Showing papers on "Diabetes management published in 2005"

Assessing psychosocial distress in diabetes: development of the diabetes distress scale.

Abstract: OBJECTIVE —The purpose of this study was to describe the development of the Diabetes Distress Scale (DDS), a new instrument for the assessment of diabetes-related emotional distress, based on four independent patient samples. RESEARCH DESIGN AND METHODS —In consultation with patients and professionals from multiple disciplines, a preliminary scale of 28 items was developed, based a priori on four distress-related domains: emotional burden subscale, physician-related distress subscale, regimen-related distress subscale, and diabetes-related interpersonal distress. The new instrument was included in a larger battery of questionnaires used in diabetes studies at four diverse sites: waiting room at a primary care clinic ( n = 200), waiting room at a diabetes specialty clinic ( n = 179), a diabetes management study program ( n = 167), and an ongoing diabetes management program ( n = 158). RESULTS —Exploratory factor analyses revealed four factors consistent across sites (involving 17 of the 28 items) that matched the critical content domains identified earlier. The correlation between the 28-item and 17-item scales was very high ( r = 0.99). The mean correlation between the 17-item total score (DDS) and the four subscales was high ( r = 0.82), but the pattern of interscale correlations suggested that the subscales, although not totally independent, tapped into relatively different areas of diabetes-related distress. Internal reliability of the DDS and the four subscales was adequate (α > 0.87), and validity coefficients yielded significant linkages with the Center for Epidemiological Studies Depression Scale, meal planning, exercise, and total cholesterol. Insulin users evidenced the highest mean DDS total scores, whereas diet-controlled subjects displayed the lowest scores ( P CONCLUSIONS —The DDS has a consistent, generalizable factor structure and good internal reliability and validity across four different clinical sites. The new instrument may serve as a valuable measure of diabetes-related emotional distress for use in research and clinical practice.

Psychosocial problems and barriers to improved diabetes management: results of the Cross-National Diabetes Attitudes, Wishes and Needs (DAWN) Study

Abstract: Aims To examine patient- and provider-reported psychosocial problems and barriers to effective self-care and resources for dealing with those barriers. Methods Cross-sectional study using face-to-face or telephone interviews with diabetic patients and health-care providers in 13 countries in Asia, Australia, Europe and North America. Participants were randomly selected adults ( n = 5104) with Type 1 or Type 2 diabetes, and providers ( n = 3827), including primary care physicians, diabetes specialist physicians and nurses. Results Regimen adherence was poor, especially for diet and exercise; provider estimates of patient self-care were lower than patient reports for all behaviours. Diabetes-related worries were common among patients, and providers generally recognized these worries. Many patients (41%) had poor psychological wellbeing. Providers reported that most patients had psychological problems that affected diabetes self-care, yet providers often reported they did not have the resources to manage these problems, and few patients (10%) reported receiving psychological treatment. Conclusions Psychosocial problems appear to be common among diabetic patients worldwide. Addressing these problems may improve diabetes outcomes, but providers often lack critical resources for doing so, particularly skill, time and adequate referral sources.

Pediatric Parenting Stress Among Parents of Children with Type 1 Diabetes: The Role of Self-Efficacy, Responsibility, and Fear

Abstract: Objective Parents of children with type 1 diabetes are crucial to promoting positive disease adaptation and health outcomes among these youngsters, yet this success may come at some consequence to parents' own well-being. Little research has examined the stress faced by parents, or explored the psychological and behavioral correlates of their stress. Methods One hundred and thirty-four parents of children with type 1 diabetes completed measures of diabetes self-efficacy, responsibility for diabetes management, fear of hypoglycemia, and a recently developed measure of pediatric parenting stress (the Pediatric Inventory for Parents [PIP]; R. Streisand, S. Braniecki, K. P. Tercyak, & A. E. Kazak, 2001). Results Bivariate analyses suggest that pediatric parenting stress is multifaceted; the frequency of parenting stress is negatively related to child age and family socioeconomic status and positively related to single parent status and regimen status (injections vs. insulin pump). Difficulty of parenting stress is negatively related to child age and positively related to regimen status. In multivariate analyses, a significant portion of the variance in stress frequency (32%) and difficulty (19%) are associated with parent psychological and behavioral functioning, including lower self-efficacy, greater responsibility for diabetes management, and greater fear of hypoglycemia. Conclusions Each area of parent functioning associated with pediatric parenting stress is amenable to behavioral intervention aimed at stress reduction or control and improvement of parent psychological and child-health outcomes.

