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Hashem R, Mulnier H, Abu Ghazaleh H, Halson-Brown S, Duaso M, Rogers R, Karalliedde J, Forbes A. Characteristics and morphology of lipohypertrophic lesions in adults with type 1 diabetes with ultrasound screening: an exploratory observational study. BMJ Open Diabetes Res Care 2021; 9:9/2/e002553. [PMID: 34876413 PMCID: PMC8655520 DOI: 10.1136/bmjdrc-2021-002553] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 11/14/2021] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Lipohypertrophy is a common complication of exposure to insulin therapy. Despite the prevalence of lipohypertrophy and its potentially hazardous effects on glucose regulation, it remains a relatively understudied problem in diabetes. The objective of this study was to characterize lipohypertrophic tissue using ultrasound in adults with type 1 diabetes. RESEARCH DESIGN AND METHODS An observational study of 74 people with type 1 diabetes from a diabetes center in South East London. Participants' insulin exposed areas were scanned with ultrasound, with a high-frequency linear probe (6-13 MHz). The observed tissue changes were described, measured and graded according to nodule size and thickness of the dermal layer. RESULTS Participants mean age and diabetes duration were 40.6 (±14.2) and 18.3 (±10.9) years, respectively, and 60% (n=44) were male. A total of 740 lipohypertrophic nodules were observed, ranging from 1.8 mm to 40 mm in width. The mean (SD/range) number of nodules per participants was 10.4 (±6.2/1-29). Delineation between the dermal layers was disrupted in all current injection sites. In 52 participants (70%), there was a 30% increase in dermal thickness compared with local none injected tissue, and in 36 participants (48%) the increase was 50%. The level of thickness was >3 mm in the abdominal areas of 22 (40%) of these participants and in thighs of eight participants (17.8%). Hypoechogenic areas suggestive of necrotic tissue were observed within the lipohypertrophic nodules of 22 (30%) participants. Needle length and nodule depth were correlated (r=0.69, p<0.001). A conceptual model of the insulin exposed tissue changes observed was constructed. CONCLUSIONS The study confirms that insulin-exposed tissue changes are heterogenous and has provided conceptual and grading frameworks for classifying these changes. Further studies are required to establish the clinical implications of these classifications, in relation to glucose regulation and other clinical parameters.
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Affiliation(s)
- Rabab Hashem
- Division of Care in Long-term Conditions, King's College London, London, UK
| | - Henrietta Mulnier
- Division of Care in Long-term Conditions, King's College London, London, UK
| | - Haya Abu Ghazaleh
- Division of Care in Long-term Conditions, King's College London, London, UK
| | - Susan Halson-Brown
- Department of Women & Children's Health, King's College London, London, UK
| | - Maria Duaso
- Division of Care in Long-term Conditions, King's College London, London, UK
| | - Rebecca Rogers
- Division of Care in Long-term Conditions, King's College London, London, UK
| | | | - Angus Forbes
- Division of Care in Long-term Conditions, King's College London, London, UK
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Hacene MNB, Saker M, Youcef A, Koudri S, Cheriet S, Merzouk H, Lounici A, Alkhatib N. Insulin injection technique in the western region of Algeria, Tlemcen. Pan Afr Med J 2020; 36:327. [PMID: 33193981 PMCID: PMC7603825 DOI: 10.11604/pamj.2020.36.327.21278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 07/13/2020] [Indexed: 11/24/2022] Open
Abstract
Introduction Algeria has more than 1.7 million diabetic patients on to whom a descriptive assessment particularly on the insulin usage behaviors has not yet been initiated, although is needed. This study aims to provide a descriptive analysis of how Algerian diabetic patients perceive and apply insulin injection techniques. Methods using the “patient” questionnaire within the Injection Technique Questionnaire (ITQ) 2016 survey, this study assessed the insulin injection practices of 100 patients recruited over a seven-month period in western Algeria at the Tlemcen University Hospital Center. The results of this study are compared to those of the ITQ 2016 survey. Results pens are the instruments of injection for 98% of Algerians who continue to use mostly long needles of 6- and 8-mm, although 4mm needles are the recommended safer option. Insulin analogues (fast and basal) are plebiscite. Arms and thighs are the preferred injection sites; the abdomen (the preferred site elsewhere) is neglected for reasons to be investigated. The correct re-suspension technique for cloudy insulin is unknown. Extensive pen needle re-use (10+ times) for over half of the patients exposes them to both higher intramuscular (IM) injection risk and lipohypertrophy (LH). Injection training is performed in Algeria by the diabetologist. Conclusion this study describes for the first time Algerian patients´ insulin injection technique. It highlights their skills and identifies many deficiencies which patients and professionals must correct given the issues in this area.
