Showing papers on "Diabetes management published in 1996"

Evaluation of a Pharmaceutical Care Model on Diabetes Management

Abstract: OBJECTIVE:To assess the effectiveness of a pharmaceutical care model on the management of non-insulin-dependent diabetes mellitus (NIDDM) in urban African-American patients.DESIGN:Eligible patients were randomized to either a pharmacist intervention or control group and followed over a 4-month period. Patients in the intervention group received diabetes education, medication counseling, instructions on dietary regulation, exercise, and home blood glucose monitoring, and evaluation and adjustment of their hypoglycemic regimen. Patients in the control group continued to receive standard medical care provided by their physicians.SETTING:A university-affiliated internal medicine outpatient clinic.PARTICIPANTS:The study population consisted of urban African-American patients with NIDDM currently attending the clinic.MAIN OUTCOME MEASURES:Primary outcome measures included fasting plasma glucose and glycated hemoglobin concentrations. Secondary outcome endpoints included blood pressure, serum creatinine, creatin...

Recombinant Human Insulin-Like Growth Factor I Increases Insulin Sensitivity and Improves Glycemic Control in Type II Diabetes

Abstract: Insulin resistance is a major factor in the pathophysiology of type II diabetes and a major impediment to successful therapy. The identification of treatments that specifically target insulin resistance could improve diabetes management significantly. Since IGFs exert insulin-like actions and increase insulin sensitivity when administered at supraphysiological doses, we determined the effect of 6 weeks of recombinant human IGF-I (rhIGF-I) administration on insulin resistance and glycemic control in obese insulin-resistant patients with type II diabetes. A total of 12 patients with type II diabetes were recruited for the study. Subcutaneous administration of rhIGF-I (100 micrograms/kg b.i.d.) significantly lowered blood glucose. Fructosamine declined from 369 to 299 mumol/l by 3 weeks of administration and then declined further to 271 at the end of 5 weeks. Glycosylated hemoglobin, which was 10.4% pretreatment, declined to 8.1% at the end of therapy. Mean 24-h blood glucose during a modal day was 14.71 +/- 4.5 mmol/l pretreatment and declined to 9.1 +/- 3.21 mmol/l by the end of treatment. These improvements in glycemia were associated with a decrease in serum insulin levels. Mean insulin concentrations declined from 108.0 to 57.0 pmol/l during the modal day measurements and from 97.2 to 72.0 pmol/l during the mixed-meal tolerance test. Changes in glycemia were accompanied by a marked increase in insulin sensitivity. The insulin sensitivity index (SI) calculated from a frequently sampled intravenous glucose tolerance test (FSIVGTT) after the method of Bergman et al. (Bergman RN, Finegold DT, Ader M: Assessment of insulin sensitivity in vivo. Endocr Rev 6:45-86, 1985) increased 3.4-fold. Furthermore, the improvement in glycemic control was accompanied by a change in body composition with a 2.1% loss in body fat as calculated by dual energy x-ray absorptiometry without change in total body weight. Significant side effects were present in some subjects, although nine subjects were able to complete at least 4.5 weeks of the protocol and six subjects completed the entire 6 weeks. Supraphysiological IGF-I concentrations were maintained throughout the study, increasing from 206 micrograms/l in the control period to 849 micrograms/l at the end of 6 weeks of rhIGF-I treatment. The increase in IGF-I levels was accompanied by a significant increase in IGF binding protein-2 levels, a slight reduction in IGF binding protein-3 levels, and an increase in levels of IGF binding protein-1. In summary, IGF-I significantly lowered blood glucose as reflected by short-term and long-term indexes of glycemic control and increased insulin sensitivity. It remains to be determined whether a dosage can be administered that avoids significant side effects and still achieves reasonable glycemic control.

