The effect of guided self-determination on self-management in persons with type 1 diabetes mellitus and HbA1c ≥64 mmol/mol: a group-based randomised controlled trial

OBJECTIVES

To determine whether the impact of guided self-determination (GSD) applied in group training (GSD-GT) in people with chronically elevated HbA_1c and type 1 diabetes mellitus (DM) was superior to 'care as usual' in improving HbA_1c and psychological functioning.

SETTING

An outpatient clinic at a university hospital in Western Norway.

PARTICIPANTS

A total of 178 adults (all Caucasian) aged 18-55 (mean age 36.7±10.7, 62% women) with type 1 DM for at least 1 year and HbA_1c ≥64 mmol/mol (8.0%) were randomly assigned to participate in either GSD-GT or a control group (CG). Exclusion criteria were severe comorbidity, major psychiatric disorder, cognitive deficiency/language barriers and pregnancy.

INTERVENTION

Intervention group met seven times for 2 hours over 14 weeks to promote patient autonomy and intrinsic motivation using reflection sheets and advanced professional communication in accordance with the GSD methodology.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was HbA_1c and secondary outcomes (all outcomes 9 months post intervention) were self-monitored blood glucose frequency, self-reported diabetes competence, autonomy support by healthcare providers (Health Care Climate Questionnaire), autonomous versus controlled diabetes motivation (Treatment Self-Regulation Questionnaire), diabetes distress (Problem Areas In Diabetes Scale (PAID) and Diabetes Distress Scale (DDS)), self-esteem (Rosenberg Self-Esteem Scale) and psychological well-being (World Health Organization five-item Well-Being Index scale).

RESULTS

Among participants allocated to the GSD-GT (=90) 48 completed the study, whereas 83 completed in the CG (n=88). With 95% CIs GSD-GT did not have effect on HbA_1c (B -0.18, CI (-0.48, 0.12), p=0.234). GSD-GT improved autonomy-motivated behaviour (B 0.51, CI (0.25, 0.77), p<0.001), diabetes distress (PAID, B -6.96, CI (-11.40, -2.52), p=0.002), total DDS (B -5.15, CI (-9.34, -0.96), p=0.016), DDS emotional burden (B -7.19, CI (-13.20, -1.19), p=0.019) and self-esteem (B 1.43, CI (0.34, 2.52), p=0.011).

CONCLUSIONS

Results from this behavioural intervention must be interpreted cautiously because of recruitment and attrition problems. Medical outcomes did not improve. Psychological outcomes improved, especially reduced diabetes distress.

TRIAL REGISTRATION NUMBER

Clinical Trials.gov NCT 01317459.

[Gastroparesis - causes, diagnosis and treatment]

BACKGROUND Gastroparesis is a motility disorder of the stomach. The symptoms are non-specific: nausea and vomiting are most common. Stomach pains, early satiety, postprandial fullness and bloating are also frequent symptoms. Current diagnostic criteria require delayed gastric emptying in the absence of any detectable mechanical obstruction. In this review article we elucidate the causes, assessment and treatment options.MATERIAL AND METHOD Structured article search in Embase and PubMed.RESULTS A number of conditions can lead to gastroparesis. The most frequent somatic cause is diabetes mellitus. Gastroparesis may also be iatrogenically inflicted by means of surgery or drugs. It may be difficult to discriminate between functional dyspepsia and idiopathic gastroparesis. Examination is based on patient history, gastroscopy and measurement of the rate of gastric emptying. Biochemical tests are also relevant for differential diagnosis. The treatment is primarily symptomatic, and consists of dietary measures, fluid therapy, drugs, gastric electrical stimulation, or endoscopic or surgical intervention in the form of insertion of a feeding tube for nutrition and abdominal relief, pyloroplasty or gastrectomy.INTERPRETATION Gastroparesis is a serious motility disorder. The condition may have significant consequences for patients, entailing reduced quality of life, reduced workforce participation and a considerable need for health assistance.