Glucommander: a computer-directed intravenous insulin system shown to be safe, simple, and effective in 120,618 h of operation.

Abstract: OBJECTIVE—Intravenous insulin is now the recommended method of diabetes management in critically ill persons in the hospital. The published methods for administering the insulin are complex and are usually limited to intensive care units with a low patient-to-nurse ratio. RESEARCH DESIGN AND METHODS—A computer-directed algorithm for advice on the delivery of intravenous insulin that is flexible in blood glucose timing and advises insulin dosing in a graduated manner has been developed. This software program, known as the Glucommander, has been used extensively by our group. The data were analyzed for this study. RESULTS—The data from 5,080 intravenous insulin runs over 120,683 h show that blood glucose levels can be safely stabilized in a target range without significant hypoglycemia by nonspecialized nurses working on any unit of a general hospital. The mean glucose level reached CONCLUSIONS—This computer-directed algorithm is a simple, safe, effective, and robust method for maintaining glycemic control. It has been extensively studied and is applicable in a wide variety of conditions. In contrast to other published intravenous insulin protocols, which have been limited to intensive care units, Glucommander can be used in all units of any hospital.

A systematic review of telemedicine interventions to support blood glucose self-monitoring in diabetes.

Abstract: Aims To evaluate evidence for feasibility, acceptability and cost-effectiveness of diabetes telemedicine applications. Methods MEDLINE , EMBASE , PSYCHINFO , CINAHL , Cochrane, and INSPEC were searched using the terms diabetes and telemedicine for clinical studies using electronic transfer of blood glucose results in people with diabetes. The technology used, trial design and clinical outcome measures used were extracted for trials and prospective cohort studies. Randomized controlled trials with HbA 1c as an outcome were pooled using standard meta-analytical methods. Results We identified 539 papers among which 32 papers described 10 prospective cohort studies, 12 parallel group randomized controlled trials (RCT), three crossover trials, and one non-parallel group trial. Only two studies described full details of randomization, blinding of outcomes and dropouts and withdrawals. Electronic transfer of glucose results appears feasible in a clinical setting. Only two of the RCTs included more than 100 patients, and only three extended to 1 year. Only one study was designed to show that telemedicine interventions might replace clinic interventions without deterioration in HbA 1c . Results pooled from the nine RCTs with reported data did not provide evidence that the interventions were effective in reducing HbA 1c ( − 0.1%, 95% CI − 0.4% to 0.04%). Conclusions Telemedicine solutions for diabetes care are feasible and acceptable, but evidence for their effectiveness in improving HbA 1c or reducing costs while maintaining HbA 1c levels, or improving other aspects of diabetes management is not strong. Further research should seek to understand how telemedicine might enhance educational and self-management interventions and RCTs are required to examine cost-effectiveness.

The Diabetes Attitudes, Wishes, and Needs (DAWN) program: A new approach to improving outcomes of diabetes care

Abstract: The Diabetes Attitudes, Wishes, and Needs (DAWN) program is an international partnership effort to improve outcomes of diabetes care by increasing the focus on the person behind the disease, especially the psychosocial and behavioral barriers to effective diabetes management. DAWN was initiated by an international survey of > 5,000 people with diabetes and almost 4,000 diabetes care providers. The DAWN program has facilitated a number of concrete initiatives to address the gaps in diabetes care identified by the DAWN study. Diabetes is one of the major world health problems. Recent estimates from the World Health Organization predict that if current trends continue, the number of people with diabetes will more than double, from 176 to 370 million people by 2030.1 Diabetes is already the single most costly health care problem in Westernized countries. Among those diagnosed with the disease, at least half still do not achieve satisfactory glycemic control, despite the availability of effective treatments.2 As a consequence, millions of people with diabetes are at elevated risk of suffering needlessly from serious complications of the disease. With the growing number of people with diabetes, there is an urgent need to find better ways of curbing the human and economic burden of this chronic progressive disease, through prevention, detection, and treatment. A review of the literature suggests several important areas that have the potential to address these problems. Suboptimal diabetes self-management has been identified by several studies as one of the possible causes of poor outcomes of diabetes care in general practice.3,4 A multitude of research studies, mainly in the Western world and with relatively small patient samples, has indicated the potential importance of a multitude of psychological, social, and behavioral factors for patient self-management.5,6Access to patient-centered self-management support and education has …