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Affiliation(s)
- Mohammed Nassim Boukli Hacene
- Department of Pharmacy, Faculty of Medicine, University Abou-Bekr Belkaïd, Tlemcen 13000, Algeria.,Laboratory of Physiology, Pathophysiology and Biochemistry of Nutrition, Department of Biology, Faculty of Natural and Life Sciences, Earth and Universe, University Abou-Bekr Belkaïd, Tlemcen 13000, Algeria
| | - Meriem Saker
- Laboratory of Physiology, Pathophysiology and Biochemistry of Nutrition, Department of Biology, Faculty of Natural and Life Sciences, Earth and Universe, University Abou-Bekr Belkaïd, Tlemcen 13000, Algeria
| | - Amina Youcef
- Department of Pharmacy, Faculty of Medicine, University Abou-Bekr Belkaïd, Tlemcen 13000, Algeria.,Laboratory of Physiology, Pathophysiology and Biochemistry of Nutrition, Department of Biology, Faculty of Natural and Life Sciences, Earth and Universe, University Abou-Bekr Belkaïd, Tlemcen 13000, Algeria
| | - Soumia Koudri
- Department of Pharmacy, Faculty of Medicine, University Abou-Bekr Belkaïd, Tlemcen 13000, Algeria
| | - Souad Cheriet
- Department of Pharmacy, Faculty of Medicine, University Abou-Bekr Belkaïd, Tlemcen 13000, Algeria
| | - Hafida Merzouk
- Laboratory of Physiology, Pathophysiology and Biochemistry of Nutrition, Department of Biology, Faculty of Natural and Life Sciences, Earth and Universe, University Abou-Bekr Belkaïd, Tlemcen 13000, Algeria
| | - Ali Lounici
- Department of Internal Medicine, University Hospital Center Tidjani Damerdji Tlemcen 13000, Algeria.,Laboratory of Research on Diabetes, Faculty of Medicine, University Abou-Bekr Belkaïd, Tlemcen 13000, Algeria
| | - Nimer Alkhatib
- Center for Health Outcomes and PharmacoEconomic Research, College of Pharmacy, University of Arizona, Tucson, Arizona, USA.,MidCapital Health Care, Amman, Jordan
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Deas CM, Clark SK, Freeman MK. Evaluation of Antidiabetic Injectable Technique: Is There an Association between Accuracy and Health Literacy or Duration of Diabetes? Innov Pharm 2020; 11. [PMID: 34017647 PMCID: PMC8132543 DOI: 10.24926/iip.v11i1.2320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Introduction: Effective diabetes pharmacotherapy often involves injectable medications, which if used inappropriately represents a type of unintentional medication nonadherence that leads to poor outcomes. Objectives: The primary objective of this study was to assess the percent of patients who accurately prepared, administered, stored, and disposed of their injectable diabetes medication. Secondary objectives included comparing the accuracy of injectable use among those with diabetes <5 years vs. ≥ 5 years duration and those with limited vs. proficient health literacy. Methods: This was a prospective analysis conducted on a convenience sample of patients who received a pilot pharmacist-led, quality improvement service at an urban, ambulatory care clinic. The service components included health literacy screening, using the Rapid Assessment of Adult Literacy in Medicine – Short Form (REALM-SF) tool, evaluation of injectable technique by use of a standardized questionnaire, and provision of medication education. Duration of diabetes was determined by patient self-report. Chi-square and Fisher’s exact tests were utilized to assess accuracy of injectable technique in two group comparisons: (1) patients with limited vs. proficient health literacy and (2) patients with diabetes <5 years vs. ≥5 years. Results: Thirty-five patients were included in the analysis. Despite the majority (71.4%) of patients reporting prior education on injectable use, 54.3% reported at least one error in product use. Significant findings noted were that those with limited health literacy had higher rates of accurately using the skin-fold technique and appropriate angle for injection vs. those with proficient health literacy (p<0.05 for both comparisons). Likewise, more patients in the cohort of diabetes duration ≥5 years accurately rotated the injection site vs. those with a duration <5 years (p=0.001). Conclusion: Errors in injectable technique were common in this study and spanned across health literacy levels and duration of diabetes. Patients prescribed injectable diabetes medications should be routinely educated on proper technique for use.