Efficacy of adrenal venous sampling is increased by point of care cortisol analysis

Primary aldosteronism (PA) is a common cause of secondary hypertension and is caused by unilateral or bilateral adrenal disease. Treatment options depend on whether the disease is lateralized or not, which is preferably evaluated with selective adrenal venous sampling (AVS). This procedure is technically challenging, and obtaining representative samples from the adrenal veins can prove difficult. Unsuccessful AVS procedures often require reexamination. Analysis of cortisol during the procedure may enhance the success rate. We invited 21 consecutive patients to participate in a study with intra-procedural point of care cortisol analysis. When this assay showed nonrepresentative sampling, new samples were drawn after redirection of the catheter. The study patients were compared using the 21 previous procedures. The intra-procedural cortisol assay increased the success rate from 10/21 patients in the historical cohort to 17/21 patients in the study group. In four of the 17 successful procedures, repeated samples needed to be drawn. Successful sampling at first attempt improved from the first seven to the last seven study patients. Point of care cortisol analysis during AVS improves success rate and reduces the need for reexaminations, in accordance with previous studies. Successful AVS is crucial when deciding which patients with PA will benefit from surgical treatment.

Acute meningitis and cerebellar dysfunction complicating high-dose cytosine arabinoside therapy

A patient with acute lymphocytic leukemia (ALL) who was treated with high-dose cytosine arabinoside (Ara-C) 3 g/m2 twice daily, developed reversible acute aseptic meningitis and signs of cerebellar dysfunction after a total dose of 24 g Ara-C. To our knowledge this is the first case report of meningitis complicating intravenous high-dose Ara-C therapy.

Islet cell autoantibodies in African patients with Type 1 and Type 2 diabetes in Dar es Salaam Tanzania: a cross sectional study

Background

The aim of the present study was to assess the occurrence of glutamic acid decarboxylase autoantibodies (GADA) and insulinoma antigen 2 autoantibodies (IA2A) among patients of African origin in Dar es Salaam, Tanzania and to compare the occurrence of autoimmune mediated Type 1 diabetes with findings previously reported from the same place and from other African diabetic populations.

Methods

Two hundred and forty five patients from the diabetic clinic at Muhimbili Hospital were recruited for a cross sectional study. Patients were clinically classified into groups with Type 1 (T1D) and Type 2 diabetes (T2D); there were 94 patients with T1D and 151 with T2D. Autoantibodies for GAD and IA2 were measured with an assay based on radioligand binding. Fasting and random blood glucose, HbA1c, and C-peptide levels were also determined.

Results

Of the patients with T1D, 28 (29.8%) were GADA positive and 20 (21.3%) were IA2A positive. The overall occurrence of any autoantibody was 42.6%. The GAD and IA2 autoantibodies were detected more frequently among patients with T1D than among patients with T2D (P < 0.001). A higher autoantibody prevalence was observed with combined GADA and IA2A measurements compared to individual autoantibody measurements; 40 (42.6%) patients with T1D versus 11 (7.3%) with T2D had at least one positive autoantibody titer. There was no correlation between duration of disease and detection of autoantibodies in patients with T1D. There was a strong association with family history of diabetes among the autoantibody positive versus autoantibody negative patients with T1D (p < 0.01).

Conclusion

The prevalence of GAD and IA2 autoantibodies among African patients with T1D in Dar es Salaam was the same as that reported previously for South Africa and Ethiopia. It was much higher than the prevalence of islet cell autoantibodies (ICA) reported from the same clinic about 15 years ago. For unknown reasons the prevalence of pancreatic related autoantibodies in this African population is lower than the prevalence found among Caucasian populations.

Microalbuminuria among Type 1 and Type 2 diabetic patients of African origin in Dar Es Salaam, Tanzania

Background

The prevalences and risk factors of microalbuminuria are not full described among black African diabetic patients. This study aimed at determining the prevalence of microalbuminuria among African diabetes patients in Dar es Salaam, Tanzania, and relate to socio-demographic features as well as clinical parameters.