Deviation from Developmentally Appropriate Self-Care Autonomy: Association with diabetes outcomes

Abstract: OBJECTIVE Treatment of IDDM in youth emphasized balancing children9s self-care autonomy with their psychological maturity. However, few data exist to guide clinicians or parents, and little is known about correlates of deviations from this ideal. RESEARCH DESIGN AND METHODS In this cross-sectional study, IDDM self-care autonomy of 100 youth was assessed using two well-validated measures. Three measures of psychological maturity (cognitive function, social-cognitive development, and academic achievement) were also collected for each child. Composite indexes of self-care autonomy and of psychological maturity were formed, and the ratio of the self-care autonomy index to the psychological maturity index quantified each child9s deviation from developmentally appropriate IDDM self-care autonomy. Based on these scores, participants were categorized as exhibiting constrained (lower tertile), appropriate (middle tertile), or excessive (higher tertile) self-care autonomy. Between-group differences in treatment adherence, diabetes knowledge, glycemic control, and hospitalization rates were explored. RESULTS Analysis of covariance controlling for age revealed that the excessive self-care autonomy group demonstrated less favorable treatment adherence, diabetes knowledge, hospitalization rates, and, marginally, glycemic control. Excessive self-care autonomy increased with age and was less common among intact two-parent families but was unrelated to other demographic factors. CONCLUSIONS The findings indicate caution about encouragement of maximal self-care autonomy among youth with IDDM and suggest that families who succeed in maintaining parental involvement in diabetes management may have better outcomes.

Quality of Outpatient Care Provided to Diabetic Patients: A health maintenance organization experience

Abstract: OBJECTIVE To document the quality of diabetes care provided to patients in a large health maintenance organization (HMO) from 1 January 1993 to 1 January 1994 and compare it to the standards of the American Diabetes Association (ADA). RESEARCH DESIGN AND METHODS To meet a Health Plan and Employer Data Information Set (HEDIS) requirement, a major HMO in California identified 14,539 members with diabetes and randomly selected 384 individuals for review. Charts were available on 353 of these patients, and after obtaining the information for the HEDIS review, additional information was extracted from the charts by an outside chart reviewer. This data set was used for an analysis of the quality of diabetic care provided by the participating medical groups to these HMO members during 1 year. Documentation of follow-up and measures of glycemic and lipid control was examined both for absolute values and for the frequency of measurement over the year. These results were compared to the ADA standards of care. RESULTS Although patients averaged 4.5 visits to their primary care physicians (PCPs) over the year, 21% had one or fewer visits per year. Glycated hemoglobin levels were not documented in 56% of patients (ADA recommends two to four measurements per year), and of those with a glycated hemoglobin level measured. 39% had at least one value ≥ 10%. Fasting plasma glucose concentrations were not documented in 65% of patients (four to six per year recommended). Foot exams (which should be performed at each regular visit) were not documented for 94% of patients. Urine protein measurements were not performed in 52% of patients. Additionally, many patients had elevated and untreated lipid abnormalities. CONCLUSIONS In spite of the frequency of PCP visits during the year for many of these patients, diabetes management was inadequate. This lack of adequate preventive care will lead to an increased risk of the development of the acute and chronic complications of diabetes, creating an even greater future burden on the health care system and negative consequences for patients.

Effects of a Brief Office-Based Intervention to Facilitate Diabetes Dietary Self-Management

Abstract: OBJECTIVE There is a pressing need for brief practical interventions that address diabetes management. Using a randomized design, we evaluated a medical office-based intervention focused on behavioral issues relevant to dietary self-management. RESEARCH DESIGN AND METHODS There were 206 adult diabetes patients randomized to usual care or brief intervention, which consisted of touchscreen computer-assisted assessment to provide immediate feedback on key barriers to dietary self-management, and goal setting and problem-solving counseling for patients. Follow-up components to the single session intervention included phone calls and interactive video or videotape instruction as needed. RESULTS Multivariate analyses of covariance revealed that the brief intervention produced greater improvements than usual care on a number of measures of dietary behavior (e.g., fewer calories from saturated fat, fewer high-fat eating habits and behaviors) at the 3-month follow-up. There were also significant differences favoring intervention on changes in serum cholesterol levels and patient satisfaction but not on glycosylated hemoglobin. The intervention effects were relatively robust across a variety of patient characteristics, the two participating physicians, and intervention staff members. CONCLUSIONS If the long-term results are equally positive and generalize to other setting, this intervention could provide a prototype for a feasible cost-effective way to integrate patient views and behavioral management into office-based care for diabetes.

