Forum for Injection Technique and Therapy Expert Recommendations, India: The Indian Recommendations for Best Practice in Insulin Injection Technique, 2017

Towards more tolerable subcutaneous administration: Review of contributing factors for improving combination product design

Subcutaneous (SC) injections can be associated with local pain and discomfort that is subjective and may affect treatment adherence and overall patient experience. With innovations increasingly focused on finding ways to deliver higher doses and volumes (≥2 mL), there is a need to better understand the multiple intertwined factors that influence pain upon SC injection. As a priority for the SC Drug Development & Delivery Consortium, this manuscript provides a comprehensive review of known attributes from published literature that contribute to pain/discomfort upon SC injection from three perspectives: (1) device and delivery factors that cause physical pain, (2) formulation factors that trigger pain responses, and (3) human factors impacting pain perception. Leveraging the Consortium's collective expertise, we provide an assessment of the comparative and interdependent factors likely to impact SC injection pain. In addition, we offer expert insights and future perspectives to fill identified gaps in knowledge to help advance the development of patient-centric and well tolerated high-dose/high-volume SC drug delivery solutions.

Knowledge, attitude, and practice of insulin among diabetic patients and pharmacists in Egypt: "cross-sectional observational study"

BACKGROUND

Diabetes recently has been identified as a growing epidemic. Although insulin's vital role in both types of diabetes, it is considered one of the harmful medications if used incorrectly. In Egypt, effective usage of insulin remains a challenge due to insufficient knowledge of insulin and diabetes management, leading to errors in insulin therapy. As pharmacists are experts in pharmacological knowledge, they are uniquely situated to assess adherence to treatment regimens, the effect of drug therapy, or potential alterations in drug therapy to meet patient goals. To provide effective patient education and counseling, community pharmacists in Egypt should be efficiently knowledgeable about diabetes and insulin.

OBJECTIVE

To identify the knowledge, attitude, and practice of pharmacists and patients about insulin. To identify pharmacists' educational preparedness and confidence in counseling diabetic patients.

METHODS

A descriptive, cross-sectional study was conducted with two knowledge, attitude, and practice surveys. This study was carried out from September 2016 to February 2023. Face-to-face interviews were conducted with patients, and a paper-based questionnaire was administered to pharmacists. The two questionnaires were adapted from previous studies.

RESULTS

A total of 492 patients and 465 pharmacists participated in this study. The mean knowledge score of correct answers among patients and pharmacists was 10.67 ± 1.9 and 15 ± 3.6. Most of the patients and pharmacists had a positive attitude regarding insulin's role in improving health and to better control blood glucose. On the negative side, around half of the patients reported that they believe that regular use of insulin leads to addiction, while only 14.5% of the pharmacists believed that insulin could cause addiction. Self-confidence scores for pharmacists differed statistically with sex, years of experience, and pharmacist's direct exposure to diabetic patients.

CONCLUSIONS

This study uncovers considerable deficiencies in patients' and pharmacists' knowledge about insulin therapy. This study also strongly recommends higher education and a more structured pharmacist training schedule.

Optimising Insulin Injection Techniques to Improve Diabetes Outcomes

The effectiveness of therapy in patients with diabetes depends on the correct use of the insulin injection technique. However, despite many established recommendations and evidence that an effective insulin injection technique is essential to improve glycaemic control and minimise the risk associated with diabetes, there is still a need to identify impediments to the insulin injection technique among patients and create awareness among patients and healthcare professionals about the importance of the optimisation of insulin injection techniques. This review focuses on the recent advancements in delivery devices, insulin injection technique teaching methods, monitoring, and complication management and highlights regional best practices and recommendations for optimising injection techniques to improve diabetes outcomes.

Subcutaneous injections: A cross-sectional study of knowledge and practice preferences of nurses

BACKGROUND

Widespread use of subcutaneous injection for parenteral medications is likely to be related to high medication bioavailability and rapid onset of action. Correct subcutaneous injection technique and site selection are essential for nursing care quality and patient safety.

AIM

The study aimed to determine nurses' knowledge and practice preferences regarding subcutaneous injection technique and administration site selection.

DESIGN

This cross-sectional study took place between March and June 2021.

METHODS

This study included 289 nurses, willing to participate who worked in units performing subcutaneous injections in a university hospital in Turkey.