Methods

Cross sectional study on 91 Type 1 and 153 Type 2 diabetic patients. Two overnight urine samples per patient were analysed. Albumin concentration was measured by an automated immunoturbidity assay. Average albumin excretion rate (AER) was used and were categorised as normalbuminuria (AER < 20 ug/min), microalbuminuria (AER 20–200 ug/min), and macroalbuminuria (AER > 200 ug/min). Information obtained also included age, diabetes duration, sex, body mass index, blood pressure, serum total cholesterol, high-density and low-density lipoprotein cholesterol, triglycerides, serum creatinine, and glycated hemoglobin A_1c.

Results

Overall prevalence of microalbuminuria was 10.7% and macroalbuminuria 4.9%. In Type 1 patients microalbuminuria was 12% and macroalbuminuria 1%. Among Type 2 patients, 9.8% had microalbuminuria, and 7.2% had macroalbuminuria. Type 2 patients with abnormal albumin excretion rate had significantly longer diabetes duration 7.5 (0.2–24 yrs) than those with normal albumin excretion rate 3 (0–25 yrs), p < 0.001. Systolic and diastolic blood pressure among Type 2 patients with abnormal albumin excretion rate were significantly higher than in those with normal albumin excretion rate, (p < 0.001).

No significant differences in body mass index, glycaemic control, and cholesterol levels was found among patients with normal compared with those with elevated albumin excretion rate either in Type 1 or Type 2 patients.

A stepwise multiple linear regression analysis among Type 2 patients, revealed AER (natural log AER) as the dependent variable to be predicted by [odds ratio (95% confidence interval)] diabetes duration 0.090 (0.049, 0.131), p < 0.0001, systolic blood pressure 0.012 (0.003–0.021), p < 0.010 and serum creatinine 0.021 (0.012, 0.030).

Conclusion

The prevalence of micro and macroalbuminuria is higher among African Type 1 patients with relatively short diabetes duration compared with prevalences among Caucasians. In Type 2 patients, the prevalence is in accordance with findings in Caucasians. The present study detects, however, a much lower prevalence than previously demonstrated in studies from sub-Saharan Africa. Abnormal AER was significantly related to diabetes duration and systolic blood pressure.

[Unexpected and unexplained deaths among young patients with diabetes mellitus]

BACKGROUND

We studied the occurrence of unexpected and unexplained deaths in 0-39 year-old subjects with diabetes.

MATERIAL AND METHODS

Statistics Norway provided information about persons who had died in the 1991-1995 period with a diagnosis of diabetes on their death certificate. Relevant information was obtained from autopsy reports and patients' physicians.

RESULTS

117 deaths from all causes were ascertained. Four patients (3.4%) fulfilled the criteria of "dead in bed" syndrome; three males and one female, age range 21-36 years, duration of diabetes 5-23 years. Severe episodes of hypoglycaemia were reported in three cases. Autopsy, performed in three cases, was negative.

INTERPRETATION

Dead in bed syndrome in young persons with diabetes is a rare, but dramatic condition. The relationship to nocturnal hypoglycaemia remains hypothetical.

[Fooled by the diurnal rhythm]

BACKGROUND

Under ordinary circumstances, the daily secretion of cortisol displays a characteristic diurnal variation with a peak in the morning and a trough at night. It is important to understand the variation in cortisol secretion when analysing results of cortisol tests.

PATIENT AND METHOD

We present a patient in whom work-up for acute headache revealed a pathologically low morning serum cortisol level. This led to further evaluation of adrenocortical function with an adrenocorticotropic hormone (ACTH) stimulation test and cortisol day profiles in serum and saliva.

RESULTS AND INTERPRETATION

The analyses showed normal adrenocortical function and diurnal variation with normal amplitudes. The morning rise in cortisol secretion was, however, delayed by 7-8 hours due to a delayed sleep phase. This case illustrates the importance of the diurnal rhythm in the assessment of pituitary-adrenal function. There should be clinical suspicion of a disorder before a test is requested.