Using Focus Groups to Characterize the Health Beliefs and Practices of Black Women with Non-Insulin-Dependent Diabetes:

Abstract: The purpose of this focus group intervention was to characterize the health beliefs, self care practices, diabetes education needs, weight-loss issues, and facilitators and barriers to diabetes health care in black women with non-insulin-dependent diabetes. Major themes that emerged from the focus group were motivation to prevent complications, unrealistic weight goals set by providers, multiple barriers to diet and exercise, and a dual role of family as supporter and deterrent to diabetes management, especially related to diet. These findings suggest that culturally sensitive and appropriate patient educational programs must be provided for minority groups such as black women who have higher rates of diabetes-related complications.

Medical Care for Patients with Diabetes: Epidemiologic Aspects

Abstract: Objective : To describe the epidemiologic characteristics of physician care and self-care for adults with diabetes in the U.S. population. Design and Subjects : Data are drawn from the 1989 National Health Interview Survey, in which a personal household interview was administered to a representative sample of U.S. adults aged 18 years or older. The response rate was 96% (n = 84 572). All subjects identified as having diabetes previously diagnosed by a physician were asked a series of questions about their diabetes. Response rate for this representative sample of U.S. diabetic patients was 95% (n = 2405). Measurements : Self-reported information was obtained about various aspects of diabetes care, including care by physicians and self-care practices of the diabetic persons. Sociodemographic and clinical factors that may influence diabetes care were also determined. Results : More than 90% of diabetic adults had one physician for the usual care of their diabetes, but 32% made fewer than four visits to this physician each year. Most physician visits by diabetic patients were not made to diabetes specialists, and the visit rate to other health care professionals such as ophthalmologists, podiatrists, and nutritionists was low. About half of insulin-treated diabetic subjects used multiple daily insulin injections ; and 40% of patients with insulin-dependent diabetes mellitus, 26% of those with non-insulin-dependent diabetes mellitus (NIDDM) who were taking insulin, and 5% of those with NIDDM who were not taking insulin monitored their blood glucose level daily. Diabetes patient education classes had been attended by 35% of diabetic adults. Conclusions : These and other data indicate that medical care for diabetic patients and their self-care practices may not be optimal for prevention of diabetes complications. The Diabetes Control and Complications Trial showed that achieving and maintaining near-normal glycemia, with a concomitant 50% to 70% reduction in diabetes complications, may require close monitoring and ongoing support from a health care team, ample financial resources, and advanced patient knowledge and motivation. Providing this level of diabetes management to all diabetic persons may require major changes in the health care system and in patient self-care practices.

Diabetes in urban African Americans. V. Use of discussion groups to identify barriers to dietary therapy among low-income individuals with non-insulin-dependent diabetes mellitus.

Abstract: Dietary therapy remains an integral part of diabetes management. The study objective was to identify potential barriers to dietary adherence among low-income, urban black patients with non-insulin-dependent diabetes. Forty-five patients participated in discussion group interviews that consisted of open-ended questions. Four problem areas were identified: habitual, economic, social, and conceptual. Most patients felt that the recommended meal plans were lacking in taste, and the cost of low-fat and sugar-free items was perceived as a major drawback. Lack of family support and family pressure to use fat-containing food seasoning were frequent problems. Participants had trouble following the food exchange system and analyzing food labels. Feedback suggested that dietary strategies may need to be revised to provide appropriate menus, identify low-cost foods, involve patients' families, and teach patients how to make healthy food choices. The discussion group approach was quick, simple, and could be easily translated to other settings.

The care of older persons with diabetes mellitus: families and primary care physicians.