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Affiliation(s)
| | | | - Maisha Kelly Freeman
- At the time of the project completion and manuscript writing, the third author, Maisha Kelly Freeman was a Professor of Pharmacy Practice at Samford University's McWhorter School of Pharmacy in Birmingham, Alabama
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Abstract
Insulin infusion pump, continuous glucose monitoring (CGM), and insulin infusion set (IIS) have been developed to be increasingly feasible for people with type 1 diabetes (T1D). Several recently approved CGMs are transitioning from 7-day to 10-day wear time without the need for fingerprick recalibration. Nevertheless, studies and improvements on IIS, a critical part of insulin pump therapy, have been limited. In particular, the recommended wear time of IIS is still 2-3 days, which can hardly match the current duration of CGM for potential closed-loop system development. It is generally believed that both the inserted catheter and the subsequent infused insulin drug could induce particular subcutaneous tissue response and skin-related complications at the infusion site. In certain cases, poor glycaemic control, increased risk of hypoglycemia, and serious cosmetic impact on people with diabetes were observed. Skin complication has also been attributed as an important factor resulting users to discontinue insulin pump therapy. This article provides the rare systematic review of IIS induced subcutaneous tissue responses and skin complications, including the impacts from the inserted catheters, the subcutaneous infused insulin, and the adhesive or tape used to immobilize the catheter. The FDA's recommendation for the frequency of IIS change was further discussed. Future studies on this topic are required to further understand the IIS-related problems, and future strategies could be developed accordingly to significantly reduce the incidence of these problems, extend the wear time, and increase the acceptance of insulin pump based therapy.
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Affiliation(s)
- Ershuai Zhang
- Department of Chemical Engineering and
Materials Science, Wayne State University, Detroit, MI, USA
| | - Zhiqiang Cao
- Department of Chemical Engineering and
Materials Science, Wayne State University, Detroit, MI, USA
- Zhiqiang Cao, PhD, Department of Chemical
Engineering and Materials Science, Wayne State University, Detroit, MI 48201,
USA.
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Gentile S, Strollo F, Satta E, Della-Corte T, Romano C, Guarino G. Insulin-induced lypodistrophy in hemodialyzed patients: A new challenge for nephrologists? Diabetes Metab Syndr 2019; 13:3081-3084. [PMID: 31765982 DOI: 10.1016/j.dsx.2019.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 11/11/2019] [Indexed: 10/25/2022]
Abstract
Diabetes Mellitus (DM) is the most common cause of renal failure and ESRD all over the world, and often requires an individualized insulin treatment regimen. Malnutrition, depression-related eating behavior changes, high on-off-dialysis day-to-day glycemic variability and frequent hypoglycemic events occurring during or immediately after dialysis make it hard to identify best insulin dosage in hemodialyzed patients. This suggests a prudent attitude including non-stringent control, despite which repeated hypoglycemia quite often occurs in such patients. When looking for possible sources of hypoglycemia, health professionals too often overlook the identification of skin lipodystrophy (LD) due to an incorrect insulin injection technique. This mini-review focuses on the high frequency (57%) of LD in a cohort of 1004 insulin-treated people with DM on dialysis consecutively referring to our joint medical centers, and on its relationship with hypoglycemia and glycemic control/variability. When taking on such patients, care team members accept to face a complex disease burdened with several risk factors requiring high professional skills, and have to keep in mind also the possible presence of any LD areas eventually interfering with expected results. A timely educational intervention on the correct injection technique can help reduce the high risk of hypoglycemia and large glycemic variability in dialysed people with DM.
