Patient self-monitoring of blood glucose and refinements of conventional insulin treatment

The role of telenursing in the management of Diabetes Type 1: A randomized controlled trial

BACKGROUND

Diabetes Mellitus type 1 (T1DM) is a chronic disease that requires patients' self-monitoring and self-management to achieve glucose targets and prevent complications. Telenursing implicates technology in the interaction of a specialized nurse with patients with chronic diseases in order to provide personalized care and support.

OBJECTIVE

To evaluate the effect of telenursing on T1DM patients' compliance with glucose self-monitoring and glycemic control.

DESIGN

Randomized controlled study.

SETTINGS

Outpatient Department of Diabetes, Endocrinology and Metabolism of a University Hospital in Northern Greece.

METHODS

Ninety-four T1DM patients were recruited and randomized in two groups by a random number generator. The intervention group (N = 48) was provided with telenursing services. A specialized nurse made a weekly contact via telephone motivating patients to frequently measure blood glucose and adopt a healthy lifestyle. The control group (N = 46) received standard diabetes advice and care in the clinic. The primary outcome was the effect of the intervention in glucose control and glucose variability. The secondary outcome was the effect on frequency of self-monitoring. SPSS 20.0 was used for data analysis.

RESULTS

The two groups did not differ in age, sex, physical activity or initial HbA1c. In the intervention group, blood glucose significantly decreased at the end of the study in all predefined measurements, compared to control group: morning (93.18 ± 13.30 mg/dl vs. 105.17 ± 13.74 mg/dl, p < 0.005), pre-prandial (114.76 ± 9.54 mg/dl vs. 120.84 ± 4.05 mg/dl, p < 0.005), post-prandial (193.35 ± 25.36 mg/dl vs. 207.84 ± 18.80 mg/dl, p < 0.005), and HbA1c decreased significantly over time in the intervention group (8.3 ± 0.6% at the beginning of the study vs. 7.8 ± 1% at the end of the study, p = 0.03). In the intervention group there were also fewer omitted glucose measurements than in the control group.

CONCLUSIONS

Patients in the intervention group achieved better glucose control and more frequent self-monitoring than patients in routine care in the clinic. The findings of our study indicate that telenursing can motivate T1DM patients to better control their disease.

Home monitoring of blood glucose and insulin therapy without a photometer

The BM-Test-Glycemie 1-44 test strip facilitates self-monitoring without the use of a photometer. In a population of 33 diabetic patients (age 24.8 +/- 2.9 years) 94% took part in home monitoring for 6-10 months. Of 29 who answered a questionnaire 25 preferred blood glucose testing to urine testing. In a "beta-cell school" it was taught that it is rational if home monitoring of blood glucose is combined with a tailored insulin treatment consisting of long-acting insulin (Ultralente) as a basal insulin and regular insulin (Actrapid) as a meal insulin. In a group of 24 labile diabetic patients 17 preferred this regime compared to earlier use of intermediate acting insulin and regular insulin. Six of these preferred the regular insulin to be taken in three doses. Hypoglycemia, when it occurred, was less distressing in symptoms than previously. Among patients with recent onset of diabetes active participation with dose reduction was seen during the honey-moon stage. The regime is logical and generative, offers a basis for an individualized therapy and a high remission frequency may be expected.

Telecare for patients with type 1 diabetes and inadequate glycemic control: a randomized controlled trial and meta-analysis

OBJECTIVE

To determine the efficacy of telecare (modem transmission of glucometer data and clinician feedback) to support intensive insulin therapy in patients with type 1 diabetes and inadequate glycemic control.

RESEARCH DESIGN AND METHODS

Thirty-one patients with type 1 diabetes on intensive insulin therapy and with HbA1c >7.8% were randomized to telecare (glucometer transmission with feedback) or control (glucometer transmission without feedback) for 6 months. The primary end point was 6-month HbA1c. To place our findings in context, we pooled HbA1c change from baseline reported in randomized trials of telecare identified in a systematic review of the literature.