Abstract: OBJECTIVES: To determine the extent to which family members participate in the day-to-day management of diabetes mellitus in older persons, and in older diabetics' medical encounters, and to identify patient and family member characteristics associated with this participation. DESIGN: A longitudinal observational study, with baseline data being reported herein. SETTING: Three primary care practice settings in Seattle, Washington, Boston, Massachusetts, and Indianapolis, Indiana. PARTICIPANTS: Family members of patients 70 years of age or older participating in the Patient Outcomes Research Team (PORT) Study of type II diabetics. MAIN OUTCOME MEASUREMENTS: The two dependent variables represent, respectively, the extent of family members' assistance with diabetes-related care and participation in older diabetics' medical encounters. RESULTS: The 357 family members enrolled were older (mean age = 66.3 years), were mostly women (76.2%), and were usually the spouses of diabetic patients (71.3%). Between 22% and 50% of family members reported helping with various aspects of diabetes care; 35.6% of family members participated regularly in their diabetic patients' medical encounters. A multiple linear regression model relating family assistance with diabetes-related care to patient and family member characteristics included four variables: patients' physical function, and the family member's relationship to the patient, assistance with basic activities of daily living (ADLs), and understanding of diabetes management issues (all P < .05). A multiple logistic regression model relating family member participation in the medical encounter to patient and family member characteristics also included four variables: patient age and physical function, and family member assistance with instrumental activities of daily living (IADLs) and with diabetes-related care (all P < .05). CONCLUSION: The family members studied frequently assisted older diabetics with diabetes-specific care; more than one-third were regular participants in older diabetics' medical encounters. Family member involvement in the day-to-day management of diabetes and in the medical encounter was more likely when patients were functionally disabled. Health care systems and physicians need to educate their older patients, and involved family members when patients are frail, about diabetes-related care issues and support them in their roles in the management of diabetes as well as other chronic diseases. J Am Geriatr Soc 44:1314–1321, 1996.

UTOPIA: A consultation system for visit-by-visit diabetes management

Abstract: UTOPIA (UTilities for OPtimizing Insulin Adjustment) is a prototype computer system proposed to support home data analysis and therapy recommendations for the individual patient. The paper describes methods of analysis and their incorporation into an overall system design that matches the iterative practices at the physician-patient consultation from visit to visit. Four modules support home data display and comparison with clinical measurements; extraction of blood glucose trends and daily cycles using time series analysis, learning relationships between insulin adjustments and changes in time series patterns via a parametric, linear systems model; and advice generation by solving the linear equation for candidate insulin adjustments. Concepts and methods are placed in context, with a discussion of comparable and related research.

Handbook Of Diabetes Medical Nutrition Therapy

Abstract: UNDERSTANDING DIABETES Pathophysiology Complications of Diabetes Mellitus SETTING AND ACHIEVING NUTRITION GOALS Nutrition-Focused Diabetes Care Nutrition Assessment Diabetes Medications/Delivery Methods Exercise and Diabetes Mellitus Monitoring of Comprehensive Diabetes Management Use of Self Blood Glucose Monitoring Achieving Goals through Self-Management Training Nutritional Counseling SELECTING NUTRITIONAL EDUCATION APPROACH Meal Planning for Diabetes: Approaches and Educational Resources The Exchange System Carbohydrate Counting Very Low Calorie Diets Cultural Considerations in Diabetes Nutrition Therapy MACRONUTRIENT INFLUENCE ON BLOOD GLUCOSE AND HEALTH The Role of Carbohydrate in the Diabetes Meal Plan Protein Lipids Calories Low-Calorie Sweeteners and Fat Replacers: The Ingredients, Use in Foods, and Diabetes Management Fiber and the Diabetic Diet MAKING FOOD CHOICES Selected Foods Altering the Basic Meal Plan Glycemic Control and Supplemental Vitamins, Minerals, and Nonfood Substances LIFE STAGES Children and Adolescents Pregnancy and Diabetes Medical Nutrition Therapy for the Older Person with Diabetes NUTRITION AND SPECIFIC CLINICAL CONDITIONS Diabetic Nephropathy Hypertension and Diabetes Eating Disorders in Diabetes Mellitus Surgery and Surgical Nutrition in Diabetes Gastrointestinal Manifestations of Diabetes Mellitus Dental Care of the Person with Diabetes Diabetes in HIV/AIDS MAKING IT WORK Reimbursement for Medical Nutrition Therapy and Diabetes Self-Management Training View from the Mountain