Patient Self-Management Program for Diabetes: First-Year Clinical, Humanistic, and Economic Outcomes

Abstract: Objective To assess the outcomes for the first year following the initiation of a multisite community pharmacy care services (PCS) program for patients with diabetes. Design Quasi-experimental, pre–post cohort study. Setting 80 community pharmacy providers with diabetes certificate program training who were reimbursed for PCS by employers in Greensboro, N.C., Wilson, N.C., Dublin, Ga., Manitowoc County, Wis., and Columbus, Ohio. Patients 256 patients with diabetes covered by self-insured employers' health plans. Interventions Community pharmacist patient care services using scheduled consultations, clinical goal setting, monitoring, and collaborative drug therapy management with physicians and referrals to diabetes educators. Main Outcome Measures Changes in glycosylated hemoglobin (A1C), low-density lipoprotein cholesterol (LDL-C), blood pressure, influenza vaccinations, foot examinations, eye examinations, patient goals for nutrition, exercise, and weight, patient satisfaction, and changes medical and medication utilization and costs. Results Over the initial year of the program, participants' mean A1C decreased from 7.9% at initial visit to 7.1%, mean LDL-C decreased from 113.4 mg/dL to 104.5 mg/dL, and mean systolic blood pressured decreased from 136.2mm Hg to 131.4mm Hg. During this time, influenza vaccination rate increased from 52% to 77%, the eye examination rate increased from 46% to 82%, and the foot examination rate increased from 38% to 80%. Patient satisfaction with overall diabetes care improved from 57% of responses in the highest range at baseline to 87% at this level after 6 months, and 95.7% of patients reported being very satisfied or satisfied with the diabetes care provided by their pharmacists. Total mean health care costs per patient were $918 lower than projections for the initial year of enrollment. Conclusion Patients who participated in the program had significant improvement in clinical indicators of diabetes management, higher rates of self-management goal setting and achievement, and increased satisfaction with diabetes care, and employers experienced a decline in mean projected total direct medical costs.

Insulin pump therapy in children and adolescents: improvements in key parameters of diabetes management including quality of life

Abstract: Aims To determine the impact of insulin pump therapy (continuous subcutaneous insulin infusion) on key parameters of diabetes management including quality of life in children and adolescents with Type 1 diabetes mellitus (T1DM). Methods All patients started on insulin pump therapy were prospectively followed before and after institution of insulin pump therapy. Data collected included age, duration of diabetes, glycated haemoglobin levels (HbA1c), anthropometric data and episodes of severe hypoglycaemia defined as hypoglycaemia resulting in coma or convulsion. A subset of patients also completed the Diabetes Quality of Life Instrument (DQOL) and Self-Efficacy for Diabetes Scale (SED) questionnaires to assess quality of life. Results At the time of analysis, 100 patients had been managed with insulin pump therapy. The mean age when starting pump therapy was 12.5 (3.9–19.6) years. Duration of therapy ranged from 0.2 to 4.0 years (mean 1.4 years, median 1.5 years). HbA1c decreased from 8.3 ± 0.1% prior to pump therapy to 7.8 ± 0.1% (P < 0.0001). Episodes of severe hypoglycaemia decreased from 32.9 to 11.4 per 100 patient years. Components of quality of life measures showed improvement on pump treatment. BMI standard deviation scores (z scores) did not increase. Conclusions Pump therapy is proving an effective means of insulin therapy in the young patient that shows promise to improve glycaemic control with a reduction in hypoglycaemia frequency. Quality of Life measures suggest that psychosocial outcomes may be improved.

Improving glucose management: ten steps to get more patients with type 2 diabetes to glycaemic goal.

Abstract: Despite increasingly stringent clinical practice guidelines for glycaemic control, the implementation of recommendations has been disappointing, with over 60% of patients not reaching recommended glycaemic goals. As a result, current management of glycaemia falls significantly short of accepted treatment goals. The Global Partnership for Effective Diabetes Management has identified a number of major barriers that can prevent individuals from achieving their glycaemic targets. This article proposes 10 key practical recommendations to aid healthcare providers in overcoming these barriers and to enable a greater proportion of patients to achieve glycaemic goals. These include advice on targeting the underlying pathophysiology of type 2 diabetes, treating early and effectively with combination therapies, adopting a holistic, multidisciplinary approach and improving patient understanding of type 2 diabetes. Implementation of these recommendations should reduce the risk of diabetes-related complications, improve patient quality of life and impact more effectively on the increasing healthcare cost related to diabetes.