RESULTS

Most nurses reported their preferred administration site for subcutaneous injections was the lateral aspects of the upper arm. More than half of the nurses did not use a rotation chart, they swabbed the skin before a subcutaneous injection, and they always pinched the skin at the injection site; 50% of nurses reported always administering subcutaneous injections at an angle of either 90 or 45 degrees. Most nurses performed an injection in less than 30 s and waited for 10 s before withdrawing the needle. They did not apply massage onto the site following the injection. Nurses' knowledge of subcutaneous injection was at a moderate level.

CONCLUSIONS

Nurse knowledge of best practice subcutaneous injection administration and site selection could be improved in line with current evidence to improve personcentred and quality and safe care delivery. Future research should involve developing and evaluating educational strategies and practice standards to enhance nurse understanding of best practice evidence to meet patient safety goals.

Insulin injection practice and health related quality of life among individuals with diabetes at Tikur Anbessa Specialized Hospital, Ethiopia: a cross-sectional study

BACKGROUND

Insulin therapy can be inconvenient, painful, burdensome, and restrict patients' daily activities and health related quality of life (HRQOL) due to improper injection techniques or the nature of administration.

OBJECTIVE

This study aimed to assess insulin injection practice, HRQOL and predictors among patients treated with insulin at Tikur Anbessa Specialized Hospital (TASH).

METHODS

An institutional-based cross-sectional study was conducted among diabetes patients on insulin therapy from May to June 2022. A structured questionnaire was used to collect patient characteristics and insulin injection practice. The validated Amharic version of an EQ-5D-5L tool was used to assess the HRQOL. The data was analyzed using SPSS version 26. The patient data were summarized using descriptive statistics. One-way ANOVA using Kruskal-Wallis H tests was used to assess factors that predict insulin handling practice scores. Multivariate linear regression analysis was used to assess factors affecting HRQOL among diabetes patients treated with insulin. The EQ5D-5L utility scores of the patients were calculated using disutility coefficients taken from the Ethiopian general population. Statistical significance was declared at p-value < 0.05.

RESULTS

Of 319 patients who agreed and completed the survey, 51.1% of them were males. Almost half of the participants (n = 158) were > 50 years of age. Among the study participants, 62.1% were only on intermediate acting insulin. A significantly higher proportion of participants 291(91.2%) in this study were taking insulin two times per day. Most of the participants 234(73.4%) had fair practice with a median insulin handling practice score of 38 out of 56. Patient characteristics such as age, educational status, occupation, disease duration, and type of diabetes were significantly association with insulin injection practice (p < 0.05). The mean ± SD utility score of patients were 0.89 ± 0.19 (ranged from -0.04 to 1). Being female (β = -5.42, 95%CI:-8.63,-2.21, p = 0.001) and treated for type-I diabetes mellitus (β =  + 9.04, 95%CI: 4.23,13.85, p-value < 0.0001) were significantly associated with HRQOL of patients on insulin therapy.

CONCLUSION

The study participants had fair practices in insulin handling, storage, and administration techniques, and it was seen that male and type one diabetes patients have a better quality of life compared to their counterparts.

Addendum 1: Forum for Injection Technique and Therapy Expert Recommendations, India

With the emerging complexities in chronic diseases and people's lifestyles, healthcare professionals (HCPs) need to update their methods to manage and educate patients with chronic lifestyle disorders, particularly diabetes. The insulin injection technique (IIT), along with various parameters, must also be updated with newer methods. Forum for Injection Technique and Therapy Expert Recommendations (FITTER), India, has updated its recommendations to cover newer ways of detecting hypoglycaemia and lipohypertrophy, preventing needlestick injuries (NSIs), discouraging the reuse of insulin needles and encouraging good disposal. FITTER, India, is also introducing recommendations to calculate insulin bolus dose. These updated recommendations will help HCPs better manage patients with diabetes and achieve improved outcomes.

Investigation of Association Between Insulin Injection Technique and Blood Glucose Control in Patients with Type 2 Diabetes

BACKGROUND

The appropriate insulin injection skill is essential for optimal blood sugar control in patients with diabetes. However, the art of insulin injection is still not well understood in numerous medical centers.

OBJECTIVES

This study was designed to determine the association between appropriate insulin injection and blood glucose control in patients with type 2 diabetes in Yazd, Iran.

METHODS

This cross-sectional study was conducted on 301 patients with type 2 diabetes who referred to Diabetes Research Center in Yazd within August 2020 to February 2021. Based on simple random sampling, the subjects with inclusion criteria, such as age >18 years, using an insulin pen for at least 3 months, and self-injection, were selected. The insulin injection technique was evaluated by a 13-item researcher-made questionnaire. The total score of this questionnaire was 26, and its validity and reliability were confirmed. The data were analyzed using SPSS software (version 20).