The development and evaluation of a computer-aided diabetes education program.

Abstract: This paper describes the development and evaluation of a computer-aided learning (CAL) program. The program was tested in a trial that involved 36 people with diabetes; 20 received CAL lessons in diabetes management and 16 attended conventional diabetes classes conducted by diabetes educators. When measurements taken before and three months after the education were compared, both groups showed significant improvement in their knowledge; the blood glucose levels of the CAL group were significantly lower but those of the conventional education group were higher. This means that the CAL program was as effective as conventional education in imparting knowledge but it was more likely to motivate people to control their glucose levels. The CAL program allows diabetes educators to spend less time on education in basic knowledge and to concentrate more on motivational and social factors that are important determinants of patient compliance. It can also benefit people with diabetes whose access to health professionals and/or conventional diabetes education is restricted.

Management of Diabetes Mellitus: Perspectives of Care Across the Life Span

Abstract: OVERVIEW OF DIABETES CARE * Overview of Diabetes Mellitus * Epidemiology of Insulin Dependent Diabetes Mellitus * Epidemiology of Non-Insulin Dependent Diabetes Mellitus * The Therapeutic Regimen * Nutritional Management of Diabetes Mellitus * Exercise and Diabetes * Pharmacologic Therapies in the Management of Diabetes Mellitus * Complications of Diabetes * Microvascular Complications * Macrovascular Disease * Foot Care (Lower Extremity Problems) * SPEICAL ISSUES IN DIABETES MANAGEMENT * Clinical Considerations * Intensive Diabetes Management * Diabetes and Pregnancy * Surgical Management * CONTEXT OF DIABETES CARE AND EDUCATION * Psychosocial Concerns of Diabetes Care & Education * Sociocultural Considerations of Diabetes Care * Social Contexts of Management: Family and Community Environments * Organizing Teaching and Learning for Diabetes Care * The Evaluation Process and Diabetes Education * DIABETES MANAGEMENT ACROSS THE LIFE SPAN * Individualizing Diabetes Care * Diabetes Mellitus and the Preschool Child * Diabetes Mellitus and the School-age Child * The Adolescent with Diabetes * Diabetes Mellitus in Young and Middle Adulthood * Diabetes Mellitus and the Older Adult

Diabetes care in middle-income countries: a Caribbean case study.

Abstract: Many middle-income countries now have a high prevalence of diabetes and need to address the problem of providing care for people with diabetes within limited resources. This study evaluated standards of preventive care in primary settings in three Caribbean countries. We studied case records at 17 clinics in 15 government health centres and 17 private general practitioners' offices in Barbados, Trinidad and Tobago and Tortola (British Virgin Islands). A census of all attenders over a 4 to 7 week period identified 1661 attenders with diabetes mellitus, approximately two-thirds were women with a median age over 60 years. Overall 676/1342 (50%) had 'poor' blood glucose control (> or = 8 mmol l-1 fasting or > or = 10 mmol l-1 random). The proportion with BP > or = 160/95 mmHg or receiving treatment for hypertension was 943/1661 (57%), of whom 781/943 (83%) were prescribed drug treatment. Among those treated for hypertension only 181/781 (23%) had blood pressures < 140/90 mmHg. Surveillance for complications affecting the feet (11%) or eyes (2%) was not performed systematically in any setting. Only 533 (32%) had recorded dietary advice and 79 (5%) had recorded exercise advice in the last 12 months. To begin to address some of these problems at a regional level, we incorporated results from this survey into a series of workshops held in collaboration with health ministries in 10 Caribbean countries, with participants from 13 countries. At these workshops health care workers participated in the process of developing guidelines for diabetes management in primary care. The guidelines have subsequently been widely disseminated through health ministries and non-governmental organizations in the region. Further research is needed to evaluate the effectiveness of this approach, the constraints on diabetes care, and the most cost-effective means of addressing them.