RESULTS

Compared with the control group, telecare patients had a significantly lower 6-month HbA1c (8.2 vs. 7.8%, P = 0.03, after accounting for HbA1c at baseline) and a nonsignificant fourfold greater chance of achieving 6-month HbA1c < or =7% (29 vs. 7%; risk difference 21.9%, 95% CI -4.7 to 50.5). Nurses spent 50 more min/patient giving feedback on the phone with telecare patients than with control patients. Meta-analysis of seven randomized trials of adult patients with type 1 diabetes found a 0.4% difference (95% CI 0-0.8) in HbA1c mean change from baseline between the telecare and control groups.

CONCLUSIONS

Telecare is associated with small effects on glycemic control in patients with type 1 diabetes on intensive insulin therapy but with inadequate glycemic control.

Patient self-management of oral anticoagulation

Patient self-management of oral anticoagulation is now widely practised in Germany and the USA. There are three different home-testing monitors available in the UK which are all reliable in terms of accuracy and reproducibility of results. Selected patients can be trained to perform their own International Normalized Ratio (INR) testing and dosing, with outcomes as good if not better than those from specialized anticoagulant clinics. Consensus on the frequency of testing and what quality control should be deployed is lacking. The cost-effectiveness in the UK is unproven.

Process improvement for bedside capillary glucose testing in a large academic medical center: the impact of new technology on point-of-care testing

Point-of-care testing (POCT) for the management of patients with diabetes has become a standard of care. Originally, diabetic monitoring was accomplished by manual urine dipsticks. The development of hand-held, battery-operated capillary glucose monitors radically improved the ability of physicians and nurses to monitor diabetic patients during their hospital stay. Capillary glucose meters have been shown to provide accurate results under controlled conditions, but a number of early meters had issues with the quality of testing when used by non-laboratory personnel. Bedside capillary glucose testing was first initiated in our hospital in 1990, using a first-generation glucose meter that could measure a glucose value within 2 min. Operator errors were common because the glucose strips required wiping and the testing required timing. Furthermore, these early meters had no data storage or data management capabilities. In 1995, we transitioned to a second-generation meter with a rudimentary data management and storage capability that could be downloaded to a portable laptop. A log of quality control (QC) data could be derived from the download. A major problem with this device was the need to bring the instruments and laptop together, which was labor intensive and difficult to sustain over long periods of time in a large institution. We recently implemented a third-generation instrument (the Abbott Precision PCx) with a data management system (Precision NET). This device significantly expands the data management and networking capabilities of the bedside glucose meter, as shown in Table 5. Glucose values can now be performed in a fraction of the time of the first-generation meters, the need to wipe the glucose strips has been eliminated, and only certified operators can use the instrument. Networking technology allows for centralized quality control management, and the ability to network with other point-of-care technologies using intranet and in the near future internet applications. Collectively, these developments have radically improved the efficiency and quality of bedside capillary glucose testing, and have significantly enhanced the ability to manage this important technology.

Outpatient self-management of warfarin therapy: a pilot study

Self-testing and adjusting of warfarin dosages by patients is an evolving strategy for management of oral anticoagulation. We performed this open, prospective, 3-month pilot study to assess the feasibility of conducting a large, randomized trial comparing self-managed with physician-managed anticoagulation. Ten competent patients with planned anticoagulation for at least 3 months were provided education on warfarin therapy and trained to use an individualized warfarin nomogram. International normalized ratios (INRs) were determined weekly for 12 weeks and reported with warfarin dosages to the investigator for the first 8 weeks only. Eight patients elected to use a home monitor (ProTime) to measure INRs. Patients maintained 76.5% (range 50-91.7%) of INRs within the target range. In 119 dosage adjustment decisions, there were only 3 errors (2.5%). No bleeding or thrombotic complications occurred. To confirm concordance, initial and final INRs were measured concurrently by the ProTime monitor and laboratory. The mean absolute difference for 16 paired INR determinations was 0.33 (range 0.02-0.9). All patients expressed satisfaction and a desire to continue with self-management. This pilot study provides support for conducting a prospective, large-scale, randomized trial.

