amputations of the lower extremities) were examined. 76% of the patients with type-1-diabetes and 91% of the patients with type-2-diabetes mellitus completed standardized questionnaires to assess quality of life and treatment satisfaction.

RESULTS

In type-1-diabetic patients HbA1c was 9.38 +/- 1.6%. In type-2-diabetic patients it was 9.53 +/- 1.91%. None of the patients examined was regularly treated by a specialized physician/diabetologist. The goal of metabolic control, a HbA1c value below 7.2%, was reached only by 4% of the patients with type-1-and 12% of the patients with type-2-diabetes mellitus. In multivariate analysis the most important factor associated with HbA1c was in type-1-diabetic patients female sex (R-squared = 0.17, c = 0.38, p = 0.059); in patients with type-2-diabetes mellitus it was the number of insulin injections per day (R-squared = 0.37, c = 0.19, p = 0.0096). All other factors investigated in the model (diabetes duration, insulin dosage/kg body weight, frequency of blood- or urine-glucose self-monitoring/week, body mass index, educational level) showed no significant associations. Quality of life and treatment satisfaction of the patients were good and comparable to other trials.

CONCLUSION

Out of other studies there is evidence for better metabolic control in patients regularly treated by specialized physicians/diabetologists and in patients who participated in structured treatment and teaching programs. These features must be the main goals of treatment for all patients with diabetes mellitus.

The JEVIN trial: a population-based survey on the quality of diabetes care in Germany: 1994/1995 compared to 1989/1990

Since 1990 in most Eastern European countries health care systems have been decentralized or are undergoing the processes of decentralization. Increasingly, diabetic patients are no longer treated by diabetologists but by non-specialized physicians. During the same period structured treatment and teaching programmes have been introduced and health care is increasingly influenced by the St. Vincent declaration. To show the effect of these changes on the quality of diabetes care 90% (n = 244) of all insulin-treated diabetic patients aged 16 to 60 years and living in the city of Jena (100247 inhabitants) were studied in 1994/1995. The results were compared with the baseline examination of 1989/1990 (n = 190). HbA1c (HbA1c/mean normal) in IDDM patients under specialized care was similar in 1994/1995 (1.54 +/- 0.27, n = 47) to 1989/1990 (1.52 +/- 0.31, n = 131, p = 0.0018), but higher under non-specialized care (1.71 +/- 0.38, n = 80, p = 0.0087). In the total group of NIDDM patients there was no significant change in HbA1c (1994/1995: 1.75 +/- 0.4, n = 117, vs 1989/1990: 1.78 +/- 0.4, n = 59, p = 0.67), but with a tendency to higher HbA1c under non-specialized (1.81 +/- 0.4, n = 79) compared to specialized care (1.66 +/- 0.39, n = 38, p = 0.06). Incidence of severe hypoglycaemia (IDDM 0.13; NIDDM 0.04), ketoacidosis (0.02; 0.01) and the prevalence of nephropathy (21%; 35%) and neuropathy (24%; 38%) remained unchanged in comparison to 1989/1990, whereas there was an increase in the prevalence of diabetic retinopathy. Specialized care is mandatory for patients with IDDM.