The influence of insulin use on glycemic control: How well do adults follow prescriptions for insulin?

Abstract: OBJECTIVE —The purposes of this study were to determine the relationship between insulin self-management and glycemic control and to identify patient characteristics associated with better control. RESEARCH DESIGN AND METHODS —A Department of Veterans Affairs regional database was used to identify patients with diabetes on chronic insulin therapy ( n = 6,222) with dose defined as number of units and doses. The rate of insulin use during a 2-year period was calculated using pharmacy data. Regression analyses were used 1 ) to predict compliance with prescribed insulin regimens using demographic variables, HbA1c levels, and a measure of diabetes management intensity and 2 ) to predict HbA1c levels using demographic variables and rates of insulin use. RESULTS —Insulin use was 77.44 ± 17% of prescribed amounts, including wastage; HbA1c levels were 7.98 ± 1.66%. Concomitant oral hypoglycemic agent use (84.89 ± 16%) was higher than insulin use ( P < 0.0001) but correlated with insulin use ( r = 0.189, P < 0.0001). Ordinary least-squares regression showed that race, HbA1c levels, and intensity of diabetes management were significant predictors of insulin use. Age, race, and insulin use were significant predictors of HbA1c levels. CONCLUSIONS —Adults prescribed a specific insulin regimen averaged using 77% of prescribed doses, demonstrating good intention to follow the prescription. However, HbA1c higher than the recommended level suggested that the rate of insulin use, the prescribed regimen, or both were inadequate to achieve good glycemic control in patients with long-term insulin use.

Caring for Poorly Controlled Diabetes Mellitus: A Randomized Pharmacist Intervention

Abstract: BACKGROUND:There is limited information from randomized controlled studies about the influence of pharmacist interventions on diabetes control.OBJECTIVE:To evaluate the effect of a pharmacist intervention on improving diabetes control; secondary endpoints were medication appropriateness and self-reported adherence.METHODS:A randomized, controlled, multi-clinic trial was conducted in the University of Washington Medicine Neighborhood Clinics. Seventy-seven subjects, ⩾18 years old with a hemoglobin (Hb) A1c ⩾9% at baseline and taking at least one oral diabetes medication, were randomized to receive a pharmacist intervention (n = 43) or usual care (n = 34) for 6 months followed by a 6-month usual-care observation period for both groups. Subjects met with a clinical pharmacist to establish and initiate a diabetes care plan followed by weekly visits or telephone calls to facilitate diabetes management and adherence. HbA1c, medication appropriateness, and self-reported adherence were assessed at baseline, 6 mon...

Pharmacist Impact on Clinical Outcomes in a Diabetes Disease Management Program via Collaborative Practice

Abstract: BACKGROUNDClinical outcomes resulting from pharmaceutical care have been incompletely addressed in the diabetes population. We conducted a retrospective study evaluating clinical outcomes in a diabetes disease management program in which clinical pharmacists possessed collaborative practice agreements.OBJECTIVETo evaluate changes in clinical outcomes for patients enrolled in a pharmacist-coordinated diabetes management program.METHODSMedical records of 157 patients enrolled in the diabetes management program between June 2003 and April 2004 were retrospectively reviewed. Data collection included baseline and follow-up values for hemoglobin A1C (A1C) and lipids as well as frequency of adherence to preventive care, including annual foot and eye examinations and daily aspirin therapy.RESULTSFor patients with both baseline and follow-up data, the mean A1C reduction was 1.6% (n = 109; p < 0.001). For patients with an initial A1C of ≥8.5%, the mean reduction was 2.7% (n = 57; p < 0.001). The percentage of patie...

Empowering patients with diabetes : a qualitative primary care study focusing on South Asians in Leicester, UK

Abstract: Results. Interviews were conducted with 15 South Asian and 5 white patients. We identified both similar and culturally specific elements within the experience, attitudes and barriers in the two ethnic groups. High regard for education, particularly in South Asians, was associated with a positive attitude to empowerment through knowledge, but also sometimes led to low motivation to become partners in diabetes management. High prevalence of diabetes and strong family networks meant that families were an important source of knowledge for South Asians and that these patients generally had good emotional support. Practical considerations such as the need for a convenient venue for educational initiatives were common to both ethnic groups, but some cultural preferences were also identified, for example for appropriate language provision and separate gender sessions. Conclusions. Educational initiatives aimed at promoting self-management in chronic diseases such as diabetes need to be designed with an awareness of the complexity of social and cultural experiences and attitudes in target communities.