Evaluation of the diabetes quality-of-life questionnaire in a Spanish population. An experience of translation and reliability.

Abstract: The aim of this study was to evaluate the reliability of a version of the diabetes quality-of-life (DQOL) questionnaire adapted and translated into Spanish. The DQOL questionnaire consists of 46 items and is not sensitive to treatment regimens or self-monitoring; therefore, the instrument might be useful to a wide range of patients with diabetes who use different methods of diabetes management. 105 patients with insulin-dependent diabetes mellitus volunteered to complete the questionnaire. This Spanish version of the DQOL achieved a high global internal consistency (; = 0.90), and some outcome similarities, such as more favourable scores among younger patients (up to 21 years of age) and adult male patients compared with the original DQOL. These data show that the Spanish version of the DQOL has a high internal consistency (reliability) and might be a useful comparable tool to evaluate quality of life in Spanish-speaking patients with diabetes mellitus.

The development of healthcare services for diabetic prisoners.

Abstract: The conditions experienced by people in custody in the UK have received considerable attention recently and there has been considerable debate concerning the standards of healthcare in British prisons. The Prison Health Care Service works under great pressure and difficulties and doctors have to deal with a large and ever-changing population, often with mental and physical disorders, who are frequently manipulative. This article highlights problems encountered in delivering diabetes care in prisons. Prisoners may self-induce diabetic ketoacidosis by refusing insulin injections, in order to be transferred to an outside hospital. On the other hand, prison staff may mis-interpret the symptoms of poorly controlled diabetes as 'acting up' by prisoners and inappropriate treatment can be given. If structured diabetes care is provided in prison, however, with close liaison between the Prison Staff and the local Diabetes Care Team, the basics of modern diabetes management can be provided. Good diabetic metabolic control can be achieved in the majority of patients, probably due to the rigid dietary regime, no alcohol and compliance with treatment. Imprisonment can ensure screening for diabetic complications and reassessment of treatment regimens. The British Diabetic Association guidelines for the provision of diabetes care in British prisons are outlined in this article.

Theory and Practical Applications of a Wellness Perspective in Diabetes Education

Abstract: From a wellness perspective, health is viewed in a broad sense that encompasses interrelationships among physical, mental, social, emotional, and spiritual components. This approach to health is particularly applicable in diabetes management because diabetes affects all areas of a person's life--work, family, social, and recreational. The boundaries of diabetes education need to be expanded to address this holistic view of health. The integration of a wellness approach in an adult-centered diabetes education program is described to offer a new perspective in diabetes management and education. This outpatient, hospital-based program is provided at regular intervals for small groups of 6 to 12 participants, most of whom have type II diabetes. Support for this wellness direction in diabetes education is discussed in relation to theoretical principles of the wellness model, including similarities and differences with other concepts such as empowerment and self-efficacy. Practical applications of the wellness perspective are clarified using this specific outpatient program as a case example.

Effects of a Glucose Polymer Sports Drink on Blood Glucose, Insulin, and Performance in Subjects With Diabetes:

Abstract: Regular exercise has long been recognized as a cornerstone of diabetes management along with diet and medication. The purpose of this study was to determine the effects of a glucose polymer sports drink (GPSD) on blood glucose and electrolyte levels in persons with type I or type II diabetes. Twenty-five subjects controlled with insulin were randomized in a double-blind, two-period, crossover design study. Blood glucose and electrolyte levels were measured at intervals during a 60-minute, submaximal treadmill test and for 60 minutes postexercise. Wide variations in blood glucose levels within and between subjects hindered statistical analysis. However, a significant difference in mean blood glucose levels was determined, with overall blood glucose levels higher in the GPSD group compared with placebo. The use of the GPSD also prevented the onset of postexercise hypoglycemia and did not cause or contribute to hyperglycemia.