Implications and results of the Diabetes Control and Complications Trial

After almost 60 years of debate, the DCCT demonstrated that intensive management that is able to lower blood glucose and HbA1c to levels that are close to normal markedly lowers the risk for and progression of the microvascular and neuropathic complications of IDDM. The challenge to pediatricians and other clinicians is to achieve and maintain such stringent treatment goals in children and adolescents, who are especially difficult to manage, without causing an unacceptably high rate of severe hypoglycemia. Translation of DCCT recommendations into clinical practice is best accomplished by multidisciplinary teams who are experienced in the management of young patients with IDDM and are willing to use the variety of unconventional treatment regimens that may be required. Patients and families must be instructed on ways to reduce the risk for hypoglycemia and be able to recognize and treat hypoglycemic events that require assistance. New agents, such as insulin lispro, may enhance the ability to achieve strict glycemic control, but the treatment remains a burden. Nevertheless, in patients in whom treatment is successful, the improvement in long-term prognosis more than justifies the investment in time, effort, and resources.

Utilization and cost analysis of bedside capillary glucose testing in a large teaching hospital: implications for managing point of care testing

PURPOSE

To study the use and cost of bedside capillary glucose testing in a large teaching hospital.

PATIENTS AND METHODS

In a prospective study of 40 inpatient units and 10 outpatient units at Massachusetts General Hospital, records were maintained by each unit of the date, time, operator, and results of patient and quality control tests. Cost analysis was performed using data from time studies, test tallies in logbooks, and hospital administration records.

RESULTS

The number of glucose meters in the hospital increased from 10 to 54 over a 2-year period. In 1992, 67,596 tests were performed by the bedside method, representing 30.7% of all glucose measurements performed in the institution. The majority of tests (94.7%) were performed on inpatients, and 10.2% of all hospital admissions underwent bedside glucose testing. The impact on the number of glucose tests performed in the clinical laboratories was minimal, indicating that bedside glucose testing was added as an extra test rather than as a substitute for laboratory-based glucose measurements. The cost of bedside glucose testing was $4.19 per test compared with $3.84 in the clinical laboratory. The cost varied from one unit to another (median $5.52, range $3.08 to $48.16), an effect largely attributed to the difference in the volume of tests performed by different units. In seven high-volume units the cost per test was lower than the corresponding value in the laboratory. The cost of bedside glucose testing included labor (80.2%) and supplies (19.8%). The percent of costs attributed directly to patient testing was 57.7%, whereas the costs for all other related activities (training, quality control, and quality assurance) was 42.3%.

CONCLUSIONS

Bedside capillary glucose testing is a rapidly expanding technology and is performed on a significant percentage of hospital admissions. Bedside glucose testing is not inherently more expensive than centralized laboratory measurements but implementation on inefficient care units with low utilization can add substantially to the cost. Much of the excess cost of the bedside method can be attributed to the high costs of quality control and quality assurance, training, and documentation.

Implementation of capillary blood glucose monitoring in a teaching hospital and determination of program requirements to maintain quality testing

PURPOSE

To study the implementation of bedside capillary glucose monitoring using a hospital-wide quality control (QC) program.

METHODS

A prospective study of QC performance in 7 outpatient and 39 inpatient treatment units was performed in a large teaching hospital over a 2-year period. Approximately 800 nurses were trained to perform bedside capillary glucose monitoring (Accu-Chek II, Boehringer-Mannheim, Indianapolis, IN). An eight-point QC program was instituted including proficiency testing, instrument maintenance, performance of daily controls, storage of reagent strips and supplies, instrument calibration, and documentation procedures.

RESULTS

Comparison of laboratory and bedside test results (split-sample proficiency testing) revealed Y = 1.004X + 7.26, r = 0.95, with a mean percent difference of -4.2% (p < 0.001). Less than 7% of results fell outside +/- 20% of the laboratory results. QC scores (0 = worst to 4 = best), based on adherence to the QC program, improved from 0 on the first inspection to 3.7 +/- 0.17 by the 11th inspection. The most common QC deficiencies were failure to perform split-sample testing (41.4%) and failure to perform instrument maintenance (30.2%). Significant differences were noted in the QC performance of different types of medical services. During the 2-year study period, the total number of glucose assays performed in the clinical laboratories decreased by 22.2% concurrent with initiation of bedside testing. The number of instruments in the hospital increased from 10 to 46.

CONCLUSIONS

Bedside capillary glucose assays can be widely implemented in large hospitals with an acceptable degree of accuracy. QC programs with frequent inspections are necessary to identify units that function inadequately, and a formal disciplinary policy is required to ensure compliance with the program.