An Endocrinologist-Supported Intervention Aimed at Providers Improves Diabetes Management in a Primary Care Site: Improving Primary Care of African Americans with Diabetes (IPCAAD) 7

Abstract: OBJECTIVE —Management of diabetes is frequently suboptimal in primary care settings, where providers often fail to intensify therapy when glucose levels are high, a problem known as clinical inertia. We asked whether interventions targeting clinical inertia can improve outcomes. RESEARCH DESIGN AND METHODS —A controlled trial over a 3-year period was conducted in a municipal hospital primary care clinic in a large academic medical center. We studied all patients (4,138) with type 2 diabetes who were seen in continuity clinics by 345 internal medicine residents and were randomized to be control subjects or to receive one of three interventions. Instead of consultative advice, the interventions were hard copy computerized reminders that provided patient-specific recommendations for management at the time of each patient’s visit, individual face-to-face feedback on performance for 5 min every 2 weeks, or both. RESULTS —Over an average patient follow-up of 15 months within the intervention site, improvements in and final HbA 1c (A1C) with feedback + reminders (ΔA1C 0.6%, final A1C 7.46%) were significantly better than control (ΔA1C 0.2%, final A1C 7.84%, P P = NS vs. control). Trends were similar but not significant with systolic blood pressure (sBP) and LDL cholesterol. Multivariable analysis showed that the feedback intervention independently facilitated attainment of American Diabetes Association goals for both A1C and sBP. Over a 2-year period, overall glycemic control improved in the intervention site but did not change in other primary care sites (final A1C 7.5 vs. 8.2%, P CONCLUSIONS —Feedback on performance aimed at overcoming clinical inertia and given to internal medicine resident primary care providers improves glycemic control. Partnering generalists with diabetes specialists may be important to enhance diabetes management in other primary care settings.

Inhaled insulin for diabetes mellitus

Abstract: Purpose. Pharmacokinetic and safety data related to the use of inhaled insulin for the management of diabetes mellitus are discussed. The various pulmonary insulin delivery systems under development are also reviewed. Summary. Several pharmaceutical companies are developing pulmonary insulin delivery systems. These products fall into two main groups: solution and drug powder formulations, which are delivered through different patented inhaler systems. Exubera, a rapid-acting insulin in powder form, has been studied extensively in patients with type 1 and type 2 diabetes mellitus. The AERx Insulin Diabetes Management System delivers a liquid form of human insulin. Preliminary data indicate that patients converting from insulin injections to this system showed higher compliance to therapy, demonstrated by improved glycemic control. Other pulmonary insulin delivery systems, including ProMaxx, AIR, Spiros, and Technosphere, are also under investigation. In humans, inhaled regular insulin is more rapidly absorbed than insulin from the subcutaneous injection site. The efficiency of inhaled insulin is lower than that of subcutaneous injection because pulmonary delivery of insulin involves some loss of drug within the inhaler or mouth during inhalation. A concern of many clinicians is the possibility of long-term effects from the intraalveolar deposition of insulin within the lung, since insulin is known to have growth-promoting properties. The long-term safety of these products has not been established. Conclusion. Several inhaled insulin products are under development. If these products receive marketing approval, the pulmonary delivery of insulin may offer patients with diabetes an alternative to repeated insulin injections.

Validation of the Australian/English version of the Diabetes Management Self-Efficacy Scale

Abstract: Australians' use of the English language is influenced by a British educational curriculum, exposure to international television programmes and cultural backgrounds. Hence, adapting research instruments for use with Australian populations can be challenging. This study adapted the United Kingdom's version of the 20-item Diabetes Management Self-Efficacy Scale and tested it psychometrically with Australians. Face validity of the adapted instrument was established through consultation with diabetes educators and people with type 2 diabetes. Data from a convenience sample of 88 people with type 2 diabetes were analysed to determine the psychometric properties of the adapted instrument. The results indicate that the Australian/English version of the instrument is internally consistent, stable over time and it measures self-efficacy. However, there was evidence to show that there might be some redundant items in the scale. Further psychometric testing is warranted with a larger sample to determine whether the scale requires refinement.

The case for low carbohydrate diets in diabetes management.