RESULTS

The mean age of the participants was 59.83 ± 10.26 years, and 60.1% had primary school or less education. Most participants (87%) used a needle more than five times, and almost half of them (53.5%) did not rotate the injection sites properly. The patients who reported pain during injection had statically lower injection scores than others (17.90 vs. 19.38, P = 0.001). There was a significant negative correlation between insulin injection score with fasting blood sugar (β = -0.232, P < 0.001), two-hour postprandial glucose (β = -0.164, P = 0.005), and hemoglobin A1c (HbA1c) level (β = -0.263, P < 0.001).

CONCLUSIONS

None of the patients in this study fully followed the principles of a proper injection, which can lead to pain during injection, lipohypertrophy, hyperglycemia, and increased HbA1c levels.

The assemblage of skin findings in the type 1 DM with incorrect injection technique: A case report

Correct insulin administration technique, insulin type, and dose play a pivotal role in attaining glycemic control. An error in any of the steps may lead to poor glycaemic control, which affects the patient in the short and long term. We are presenting here unusual skin findings in children with the wrong injection technique. A 10-year-old male child already diagnosed with type 1 Diabetes Mellitus (DM), presented with poor glycemic control. On examination, we found skin rashes encircling most of his abdominal area circularly. Rashes were round to oval, well-circumscribed, hyperpigmented to hypopigmented to depigmented macules to papules surrounded by a hyperpigmented halo, 0.5 to 1 cm in diameter, painless varying in color from white to pinkish-red to light brown to brownish-black. On observing the administration technique of insulin, we found it was administered incorrectly as intradermal instead of subcutaneous. Proper Diabetes education and insulin administration techniques remain the cornerstone in the management of type 1 DM. We should ensure appropriate insulin administration on every visit.

Counseling for Growth Hormone Therapy

Growth hormone (GH) therapy is an integral part of the treatment of short stature. Over the period of the last few decades, due to the better availability of recombinant human growth hormone (rHGH), we have more clinical data on the uses of GH in various diseases. The list of approved uses of the GH apart from the classical growth hormone deficiency (GHD) is increasing and is much longer than before but still, adherence to therapy is poor as seen in other chronic diseases also. In this review, we plan to discuss the means of better communication and counseling of the patient to ensure adequate adherence to therapy for optimal clinical outcome.

Uncurtaining the effect of COVID-19 in diabetes mellitus: a complex clinical management approach

The aim of the present review is to overview the common properties of corona virus and hence proofs well beginning of corona virus in persons with diabetes, and its treatment. Globally, it has been observed that according to the statistics, India has the second largest number of people with diabetes. Literature review has been implemented within the databases using suitable keywords. For persons suffering from diabetic disorder, the COVID-19 infection becomes a dual challenge. Diabetes is a severe metabolic situation which causes the sugar levels in the blood to increase than the normal level. Normally, communicable disease like COVID-19 is more prevailing in patients with diabetes. Diabetic patient has poor immune response to infections. The different bacterial, viral, parasitic, and mycotic infections showed increased probability in diabetic patients as compared to non-diabetic patient. All these conclusions clear out the intention that the diabetic patients are more susceptible to enhanced inflammatory response that may lead to rapid spreading of COVID-19 infection with high rate of mortality. In the present situation of pandemic, managing diabetes seems to be quite challenging and diabetic patient having COVID-19 infection should follow normal course of antihypertensive and antidiabetic drugs prescribed with the exception of sodium glucose co-transpoters-2 inhibitors which would increase the risk of dehydration and ketoacidosis. In view of above discussion, this article highlights the proposed mechanism of COVID-19 infection linking it with diabetes, antidiabetic drugs to be used in COVID-19 infection along with their advantages, and disadvantages and management of COVID-19 infection diabetic patient.

Practical aspects of usage of insulin in India: Descriptive review and key recommendations

BACKGROUND AND AIMS

Insulin therapy is an integral part of diabetes management. However, reliable and easily accessible information on a number of basic facts concerning insulin therapy, including storage of insulin, managing insulin therapy during travel, nuances of insulin use while driving, and dose adjustments during sick days is lacking. This document aims to make readily available, reliable, and easy to implement information on these essential but relatively less discussed aspects of insulin therapy.

METHOD

Literature search was performed using PubMed and Cochrane Library from inception till 1^st of July 2019. The relevant topics were reviewed by a panel of 5 specialists and 23 contributing physicians and endocrinologists, who had assembled at Bengaluru, India for the 13th National Insulin Summit. After a thorough review of the literature, and following detailed discussions, the committee arrived at these recommendations.