Risks of jet injection of insulin in children

The aim of our study was to assess whether a non-invasive insulin injector could improve the metabolic control of ten diabetic children complaining of painful injections with syringe and needle. The cumulative study period amounted to 1347 days. Whereas a non-significant rise in insulin needs was observed (from 0.98 +/- 0.03 to 1.03 +/- 0.06 units/kg per day, mean +/- sem), mean HbA1c value remained unchanged (8.9% +/- 0.4% vs 9.0% +/- 0.5%). Jet injections were felt as less painful than those using syringe and needle (nine out of ten cases). This advantage was hampered by side-effects in eight out of ten cases such as episodes of glycoketonuria (six out of ten cases) leading to hospitalization in three patients. Other side-effects included inability to adjust injection pressure (four out of ten cases) and technical failure requiring an exchange of injector in five cases. The four children with most serious problems were significantly younger (P = 0.009) than other subjects. In conclusion, this type of injector should be discouraged in young diabetic children. For older children and adolescents, it may be an alternative to syringe and needle provided repeated detailed information and tight medical supervision is available.

How efficient is sliding-scale insulin therapy? Problems with a 'cookbook' approach in hospitalized patients

Sliding-scale insulin therapy is seldom the best way to treat hospitalized diabetic patients. In the few clinical situations in which it is appropriate, close attention to details and solidly based scientific principles is absolutely necessary. Well-organized alternative approaches to insulin therapy usually offer greater efficiency and effectiveness.

A contribution of qualitative research to a better understanding of diabetic patients

In spite of advances in the management of diabetes mellitus, late complications still present problems. Research suggests that improved metabolic control, including the change of lifestyle, which requires the patient's own willingness and ability to adapt, could limit those complications. This article is intended to provide the background to a long-term research programme designed to gain a deeper understanding of diabetic patients' perspectives in their attempt to adapt. It describes an important phase in the programme, building on the conceptual categories emerging from a group of diabetic patients in a previous study (Ternulf Nyhlin et al. 1987). It also uses the experiences of further groups of diabetic patients, in an attempt to show the usefulness of a cumulative approach towards the building up of a theoretical framework. Some inherent methodological issues are discussed.

Monitoring of diabetes in children

There is increasing evidence to show that a high degree of metabolic control in diabetes mellitus delays and reduces the severity and incidence of the microvascular complications of diabetes. The goals of appropriate therapy for diabetes should hence include an all-out effort to achieve as near normal metabolism as possible but it should be individualized accordingly. In actual practice it is difficult to achieve "good" control especially in diabetic children without attendant hypoglycaemia and its sequelae. Diabetic control is difficult to define in clinical terms, and the maintenance of metabolic control in diabetes involves a complex interaction of pathological, physiological, psychological, familial, social and environmental variables. The aims in insulin-dependent diabetic children is to ensure optimal emotional and physical health of the child or adolescent. The various modalities available for monitoring or assessment of diabetic control shall be discussed.

Long-term safety, efficacy and side-effects of continuous subcutaneous insulin infusion treatment for type 1 (insulin-dependent) diabetes mellitus: a one centre experience

A follow-up study of 116 Type 1 (insulin-dependent) diabetic patients on long-term continuous subcutaneous insulin infusion was conducted after 4.5 +/- 0.2 years. The average HbA1c-value of these patients decreased by 1% to 6.7 +/- 0.1% during this observation period. Typical side effects of continuous subcutaneous insulin infusion such as skin inflammation at the catheter insertion site occurred with similar frequency as has been reported previously by other authors. Diabetic ketoacidosis (0.14 per patient year) and disabling hypoglycaemia (0.1 per patient year, including 0.05 hypoglycaemic coma per patient-year) occurred at substantially lower rates than in other comparable studies with Type 1 diabetic patients at a similar degree of metabolic control. Subgroup evaluation suggested that a normal (less than 5.6%) HbA1c-value at follow-up was associated with increased incidence of disabling hypoglycaemia, whereas poor metabolic control (HbA1c greater than 7.5%) was associated with increased rates of skin complications and hospital treatment for ketoacidosis. Thus, under the policies of this diabetes centre, continuous subcutaneous insulin infusion has proved to be beneficial to a large proportion of experienced adult Type 1 diabetic patients, who voluntarily had opted for, and continued with, this particular mode of insulin treatment.