Dead-in-bed syndrome in young diabetic patients

The so-called dead-in-bed syndrome refers to sudden death in young diabetic patients without any history of long-term complications. Autopsy is typically negative. The present report summarizes frequency data on this condition from studies in the U.K. and the Scandinavian countries. It appears that such deaths occur in 6% of all deaths in diabetic patients below age 40 years. The frequency may also be expressed as 2-6 events per 10,000 [corrected] patient-years. The causes are by definition unknown, but a plausible theory is a death in hypoglycemia, since a history of nocturnal hypoglycemia is noted in most cases. While waiting for the clarification of the underlying pathophysiology, one should attempt to identify patients who are at particular risk of hypoglycemia and advocate caution in efforts to normalize blood glucose and HbAlc in these cases.

[Scintigraphic localization of ectopic parathyroid tissue]

Ectopic parathyroid adenomas and hyperplastic glands are difficult to locate during surgical exploration. Failure to find and remove them is the most usual cause of surgical failure in the treatment of hyperparathyroidism. Earlier methods of preoperative localization of pathological parathyroid tissue had low sensitivity and were not generally recommended. Recent advances in parathyroid scintigraphy have improved this technique; the sensitivity is now as high as 95% for parathyroid adenomas. In the present study, ectopic parathyroid adenomas and hyperplasia were correctly localized by scintigraphy and were verified surgically in seven patients. Six of the patients had previously undergone ten unsuccessful operations altogether. Preoperative parathyroid scintigraphy might have saved these failed surgical explorations. In a pregnant woman, a mediastinal parathyroid adenoma was correctly localized by preoperative parathyroid scintigraphy. This patient was successfully operated by a sternotomy, and she was the only one of five patients with a mediastinal parathyroid adenoma who escaped unnecessary neck exploration. Preoperative parathyroid scintigraphy may reduce the number of surgical failures in hyperparathyroidism and shorten the operation time by less extensive exploration and thus fewer complications.

[Diabetes mellitus in pregnancy]

The authors highlight some aspects of diabetes mellitus that complicate pregnancy. Several complications, e.g. hypoglycaemia, hyperglycaemia and macrosomia are described briefly. Macrosomia can be diagnosed by ultrasound examination, which should be performed every other week from the 24th week of gestation. Accelerated abdominal circumference (> or = 1.2 cm/week) between 32 and 39 weeks and excess thickness of soft tissue over the proximal humerus of the foetus after the 32nd week (> 13 mm at term) may imply development of macrosomia. The elevated risk related to adiposity and poor metabolic control can be avoided by intensive treatment. Intensive metabolic treatment can also reduce the frequency of preeclampsia and polyhydramnion. Ketoacidosis and intrauterine foetal death may be consequences of poor diabetic control. The authors discuss infectious problems, some aspects of treatment, e.g. risk of preterm delivery, dietary treatment and insulin, indications for delivery and various neonatal problems.

[Pregnancy in diabetes]

The authors review various aspects of gestational diabetes, including definition, screening, diagnostic procedures, complications (hypertension, macrosomia), clinical evaluation (ultrasound, non-stress test), treatment (diet, insulin), indications for delivery and neonatal aspects (hypoglycaemia, hypocalcaemia). Complications can be reduced by intensive dietary treatment and insulin. If the gestational diabetes is regulated well the woman can wait for spontaneous birth at term. In the case of pregnant women with less than optimal regulated diabetes, however, or with complications such as hypertension, macrosomia, previous stillbirth, labour can be induced preterm by local administration of prostaglandin or infusion of oxytocin. Physical training and weight reduction should be instituted to avoid later development of type II diabetes mellitus. There is still some uncertainty about different aspects of gestational diabetes.

Dead in bed syndrome in young diabetic patients in Norway

The incidence of unexplained deaths ('dead in bed syndrome') in Norwegian diabetic patients under the age of 40 was investigated during the period 1981-1990. During this 10-year period there were 240 deaths of all causes in the age group 0-39 years. Sixteen of these cases fulfilled the following criteria of the 'dead in bed syndrome': (1) patient found dead in an undisturbed bed; (2) patient observed to be in good health condition the day before; (3) no clinical evidence of late complications (except background retinopathy in two cases). Of the 16 cases ascertained, 10 were males and 6 females. The age range was 7-35 years, and the duration of diabetes varied between a few months and 26 years. Autopsy, performed in 13 cases, did not reveal any cause of death. Nine patients had been using insulin regimens with multiple daily doses. Twelve patients were reported as having had frequent episodes of hypoglycaemia, with nocturnal episodes in 10 cases. There was apparently an increasing incidence of unexplained deaths during the study period, with 12 of 16 cases occurring in the years 1988 to 1990.