RESULTS

Unopened vials and cartridges of insulin should be stored at 2 °C-8 °C in a refrigerator and protected from direct sunlight. For opened vials and in-use cartridges, manufacturer's instructions must be followed at all times. While traveling by air, dose adjustments are required only when flying across more than five time zones in the east or west directions. Insulin therapy should not be omitted or stopped during an acute illness; rather the doses need careful adjustments based on self-monitoring of blood glucose.

CONCLUSION

Recommendations and guidelines, covering many common aspects of insulin therapy are readily available. This consensus document aims to make recommendations for those essential aspects of insulin therapy that are crucial for its success but are relatively less known and less discussed.

Is skin disinfection before subcutaneous injection necessary? The reasoning of Certified Nurses in Infection Control in Japan

Nurses continue to disinfect the skin before administering subcutaneous injections as a standard process in clinical settings; despite evidence that disinfection is not necessary. To implement evidence-based practice, it is critical to explore why this gap between "evidence" and "practice" exists. This study aimed to describe the reasons offered by Certified Nurses in Infection Control (CNIC) in Japan for performing skin disinfection before subcutaneous injection. Adopting an inductive qualitative design, interviews were conducted with 10 CNIC in 2013. According to the participants, skin disinfection before subcutaneous injection: (a) was common practice; (b) may have been beneficial if it was omitted; (c) adhered to hospital norms; (d) prevented persistent suspicion of infection; (e) had no detrimental effect; (f) was an ingrained custom; and (g) involved a tacit approval for not disinfecting in home care settings. The themes (c) and (g) were cited as the main reasons affecting decision-making. The CNIC administered injections following skin disinfection in hospitals in accordance with hospital norms. On the contrary, outside the hospital, they administered subcutaneous injections without skin disinfection. All themes except (b) and (g) reflect the barriers and resistance to omitting skin disinfection, while (g) shows that it is already partly implemented in home care settings. It is necessary to create a guideline for skin disinfection before subcutaneous injection that considers the quality of life of patients at home, their physical conditions, and the surrounding environment at the time of injection, in addition to the guidelines applicable in hospitals.

Consensus on Choice of Insulin Pen Devices in Routine Clinical Practice in India

Although insulin delivery devices are widely used by the patients, there is a paucity of published guidelines to help professionals manage their patients in insulin therapies. To provide simple and easily implementable guidelines to health care physicians on the choice of insulin delivery devices in routine clinical practice, experts in diabetes gathered together and discussed the recommendations at the National insulin Summit 2018. An ideal insulin delivery device should accurately deliver the prescribed dose of insulin and be easy to use. Recommendations are: (1) insulin should be initiated by using an insulin device if the patient seems to discontinue insulin therapy. (2) Pen devices offer accurate dosing than a syringe and vial and are associated with cost savings in the long term. (3) Switching over from syringes and vial to disposable pen devices improves adherence. (4) FlexPen^® offers better accuracy, and it requires lower dose force and injection force than SoloStar^® and KwikPen^® (5). Durable delivery pens such as NovoPen^® 4 maintain accuracy and low dose force compared with vials and syringes. (6) One pen should be used by only one patient. (7) Regular counseling on the proper use of the pen device is required regularly. This consensus-based recommendation is a useful reference tool for health care practitioners to initiate insulin therapy in patients with diabetes by using the appropriate insulin pen device.

Basal-Bolus Insulin Regimen for Hospitalised Patients with COVID-19 and Diabetes Mellitus: A Practical Approach

BACKGROUND AND AIM

The coronavirus disease 2019 (COVID-19) outbreak has rapidly crossed international boundaries and placed increasing demands on healthcare facilities worldwide. Patients with diabetes and uncontrolled blood glucose levels are at increased risk for poor clinical outcomes and in-hospital mortality related to COVID-19. Therefore, achieving good glycaemic control is of paramount importance among hospitalised patients with COVID-19. Basal-bolus insulin therapy is a safe and effective intervention for the management of hyperglycaemia in hospitalised patients. The aim of this article is to provide a practical guidance for the use of the basal-bolus insulin regimen in hospitalised patients with COVID-19 and diabetes mellitus.

METHODS

This guidance document was formulated based on the review of available literature and the combined personal experiences of the authors. We provide a comprehensive review on the use of the basal-bolus insulin regimen, including its principles, rationale, indications, prerequisites, initiation, and dose titration, and also suggest targets for blood glucose control and different levels of capillary blood glucose monitoring. Various case scenarios are used to illustrate how optimal glucose control can be achieved, such as through adjustments in doses of prandial and basal insulin, the use of correctional insulin dosing and changes in the timing and content of major and minor meals.