Implementation of a successful bedside capillary blood glucose monitoring program by registered nurses in an acute care facility

This paper describes the process of implementing a successful bedside capillary blood glucose monitoring (CBGM) program in an acute care, university- affiliated, general hospital. A quality-assurance program was established that included simulta neous laboratory analysis and bedside analysis of the same specimen. Results were correlated over a 12-month period (r = . 92). The findings suggest that sustained positive results are possible in a well-planned bedside CBGM program by registered nurses if the nursing staff receives adequate preparation and partici pates in an ongoing quality- assurance program.

The Minnesota Arthritis Training Program: emphasis on self-management, not compliance

Based on a needs assessment of our ambulatory patients and review of available arthritis education programs, we developed an innovative education and exercise program, the Minnesota Arthritis Training Program (MATP). Patients are taught self-management skills including how to: (1) interpret changing physical symptoms and limitations caused by joint inflammation and apply modifications to their individualized exercise program; (2) recognize common drug toxicites and use a decision analysis schema to manage side effects to decrease the risk of serious toxicity and decrease dependency on professionals safely; (3) develop strategies to modify activity schedules to make the most of limited stamina; (4) recognize and understand psychological problems produced by rheumatoid arthritis (RA) including sexual dysfunction, depression and breakdown of communication; and (5) reconstitute social support systems.

Management of diabetics with the use of a microprocessor: comparison of insulin treatments based on blood and urine glucose levels

The insulin treatment of 8 insulin-dependent diabetics was controlled with a microprocessor (Better Control Medical Computer, BCMC, Inc., Toronto, Canada) with information derived from blood or first voided urine glucose concentrations assessed by reagent strips four times a day, before the three main meals and bedtime snack. The microprocessor recommends modification of the insulin doses so as to reach a pre-prandial blood glucose value of 110 mg/dl or a urine glucose concentration of 0.1 g/dl. During the first two weeks self-management was uniformly applied by the patients, based on their blood glucose concentration. Subsequently, it was continued by the patients who were divided into two groups, one using the blood, the other the urine glucose concentrations, each for three weeks, alternately. During microprocessor treatment the patients' mean blood glucose profiles decreased from 152 +/- 37 mg/dl to 126 +/- 28 mg/dl. No difference was found between treatments based on blood or urine glucose concentrations concerning either the mean blood glucose profiles or the number of hypoglycemic episodes in the presence of an average glucose threshold and good renal function. The first voided urine glucose concentration and mean and maximal blood glucose values obtained at the time of urine filtration were closely correlated (r = 0.82 and 0.86, p less than 0.001).

A primer on insulin use

Insulin treatment, if thoughtfully designed and carefully monitored, can allow the diabetic patient to lead a close-to-normal life. Several types of insulin with varying times of action are available, and regimens can be tailored to a patient's needs and life-style, with alterations made for such things as time changes, exercise, and fasting for surgical procedures. Self-monitoring of blood glucose levels can provide patients with an important measure of independence, as can instruction on recognizing and correcting episodes of hypoglycemia. Insulin is an important part of managing ketoacidosis and hyperosmolar hyperglycemia syndrome, although success depends on overall care.

Home blood glucose monitoring: keystone for modern diabetes care

Home monitoring of capillary blood glucose concentrations has changed diabetes care, giving physicians and patients a way to adjust their therapy and achieve better diabetic control. The practical strategies and equipment for home diabetic monitoring are discussed, including the changing role of urine testing and how inexpensive machines may enhance the value of blood glucose monitoring.

Rapid insulin initiation in non-insulin-dependent diabetes mellitus

Three insulin-initiation regimens were compared in 43 severely hyperglycemic non-insulin-dependent diabetic patients: a "standard" regimen (Lente insulin once daily), a "rapid" regimen (a mixture of regular and Lente insulins twice daily), and a "rapid/intravenous" regimen (the "rapid" regimen preceded by overnight intravenous infusion of regular insulin). The mean serum glucose level fell more rapidly in both groups receiving "rapid" regimens, reaching less than 200 mg/dl in 3.0 days with the "rapid" regimen compared with 5.9 days with the "standard" regimen (p less than 0.005). Duration of hospitalization was similarly reduced (6.4 versus 9.9 days, p less than 0.0001) as was the cost of hospitalization. In contrast to the "rapid" regimens, symptomatic hypoglycemia was common and adequate glycemic control was rare with the "standard" regimen. Thus, rapid initiation of insulin therapy with 0.5 to 0.6 units/kg per day of a mixture of regular and intermediate-acting insulins given twice daily is effective, safe, and reduces the cost of hospitalization in patients with non-insulin-dependent diabetes mellitus who require insulin treatment.