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Affiliation(s)
- S Gentile
- Campania University ''Luigi Vanvitelli", Naples, Italy; Nefrocenter Research Network, Naples, Italy.
| | - F Strollo
- Nefrocenter Research Network, Naples, Italy; Elle-Di and San Raffaele Research Institute, Rome, Italy
| | - E Satta
- Nefrocenter Research Network, Naples, Italy
| | - T Della-Corte
- Campania University ''Luigi Vanvitelli", Naples, Italy; Nefrocenter Research Network, Naples, Italy
| | - C Romano
- Nefrocenter Research Network, Naples, Italy
| | - G Guarino
- Campania University ''Luigi Vanvitelli", Naples, Italy
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Tosun B, Cinar FI, Topcu Z, Masatoglu B, Ozen N, Bagcivan G, Kilic O, Demirci C, Altunbas A, Sonmez A. Do patients with diabetes use the insulin pen properly? Afr Health Sci 2019; 19:1628-1637. [PMID: 31148992 PMCID: PMC6531956 DOI: 10.4314/ahs.v19i1.38] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM This study was conducted to evaluate the insulin pen application knowledge and skills of patients with diabetes. METHODS In our descriptive study, 200 patients with diabetes were asked to present the insulin pen injection technique on a mannequin and the steps of the pen injection implementation were noted on the data collection form as correct/incorrect by researchers. RESULTS More than 3 out of 4 (79.5%) of the participants were using the insulin pen or the cartridge after the expiry date, 70.5% were not rotating the injection site, and 63.0% were massaging the skin after injection. Injection sites complications were significantly more in those who were using the insulin pen or the cartridge after the expiry date, those who don't know the proper length of the needle and the possible body injection sites, those who don't rotate the injection sites, those who massage after injection, and those who don't use a new needle at each injection (p<0.05). CONCLUSION This study put into light some failures in the knowledge and skills of patients with diabetes regarding insulin pen use. Nurses should provide patients with diabetes an effective and repetitive training concerning insulin pen use.
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Affiliation(s)
- Betul Tosun
- Hasan Kalyoncu University, Faculty of Health Sciences, Gaziantep, Turkey
| | - Fatma Ilknur Cinar
- University of Health Sciences, Gulhane Faculty of Nursing, Ankara, Turkey
| | - Zeliha Topcu
- Mechanized Infantry Brigade, 1st Stage Health Inspection Center, Mardin, Turkey
| | - Burcu Masatoglu
- University of Health Sciences, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Nurten Ozen
- Istinye University, Faculty of Health Science, Istanbul, Turkey
| | | | - Ozge Kilic
- University of Health Sciences, Gulhane Training and Research Hospital, Department of Endocrinology and Metabolism Disease, Ankara, Turkey
| | - Canan Demirci
- University of Health Sciences, Gulhane Training and Research Hospital, Department of Endocrinology and Metabolism Disease, Ankara, Turkey
| | - Ayten Altunbas
- University of Health Sciences, Gulhane Training and Research Hospital, Department of Endocrinology and Metabolism Disease, Ankara, Turkey
| | - Alper Sonmez
- University of Health Sciences, Gulhane Training and Research Hospital, Department of Endocrinology and Metabolism Disease, Ankara, Turkey
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Diabetes Mellitus with Poor Glycemic Control as a Consequence of Inappropriate Injection Technique. Case Rep Endocrinol 2018; 2018:7236452. [PMID: 29805817 PMCID: PMC5899865 DOI: 10.1155/2018/7236452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 02/16/2018] [Accepted: 02/25/2018] [Indexed: 01/12/2023] Open
Abstract
Majority of patients with diabetes mellitus (DM), who are on insulin therapy, use insulin pen for convenience, accuracy, and comfort. Some patients may require two different types of insulin preparations for better glycemic control. We have reported a case of poor glycemic control as a consequence of inappropriate insulin injection technique. A 57-year-old man with type 2 DM had been using premix insulin 30 : 70 for his glycemic control for the last 12 years. On follow-up visit, his blood sugar level (BSL) had increased; therefore the treating physician increased the dose of premix insulin and added basal insulin with the aim of controlling his blood sugar level. Despite these changes, his BSL was significantly higher than his previous level. On investigation, the cause of his poor glycemic control was found to be due to inadequate delivery of insulin (primarily premix) as a consequence of lack of priming and incompatibility of single insulin pen for two cartridges. His basal insulin was discontinued and the patient along with his grandson was instructed to administer insulin correctly. After correction of the errors, the patient had a better glycemic control.