Osteopenia caused by heparin treatment in pregnancy

A case is reported of severe osteopenia caused by heparin treatment of thrombosis in the eleventh week of pregnancy followed by heparin prophylaxis (5000 IU three times daily) during pregnancy and lactation. The mother complained of back pain during the last two weeks of pregnancy. Six weeks post partum, generalized osteopenia in the skeleton was diagnosed and a compression fracture of the body of the sixth thoracic vertebra. During pregnancy the mother had relatively low serum concentrations of 1,25(OH)2D, the active metabolite of vitamin D, and six weeks after delivery the serum concentration had fallen to about 50% of the lowest reference level. Eight and fourteen weeks after delivery, when heparin treatment had been discontinued, the serum concentrations of 1,25(OH)2D were within the reference range for non-pregnant adults.

Calcium homeostasis in pregnancy and lactation

This paper discusses different aspects of calcium homeostasis in pregnancy: the calcium demands of the mother, regulation mechanisms and the risk factors for demineralization. Special care should be paid to patients lying in bed for long periods and patients given heparin prophylaxis. One to two grams of calcium and 400 IU of vitamin D daily should be given orally to patients who are being treated for deep vein thrombosis. In addition, bone density should be checked to detect osteoporosis. The period of heparin prophylaxis must be as short as possible and bed rest must not be unnecessarily prolonged.

[Rapid calcium infusion in the diagnosis of hypoglycemia]

The diagnosis of beta cell tumours of the pancreas is a clinical problem. It is also difficult to exclude this diagnosis in patients who are suspected of suffering from recurrent hypoglycemia, but do not have beta cell tumours. The most widely used diagnostic procedure has been suppression of endogenous insulin production with prolonged fasting up to 72 hours. This procedure is troublesome to the patient, time-consuming and expensive, and demands the complete cooperation of the patient. Therefore several diagnostic tests have been developed, but none has been generally accepted. A newly described test involving calcium infusion, 2 mg/kg in one minute, seems to give a diagnostic response in most patients with insulinomas, few false positive results and few side effects. We have used this test for four years and found it safe and easy to perform. It has given diagnostic response in three patients with insulinomas and no false positive results in 27 other patients.

Aortic stiffness in insulin-dependent diabetics: an echocardiographic study

To assess the aortic stiffness (AS) in young (15-35 year old) insulin-dependent diabetics without manifestations of atherosclerotic disease or hypertension, M-mode echocardiography was used to measure relative changes in aortic diameter expressed as Aortic strain = Diameter change/Diastolic diameter-100% Aortic stiffness can be calculated from the formula AS = Pulse pressure/Aortic strain. Fifty-seven diabetics were investigated, 31 men (aged 23.6 +/- 5.6 years, mean +/- SD) and 26 women (aged 25.7 +/- 6.4 years). There were 26 healthy controls with similar blood pressure, 14 men (aged 25.0 +/- 5.5 years) and 12 women (aged 24.6 +/- 7.1). The AS in diabetic men was 14 +/- 8.0 (mean +/- SD) compared to 3.6 +/- 0.7 in controls (p less than 0.001). In diabetic women the AS was 5.8 +/- 3.1 compared to 4.3 +/- 1.3 in controls (p less than 0.05). Diabetic men also had much stiffer aortas than diabetic women (p less than 0.001). There was a linear correlation between AS and duration of diabetes in men (R = 0.70; (p less than 0.001). For females no such correlation was found, the AS frequently being within the range of the controls in spite of long duration of the disease. In males there was a significant correlation between AS and retinopathy (R = 0.49; p less than 0.01) and an inverse correlation with HDL-cholesterol/total cholesterol ratio (R = 0.51; p less than 0.01). In diabetic females AS was significantly greater in smokers (7.0 +/- 3.7) than in non-smokers (4.2 +/- 2.2; p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)