Assessment of long-term glycemia in type I diabetes using multiple blood glucose values stored in a memory-containing reflectometer

The relationship between repetitive hemoglobin A1 values and daily blood glucose tests performed by 20 insulin-dependent diabetic outpatients was assessed over a six-week period using a modified reflectance meter capable of storing blood glucose determinations automatically. An average of four and a half determinations per subject per day was recorded with a range of average blood glucose values between 82 +/- 2 mg/dl and 316 +/- 5 mg/dl (mean +/- SE). The relationship between average blood glucose and hemoglobin A1 values was significant when hemoglobin A1 values at the end of the six-week period were correlated with the mean blood glucose level over that period (r = 0.55, p less than 0.02), but improved when a more remote hemoglobin A1 value obtained at 10 weeks was used (r = 0.64, p less than 0.005). Hemoglobin A1 values covering two-week intervals were extremely poor in reflecting average glycemia. The average fasting blood glucose level in these subjects was highly correlated with the overall daily blood glucose values (r = 0.89, p less than 0.0001), although the coefficients of variation of these parameters averaged 43 +/- 3 percent and 47 +/- 2 percent, respectively, and were greater than that of the hemoglobin A1 values over six weeks (10 +/- 2 percent). It is concluded that labile blood glucose control in patients with insulin-dependent diabetes is accurately reflected by the average fasting blood glucose level, although multiple determinations must be employed. Satisfactory assessment may be made by use of hemoglobin A1 value provided that the hemoglobin A1 determination follows a sufficiently long period of time, presumably related to the turnover of glycosylated hemoglobin.

Bedside capillary glucose measurement by staff nurses in a general hospital

The accuracy of capillary blood glucose monitoring has been well demonstrated when applied by patients in the outpatient setting or by specially trained nurses on inpatient diabetes units. In order to determine the applicability of this technique in the more general hospital setting, a program was initiated for instructing general staff nurses in the use of Chemstrips bG strips and the Accu-Chek bG meter. As a pilot study, nurses on four general medical and surgical hospital floors performed capillary glucose determinations within 15 minutes of the drawing of venous blood samples for determination of plasma glucose in the hospital's Chemistry Laboratory. Two hundred ten paired measurements were made by 31 nurses. Linear regression analysis yielded a Pearson correlation coefficient of 0.96 between bedside and laboratory glucose measurements. The mean percent deviation between the two values was 7.9 percent. Acceptance by both nurses and patients was high. Properly supervised capillary glucose monitoring can provide a valuable adjunct to the care of hospitalized patients with diabetes.

Serum fructosamine concentration as measure of blood glucose control in type I (insulin dependent) diabetes mellitus

Serum fructosamine activity was studied in 42 patients with type I (insulin dependent) diabetes mellitus and 30 non-diabetic volunteers as an index of blood glucose control. There was a significant correlation both between fructosamine and glycosylated haemoglobin values (r = 0.82) and between fructosamine and the fasting C peptide concentration (r = -0.81). Test results in 14 of the diabetics reflected the mean plasma glucose concentration calculated from 25 serial estimations in a single 24 hour period (r = 0.75; p less than 0.01) but not the mean amplitude of glycaemic excursion (r = 0.23; p greater than 0.05). Fructosamine concentrations measured in these multiple blood specimens did not change significantly throughout the day (mean coefficient of variation 4.1%) despite wide variability of the respective plasma glucose concentrations (mean coefficient of variation 36.2%). It is concluded that a single random serum sample analysed for fructosamine concentration provides a simple and reliable assessment of glucose homoeostasis in patients with type I diabetes mellitus.