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8
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Sampson Perrin AJ, Guzzetta RC, Miller KM, Foster NC, Lee A, Lee JM, Block JM, Beck RW. A web-based study of the relationship of duration of insulin pump infusion set use and fasting blood glucose level in adults with type 1 diabetes. Diabetes Technol Ther 2015; 17:307-10. [PMID: 25622214 DOI: 10.1089/dia.2014.0336] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND To evaluate the impact of infusion set use duration on glycemic control, we conducted an Internet-based study using the T1D Exchange's online patient community, Glu ( myGlu.org ). SUBJECTS AND METHODS For 14 days, 243 electronically consented adults with type 1 diabetes (T1D) entered online that day's fasting blood glucose (FBG) level, the prior day's total daily insulin (TDI) dose, and whether the infusion set was changed. RESULTS Mean duration of infusion set use was 3.0 days. Mean FBG level was higher with each successive day of infusion set use, increasing from 126 mg/dL on Day 1 to 133 mg/dL on Day 3 to 147 mg/dL on Day 5 (P<0.001). TDI dose did not vary with increased duration of infusion set use. CONCLUSIONS Internet-based data collection was used to rapidly conduct the study at low cost. The results indicate that FBG levels increase with each additional day of insulin pump infusion set use.
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Abstract
OBJECTIVE The efficacy of injection therapy in diabetes depends on correct injection technique. To provide patients with guidance in this area and help patients inject themselves correctly, we must understand how they currently inject; therefore, the purpose of this study was to assess the current situation of insulin injection technique in patients with diabetes in mainland China. DESIGN AND METHODS From October 2010 to November 2010, a cross-sectional survey of 380 diabetes patients from 20 centers in mainland China was conducted regarding their daily insulin pen injection practice. RESULTS Overall, 35.26% of patients had lipohypertrophy; 58.68% of patients had bleeding and bruising, and abdominal lipohypertrophy at injection sites. Bleeding and bruising were more frequent. We found a significant relationship between the frequency of a single needle reuse and lipohypertrophy (r = 0.426, P = 0.000). In addition, there was a significant relationship between the frequency of daily insulin injection and lipohypertrophy (r = 0.146, P = 0.004), between rolling the pen while pulling out the needle after injection and lipohypertrophy (χ(2 )= 7.355, P = 0.007). Bleeding and bruising at injection sites were found to be related to HbA1c levels (r = 0.151, P = 0.003). LIMITATIONS A few limitations linked with this survey should be noted. Because of the limited budget, the ultrasound was not used to evaluate lipodystrophy and the photographs of lipodystrophy were not taken. On the other hand, specific size of lipodystrophy and the cost of insulin wastage were not evaluated. Furthermore, the population of this survey is limited, and it was only done in general hospitals and not in community hospitals, therefore, a larger study sample is advisable. CONCLUSIONS The insulin injection skill of patients with diabetes in mainland China was poor, and the incidence of lipohypertrophy, bleeding, and needle reuse was high. Frequency of daily insulin injection and needle reuse may relate to the incidence of lipohypertrophy and bleeding. The bleeding and bruising at the injection sites may be associated with suboptimal absorption of injected insulin. Improved education in optimal insulin injection technique, including reducing needle reuse and correct rotation of injection sites should be emphasized.