Abstract: A low fat, high carbohydrate diet in combination with regular exercise is the traditional recommendation for treating diabetes. Compliance with these lifestyle modifications is less than satisfactory, however, and a high carbohydrate diet raises postprandial plasma glucose and insulin secretion, thereby increasing risk of CVD, hypertension, dyslipidemia, obesity and diabetes. Moreover, the current epidemic of diabetes and obesity has been, over the past three decades, accompanied by a significant decrease in fat consumption and an increase in carbohydrate consumption. This apparent failure of the traditional diet, from a public health point of view, indicates that alternative dietary approaches are needed. Because carbohydrate is the major secretagogue of insulin, some form of carbohydrate restriction is a prima facie candidate for dietary control of diabetes. Evidence from various randomized controlled trials in recent years has convinced us that such diets are safe and effective, at least in short-term. These data show low carbohydrate diets to be comparable or better than traditional low fat high carbohydrate diets for weight reduction, improvement in the dyslipidemia of diabetes and metabolic syndrome as well as control of blood pressure, postprandial glycemia and insulin secretion. Furthermore, the ability of low carbohydrate diets to reduce triglycerides and to increase HDL is of particular importance. Resistance to such strategies has been due, in part, to equating it with the popular Atkins diet. However, there are many variations and room for individual physician planning. Some form of low carbohydrate diet, in combination with exercise, is a viable option for patients with diabetes. However, the extreme reduction of carbohydrate of popular diets (<30 g/day) cannot be recommended for a diabetic population at this time without further study. On the other hand, the dire objections continually raised in the literature appear to have very little scientific basis. Whereas it is traditional to say that more work needs to be done, the same is true of the assumed standard low fat diets which have an ambiguous record at best. We see current trends in the national dietary recommendations as a positive sign and an appropriate move in the right direction.

Predictors of glucose control in children and adolescents with type 1 diabetes mellitus.

Abstract: Aims: To evaluate the glucose control [(as measured by hemoglobin A1c (HbA1c)], the factors associated with glycemic control, and possible explanations for these associations in a sample of children and adolescents with type 1 diabetes. Methods: Data were collected on 155 children and adolescents, with type 1 diabetes mellitus, attending a multidisciplinary diabetes clinic in Portland, OR. Patients' hospital charts were reviewed to determine demographic factors, disease-related characteristics, and HbA1c level. Results: Mean percent HbA1c was 9.3. Adolescents between the ages of 14 and 18 yr were in poorer metabolic control (adjusted mean percent HbA1c 0.56 higher than children 2–8 yr). Children who attended the clinic three to four times in the previous year were in better control (adjusted mean percent HbA1c 0.46 lower than those who visited two or fewer times and 1.11 lower than those who attended five or more times). Children with married parents were in better glycemic control than those of single, separated, or divorced parents (adjusted mean percent HbA1c 0.47 lower for children of married parents). This effect appeared to be mediated, in part, by the number of glucose checks performed per day. Conclusions: This study suggests that adolescents should be targeted for improved metabolic control. Diabetes team members need to be aware of changing family situations and provide extra support during stressful times. Regular clinic attendance is an important component of intensive diabetes management. Strategies must be developed to improve accessibility to the clinic and to identify patients who frequently miss appointments.

Age, metabolic control and type of insulin regime influences health-related quality of life in children and adolescents with type 1 diabetes mellitus.

Abstract: The effects of illness and treatment of diabetes mellitus extend beyond medical outcomes. We therefore evaluated health-related quality of life (HRQOL) in children (aged 8–12 years) and adolescents (aged 13–16 years) with type 1 diabetes to compare their results with healthy peers and to identify HRQOL determinants. A total of 68 children and adolescents from a tertiary care clinic which specialises in the management of diabetes, completed the generic KINDL-R questionnaire. This instrument for children and adolescents has six dimensions and an additional module assessing condition-related HRQOL. Overall, the HRQOL was not different between patients with type 1 diabetes and healthy controls. In some areas, children and adolescents with diabetes reported a better HRQOL compared to healthy peers: adolescents reported better psychological well-being ( P 3 injections/day) were associated with a better HRQOL in different domains ( P <0.05). The subscale “chronic illness” showed a better HRQOL ( P <0.001) in children and adolescents with diabetes compared to age-matched controls with other chronic conditions. Conclusion:Children and adolescents from a paediatric department specialising in diabetes management report good health-related quality of life. Younger age, good metabolic control and intensified insulin therapy are associated with a better health-related quality of life. Dimensions of health-related quality of life appear to play different roles at different ages, emphasising the importance of the multidimensional health-related quality of life concept and the value of age-appropriate self-reports.