Seven years experience of home management in pregnancy in women with insulin-dependent diabetes

Fifty-eight of a consecutive series of 75 pregnancies in women with insulin-dependent diabetes went into the third trimester. Diabetes was managed by home blood glucose monitoring and women were not routinely admitted at any stage before delivery. The mean number of in-patient days before delivery was 15 for the whole series but has been reduced to 9 during the past four years. Each woman performed an average of 171 blood glucose measurements during her pregnancy. Mean blood glucose (including post-prandial levels) fell significantly from 7.9 mmol/l in the first trimester to 7.3 in the second and 6.4 in the third. Mean percentage of haemoglobin A1 was within the normal range in the second and third trimesters. The cesarean section rate was high at 66% but there were no perinatal deaths. Three infants had congenital abnormalities. We conclude that home blood glucose monitoring is a safe and effective way of managing pregnant diabetic women as out-patients. The cost of meters and sticks is repaid many times over in the saving of hospital costs. In addition, home blood glucose monitoring is popular with the patients and many choose to continue it after delivery.

Reliability of blood glucose monitoring by patients with diabetes mellitus

Nineteen patients with insulin-dependent diabetes mellitus were evaluated for overall reliability of self-generated data from capillary blood glucose monitoring. For a period of 12 to 14 days, standard reflectance meters used by these subjects were replaced by meters internally modified with memory chips capable of storing all glucose readings by date and time. The subjects were not aware of this modification and were instructed to continue to test capillary blood glucose as they had been and to continue their practice of recording the meter readings in a logbook. To assess reliability of patient-generated data as recorded in the logbook, the addition, deletion, and alteration of test results were determined. A significantly lower (p less than 0.0001) mean blood glucose level was reported in the logbooks than recorded in the memory reflectance meters. Differences in logbooks and memory reflectance meters ranged from 0 to 109 mg/dl. Three fourths of the subjects had reported lower than actual mean blood glucose values. Under-reporting, or omission of memory reflectance meter readings, averaged 10 percent, whereas over-reporting or addition of phantom values averaged 40 percent. An average of 26 percent of the logbook entries were not identical to memory reflectance meter values determined at the corresponding time. Two thirds of the subjects had reported values in such a manner as to obscure hyper- and hypoglycemia, leading to misleading clinical impressions about the fluctuation in metabolic control. Previous glycemic control, patterns of logbook recording, or visits to the clinic were not found to be predictive of the reliability of patient self-monitoring regimens.

Absorption of isophane (NPH) insulin and its clinical implications

Absorption of 125I-NPH insulin (125I-isophane insulin) (40 IU/ml) was studied in eight diabetics given 50% and 150% of their normal daily dose of insulin. Insulin absorption correlated with plasma insulin (r = 0.97, p less than 0.001) and blood glucose (r = -0.87, p less than 0.01) concentrations. Absorption was slower at higher doses, so that trebling the insulin dose only doubled the amount absorbed over the first 24 hours. The plasma elimination half time (t12) of insulin was about five minutes. Thus, the disappearance of radiolabelled insulin is a reliable and quantitative index of insulin absorption; subcutaneous degradation, if present, is minimal and constant. Changes in dise of intermediate-acting insulin further increases the large variation in insulin absorption. This implies that minor adjustments of intermediate insulin dosage are probably futile.

Glycemic control in insulin-dependent diabetes mellitus. Comparison of outpatient intensified conventional therapy with continuous subcutaneous insulin infusion

We compared glycemic control achieved on an outpatient basic with three insulin regimens in 10 patients with insulin-dependent diabetes mellitus. The regimens studied included: (1) intensified conventional therapy with twice-daily regular and lente insulin; (2) intensified conventional therapy with long-acting ultralente insulin plus multiple preprandial injections of regular insulin; (3) continuous subcutaneous insulin infusion. Each treatment period was two months long. At the beginning of the study and the close of each study period, patients were hospitalized for a 48-hour evaluation of glycemic control. Each new insulin regimen was begun after discharge, with the dosage adjusted using preplanned algorithms, patient self-monitoring of blood glucose and defined blood glucose targets. Glycemic control markedly improved on all three treatment regimens, to a comparable degree, as assessed by mean plasma glucose level, mean amplitude of glycemic excursions, M value (an index of glycemic lability), urinary glucose excretion and glycosylated hemoglobin level.

Diabetes mellitus in childhood

This review has attempted to highlight current views on the aetiology and management of children with type 1 diabetes mellitus. Emphasis has been placed on the management of ketoacidosis, the need for education and the use of home blood glucose monitoring. A perspective on new research direction has been given.