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Affiliation(s)
- Jiajia Ji
- Nanjing University of Chinese Medicine , Nanjing , PR China
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Nakatani Y, Matsumura M, Monden T, Aso Y, Nakamoto T. Improvement of glycemic control by re-education in insulin injection technique in patients with diabetes mellitus. Adv Ther 2013; 30:897-906. [PMID: 24170590 DOI: 10.1007/s12325-013-0066-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The aim of this study was to evaluate the effectiveness of re-education in the insulin injection technique for glycemic control. METHODS A preliminary experimental study was performed with 87 insulin-treated diabetic outpatients (11 with type 1 diabetes, 76 with type 2 diabetes; 43 men, 44 women). All patients had been treated with insulin for more than 3 years. After answering questions about the insulin injection technique, the patients' knowledge levels were scored. Correct answers and explanation sheets were subsequently given to all patients. The physicians in charge gave a short lecture and provided 10 min of individual advice. Two, three, and four months after re-education the HbA1c and glycoalbumin levels were measured. RESULTS The mean HbA1c levels of almost all patients significantly improved from 7.46 ± 0.09% to 6.73 ± 0.10% (P < 0.01), and the mean glycoalbumin levels significantly improved from 22.76 ± 0.50% to 20.26 ± 0.68% (P < 0.01). Twenty-five patients demonstrated a poor understanding (score of ≤6 points) and showed a significant decrease in the HbA1c level from 7.62 ± 0.20% to 6.71 ± 0.21% (P = 0.02). Forty-three patients demonstrated a moderate understanding (score of 7 or 8 points) and showed a decrease in the HbA1c level from 7.40 ± 0.13% to 6.68 ± 0.07% (P = 0.07). Finally, 19 patients demonstrated a good understanding (score of ≥9 points) and showed a slight decrease in the HbA1c level from 7.38 ± 0.15% to 6.93 ± 0.12% (P = 0.09). Patients with a poor understanding showed the largest decrease in the mean level of HbA1c. CONCLUSION Re-education in the insulin injection technique led to an improvement in glycemic control in insulin-treated diabetic patients, especially in those with a poor understanding of the insulin injection technique. More attention should be paid to these strategies for outpatients.
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Affiliation(s)
- Yuki Nakatani
- Department of Diabetes and Endocrinology, Dokkyo Medical University Nikko Medical Center, Tochigi, 321-2593, Japan
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Abstract
Continuous subcutaneous insulin infusion from an insulin pump depends on reliable transfer of the pumped insulin to the subcutaneous insulin depot by means of an insulin infusion set (IIS). Despite their widespread use, the published knowledge about IISs and related issues regarding the impact of placement and wear time on insulin absorption/insulin action is relatively small. We also have to acknowledge that our knowledge is limited with regard to how often patients encounter issues with IISs. Reading pump wearer blogs, for instance, suggests that these are a frequent source of trouble. There are no prospective clinical studies available on current IIS and insulin formulations that provide representative data on the type and frequency of issues with infusion sets. The introduction of new IISs and patch pumps may foster a reassessment of available products and of patient problems related to their use. The aim of this review is to summarize the current knowledge and recommendations about IISs and to highlight potential directions of IIS development in order to make insulin absorption safer and more efficient.
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