Causes of hyperglycemia and hypoglycemia in adult inpatients

Abstract: Purpose. The underlying causes of hyperglycemia and hypoglycemia in adult medical and surgical inpatients were studied. Methods. Hyperglycemic and hypoglycemic events occurring in adult medical and surgical patients admitted between February and July 2003 to a tertiary care hospital were identified prospectively from automated daily printouts of abnormal blood glucose levels generated by the hospital laboratory. Information on the causes of a random sample of events was ascertained within 24 hours through chart review and provider and patient interviews. Narratives were presented to an expert committee to assess the causes of each event and preventability. Results. Eighteen of 24 hypoglycemic events and 26 of 26 hyperglycemic episodes were considered preventable. Failure to adjust antidiabetic drugs in response to decreases in oral intake and unexpected deviation from normal hospital routine were the most common factors contributing to hypoglycemia. Hyperglycemia was most often associated with an unwillingness of providers to take responsibility for diabetes management and the exclusive use of sliding-scale insulin regimens. Conclusion. Hyperglycemia and hypoglycemia in medical and surgical inpatients were mostly related to inadequate prescribing, monitoring, and communication practices.

Effectiveness of Pharmacist-Administered Diabetes Mellitus Education and Management Services

Abstract: Study Objectives. To evaluate the effectiveness of pharmacist-administered diabetes mellitus education and management services on selected diabetes performance measures. Additional goals were to compare outcomes with goals specified for patients with diabetes by the National Committee for Quality Assurance (NCQA) and identify areas for improvement. Design. One-year observational study. Setting. Three university-based primary care clinics. Patients. One hundred ninety-one patients with diabetes. Intervention. Pharmacist-provided diabetes education and management services. Measurements and Main Results. Each patient was assessed for hemoglobin A1c (A1C) values, blood pressure, low-density lipoprotein cholesterol (LDL) levels, and aspirin use at baseline and at 1 year after enrollment. Cost avoidance comparators were calculated for those patients with reductions in A1C of at least 1%. Average A1C at 1 year was 7.8% (range 4.5–13.9%) versus 9.5% (range 5.4–19%) at baseline (change −1.7%, p 0.05). Aspirin use increased from 34% at baseline to 73% at 1 year (p<0.0001). The program achieved the A1C and LDL values required to qualify for NCQA diabetes recognition. Based on an estimated savings of $820 for each 1% decrease in A1C, cost avoidance was calculated as $59,040. Conclusion. Diabetes management services from clinical pharmacists achieved significant improvements in A1C values, blood pressure, and aspirin use. Continued efforts in diabetes education and management are needed to further improve clinical, economic, and humanistic outcomes.

The Effect of Diabetes on Disability in Middle-Aged and Older Adults

Abstract: Background. Physical disability is increasingly recognized as an adverse health consequence of type 2 diabetes in older adults. We studied the effect of diabetes on disability in middle-aged and older adults to: 1) characterize the association of diabetes with physical disability in middle-aged adults, and 2) determine the extent to which the effect of diabetes is explained by related covariates in either or both age groups. Methods. We used data from two parallel national panel studies of middle-aged and older adults to study the effect of self-reported diabetes at baseline on disability 2 years later, adjusting for baseline covariates. Results. Diabetes was strongly associated with subsequent physical disability (measured by a composite variable combining activities of daily living, mobility, and strength tasks) in middle-aged and older adults. Controlling for socioeconomic characteristics and common diabetes-related and unrelated comorbidities and conditions reduced the diabetes effect substantially, but it remained a significant predictor of disability in both groups. Conclusions. Our analyses demonstrated that disability is an important diabetes-related health outcome in middle-aged and older adults that should be prevented or mitigated through appropriate diabetes management.

Outcomes of Project Dulce: A Culturally Specific Diabetes Management Program

Abstract: BACKGROUND:Diabetes mellitus is a common and costly chronic disease that increasingly affects minority populations; however, there is little evidence regarding the clinical effectiveness and costs of culturally appropriate disease management programs.OBJECTIVE:To determine the clinical outcomes and costs of Project Dulce, a combined stepped-care diabetes nurse case management program and culturally oriented peer-led self-empowerment training program.METHODS:Pre—post clinical outcome and cost analysis of Project Dulce participants were compared with a cohort of historical controls over a one-year period. Subjects included 348 persons with diabetes with coverage under County Medical Services who were receiving services in community health centers in San Diego, CA. Generalized regression models were used to estimate changes in clinical outcomes (hemoglobin [Hb] A1c, blood pressure, cholesterol level) and costs associated with participation in Project Dulce.RESULTS:Project Dulce participants had significant r...