Glucose monitoring as a guide to diabetes management. Critical subject review.

Abstract: PURPOSE: To encourage a balanced approach to blood glucose monitoring in diabetes by a critical review of the history, power and cost of glucose testing. DATA SOURCES: The Cambridge Data Base was searched and was supplemented by a random review of other relevant sources, including textbooks, company pamphlets, and laboratory manuals. STUDY SELECTION: Keywords used were "glucosuria diagnosis," "blood glucose self-monitoring," "glycosylated hemoglobin," and "fructosamine" for the 10-year period ending 1992, restricted to English language and human. DATA EXTRACTION: About 200 titles were retrieved and reviewed according to the author's judgment of relevance. FINDINGS: "Snapshot tests" (venous and capillary blood glucose) and "memory tests" (urine glucose, glycated hemoglobin fractions and fructosamine) must be employed according to individual patients treatment goals. Day-to-day metabolic guidance is facilitated by capillary blood glucose testing for patients receiving insulin and by urine glucose testing for others. Capillary blood glucose testing is mandatory in cases of hypoglycemia unawareness (inability to sense hypoglycemia because of neuropathy) but is not a substitute for a knowledge of clinical hypoglycemia self-care. Criteria by reason (clinical judgement and cost effectiveness) must be separated from criteria by emotion (preoccupation with technology and marketing). No randomized studies show that any of these tests consistently improve clinical outcome. Optimal metabolic control and cost savings can be expected from a rational selection of tests.

Glucose monitoring of patients with diabetes mellitus receiving general anesthesia: a study of the practices of anesthesia providers in a large community hospital.

Abstract: Surgical stress causes hyperglycemia with potential complications (e.g., impaired granulocytic function and delayed wound healing) particularly when glucose levels exceed 250 mg/dL. Standards of care for patients with diabetes undergoing surgery may vary by geographic locale, type of surgical procedure, and type of diabetes. We explored whether anesthesia providers monitor glucose levels in patients with diabetes. Records of 100 patients with diabetes who underwent surgery under general anesthesia (length of procedure: range, 1.9-11.8 hours) were reviewed. Demographic information, glucose levels, frequency of glucose monitoring, and treatment used for diabetes management preoperatively, intraoperatively, and postoperatively were recorded. There were 46 males and 54 females, aged 62 +/- 13 years (55% currently treated with insulin). Of the study cohort, 89% had preoperative, 23% had intraoperative, and 54% had postoperative glucose monitoring performed. As expected, postoperative glucose concentrations were significantly higher than preoperative glucose levels (mean difference, 99 mg/dL, P < .01). The mean postoperative glucose level was 262 +/- 89 mg/dL with 30 of the 54 monitored patients having a postoperative glucose level greater than 250 mg/dL. Individuals treated with insulin and those who underwent major surgery were more likely to have glucose levels monitored. These results suggest that better strategies for monitoring glucose levels during the surgical period are needed.

News from the divisions: diabetes shared care.

Abstract: It is not surprising that diabetes care has been a very active area for divisional projects and activities. Diabetes is prevalent in the community (up to one million Australians) and in general practice (1% of GP encounters). Optimal cost-effective diabetes management involves collaboration between general practice and public and private health services--one of the purposes for which divisions were created. Because diabetes is a multisystem chronic disease requiring multi-disciplinary interventions, it has also been a model for applying the health outcomes approach in general practice, especially in New South Wales.

Psychological issues in the diabetes clinic

Abstract: Psychological difficulties and their effect on diabetes management and diabetes control continue to be debated, whilst the need for psychological treatment is ignored. St Thomas' and Guy's Hospitals offer structured psychological support for their poorly controlled patients using Cognitive Analytic Therapy (CAT). Brief details of CAT are given and the change which occurs in the therapy is outlined in a letter written by a patient at the end of treatment. If we are to maximise diabetes services and minimise disability, psychological treatment needs to be made available to our patients.