Accommodating Type 2 Diabetes in the Chinese American Family

Abstract: In this interpretive study, the authors aimed to describe family responses to type 2 diabetes in Chinese Americans as reported by persons with diabetes (PWD) and spouses Twenty participants representing 16 families completed multiple group interviews The authors elicited positive and difficult diabetes care narratives and conducted narrative and thematic analysis of transcribed interview texts Accommodation, the key family response, comprised the enactment of social concerns and practices to balance quality of life for individuals and families with quality of diabetes care PWDs' accommodation included negotiating disease disclosure, protecting the family's meals, and maintaining ease in family relations despite diabetes symptoms Accommodation by family members included developing shared diabetes care practices and indirect approaches to disagreements about diabetes management

Influence of acute upper respiratory tract infection on the absorption of inhaled insulin using the AERx® insulin Diabetes Management System

Abstract: Aims To assess the effects due to an uncomplicated acute upper respiratory tract infection (URTI) on the pharmacokinetics and glucose response of insulin when delivered by oral pulmonary absorption. Methods Normally healthy adult men (n = 11) and women (n = 9) received a single dose of inhaled human insulin, equivalent to ∼ 6 IU subcutaneous, using the AERx® insulin Diabetes Management System (iDMS), during and following recovery from an URTI. The first dose was administered with ongoing symptoms of < 3 days’ duration, the second dose following recovery, and within 3 weeks of the first. Blood sampling for determination of insulin pharmacokinetics (serum AUC(0−6 h), AUC(0−8), Cmax,tmax, t1/2, MRT) and glucose response (plasma AOC(0−6 h)) was performed from 15 min predose to 6 h postdose. Results Insulin pharmacokinetics were not different for subjects during and following recovery from URTI [e.g. URTI: no URTI ratio in serum AUC(0−6 h) = 0.92 (95% confidence interval 0.81, 1.05)]; this was reflected by a similar glucose response. Inhaled insulin delivered by AERx® iDMS was well tolerated by all subjects; no significant changes were observed in pulmonary function tests. No safety concerns arising from the mode of insulin administration were raised by either dose. Conclusions The results suggest that insulin can be administered via AERx® iDMS to nondiabetic subjects experiencing a URTI without any statistically significant changes in insulin pharmacokinetics or pharmacodynamics, and that the necessity for dose adjustments will not differ from subjects with an acute URTI who are receiving subcutaneous insulin.

The Association of Increased Total Glycosylated Hemoglobin Levels with Delayed Age at Menarche in Young Women with Type 1 Diabetes

Abstract: Context: Delayed menarche is associated with subsequent reproductive and skeletal complications. Previous research has found delayed growth and pubertal maturation with type 1 diabetes and poor glycemic control. The effect of diabetes management on menarche is important to clarify, because tighter control might prevent these complications. Objective: The objective of this study was to investigate age at menarche in young women with type 1 diabetes and examine the effect of diabetes management [e.g. total glycosylated hemoglobin (GHb) level, number of blood glucose checks, insulin therapy intensity, and insulin dose] on age at menarche in those diagnosed before menarche. Design: The Wisconsin Diabetes Registry Project is a follow-up study of a type 1 diabetes population-based incident cohort initially enrolled between 1987 and 1992. Setting: This study was performed in 28 counties in south-central Wisconsin. Patients or Other Participants: The study participants were recruited through referrals, self-repor...

Management of diabetes using adaptive control

Abstract: The review focuses on adaptive systems for insulin treatment in type 1 diabetes. The review consists of two parts. First, adaptive approaches are described, which exploit infrequent glucose measurements (four to seven measurements per day). Second, adaptive approaches are described, which exploit frequent or continuous glucose measurements (every hour or more often). Each part is further divided into two subparts separating off-line and on-line adaptive techniques. The latter represents treatment strategies, which rely on continuous re-assessment of the glucoregulatory system. The former refers to treatment strategies, which are fixed for a day or longer and are revisited from time to time. It is concluded that the role of adaptive approaches will increase as new continuous glucose-sensing monitors reach the market. Copyright © 2004 John Wiley & Sons, Ltd.