Response to Garber. Chronic, persistent hyperglycemia: an essential flaw in diabetes management in America.

Abstract: plus 850 mg oral metformin. The areas under the plasma glucose curve were essentially the same: 2,403 ± 155 and 2,498 ±160 mmol at the low and high (plus metformin) dextrose dose, respectively. Plasma insulin (Fig. IB) and Cpeptide (Fig. 1C) concentrations rose higher after metformin administration. The areas under the plasma insulin curve were 25,295 ± 4,641 and 33,408 ± 6,327 pmol (P < 0.01) after 35 g glucose and 50 g glucose plus metformin, respectively. The values for the plasma C-peptide curves were 16.7 ± 2 and 21.0 ± 3 nmol (P < 0.01), respectively, without and with metformin. In the perifusion experiments performed with 3.3 mmol/1 glucose (six replicates), basal insulin release was 24.0 ±1.4 pmol/1, and the addition of 3.7 ju-g/ml metformin had no significant effect on hormone output (peak value, 32 ± 8 pmol/1). In the experiments in which after 40 min of perifusion with 3.3 mmol/1 glucose the concentration of dextrose was increased to 16.7 mmol/1, either with or without the addition of metformin (five replicates each), peak insulin secretion in the presence of 16.7 mmol/1 glucose plus metformin (126 ± 46 pmol/1) was significantly (P < 0.05) higher than the peak insulin release from islets from the same pancreases at 16.7 mmol/1 glucose without metformin (94 ± 3 1 pmol/1) (Fig. 2). Total insulin release from islets perifused for 40 min with 16.7 mmol/1 glucose plus metformin was 3,640 ±741 pmol. This value was significantly higher (P < 0.05) than that from islets perifused with 16.7 mmol/1 glucose without metformin (2,161 ± 438 pmol). Thus, in our NIDDM patients, after 35 g oral glucose and 50 g oral glucose plus 850 mg oral metformin, similar peripheral plasma glucose concentrations were achieved. Under this condition, a significant increase of plasma insulin and C-peptide levels was found, after metformin dosing. Although increasing doses of oral glucose per se may stimulate greater levels of insulin, possibly by enhancing gastric inhibitory polypeptide (G1P) or other gastrointestinal hormones, significant changes in maximal GIP and insulin levels after oral glucose usually occur when the glucose load increase is at least twofold (5). Conversely, metformin does not cause any significant change in GIP concentrations either fasting or after a test meal (6). Therefore, our results might be explained, at least in part, by an effect of metformin on the j8-cell. Indeed, the drug significantly potentiated insulin release from isolated perifused human islets in the presence of 16.7 mmol/1 glucose. Since metformin did not affect insulin release at low glucose, this might explain why the drug does not cause hypoglycemia. Although the mechanism(s) by which metformin affects insulin release is not known at this time, our results suggest that oral metformin may potentiate insulin release in patients with NIDDM, given oral glucose, and that this effect is at least in part due to a direct action of the drug on the /8-cell.

Feeling stuck. Some useful questions for a diabetes team

Abstract: A psychotherapist, meeting regularly with a diabetes care team, helped them to devise a series of questions about feelings, control, and problems with diabetes. These questions were used when the team felt ‘stuck’ with patients or when reviewing their diabetes management. The questions were ones frequently used by counsellors and were adapted for use in a diabetes clinic. The team found that the use of the questions enlarged their clinical repertoire, increased their empathy with their patients, and at times yielded surprising information. The questions allowed for exploration of highly charged emotional issues in a neutral manner. They at times ascertained how knowledge of diabetes was actually put into practice by revealing hidden behaviours. Occasionally unforseen answers posed difficulties for the team and left them feeling out of their depth, and strategies needed to be devised to cope with such important contingencies.