CONCLUSION

The practical guidance for the use of the basal-bolus insulin regimen in hospitalised patients with COVID-19 and diabetes mellitus presented here can be used for patients admitted to hospital for indications other than COVID-19 and for those in ambulatory care.

Therapeutic Advancements in the Management of Diabetes Mellitus with Special Reference to Nanotechnology

For improvisation of diabetic's quality of life, nanotechnology is facilitating the development of advanced glucose sensors as well as efficient insulin delivery systems. Our prime focus of the review is to highlight the advancement in diabetic research with special reference to nanotechnology at its interface. Recent studies are more focused on enhancing sensitivity, accuracy, and response by employing metal as well as nanoparticles based glucose sensors. Moreover, the review focuses on nanoscale based approaches i.e. closed-loop insulin delivery systems, which detect any fluctuation in blood glucose levels and allow controlled release of a drug, thus are also called self-regulating insulin release system. Additionally, this review summarizes the role of nanotechnology in the diagnosis and treatment of diabetic complications through little advancement in the existing techniques. To improve health, as well as the quality of life in diabetic's new sensing systems for blood glucose level evaluation and controlled administration of drugs through efficient drug delivery systems should be explored.

Insulin Injection Practice and Injection Complications - Results from the Bangladesh Insulin Injection Technique Survey

INTRODUCTION

Diabetes mellitus is highly prevalent in Bangladesh and insulin is often needed for diabetes control. We lack sufficient data on the insulin injection technique and injection-related complications.

METHODS

The Bangladesh Insulin Injection Technique Survey (BIITS) was conducted in 2018 in 18 centres throughout Bangladesh, involving 847 patients taking insulin for at least 6 months. All of the study subjects were interviewed using a structured questionnaire focusing on key insulin injection parameters.

RESULTS

The mean duration of insulin use by the study subjects was 3.84 (± 4.05) years and the mean daily dose of insulin was 41 (± 25) units. A total of 71.6% participants performed ≤2 injections/day and premixed insulins were the most commonly used insulins. Mean glycated haemoglobin (HbA1c) was 9.5% (± 2%). The proportion of syringe users and pen-device users was 68.1% and 31.9%, respectively. Most of the participants injected in the abdomen and rotated the injection site(s). The majority lifted the skinfold correctly and inserted the needle at a 90-degree angle, but their dwell times after injections were not adequate. A total of 9.2% of the subjects had injection-site lipohypertrophy (LH) and among them, 38.5% injected into the lesion. Patients with LH had higher HbA1c. Higher duration of insulin use (≥5 years), reusing needles more often (>10 times), and injecting at angles other than 90 degrees were independent predictors of LH. The incidences of hypoglycaemia (36.7%) and hyperglycaemia (67.4%) were very high, and subjects with LH had higher chances of both hypoglycaemia and hyperglycaemia. Though most (92.1%) of the patients received education about insulin injection initially, it was not repeated in the recent follow-up and was found to be ineffective.

CONCLUSION

A huge gap between the insulin administration guidelines and current practice was observed in this study. Complications of insulin injections were also common. Healthcare providers should pay more attention to insulin education and re-evaluate injection practices from time to time.

Capacity and confidence building for general practitioners on optimum insulin use

Type 2 diabetes is characterised by a progressive decline in insulin secretion, and sooner or later patients require insulin therapy. However, physicians are reluctant to initiate insulin therapy because of perceived inadequacy in managing insulin therapy, cost and lack of benefits. Experts from across the country met at a workshop during 12th National Insulin Summit which was held in September at Hyderabad and came up with key recommendations to build capacity and confidence in general practitioners for insulin usage. Barriers can be overcome through self-education and training; effective patient education; imparting coping skill training to patients; and bridging gaps to improve adherence. Moreover, optimum insulinization requires knowledge about the available options for initiation and intensification of insulin therapy; various insulin regimens; dosing and titration; and choosing effective and simple insulin therapy as per patient characteristics. Hence, the objective of this review article is to help build capacity and confidence among general practitioners on optimising insulin therapy.

Insulin-induced lypodistrophy in hemodialyzed patients: A new challenge for nephrologists?

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.

The level of knowledge and attitude on insulin therapy in patients with diabetes mellitus in a teaching hospital of Southern India

Aim of the Study:

To assess the level of knowledge and attitude on insulin therapy in patients with diabetes mellitus in a teaching hospital.

Objectives:

1. To assess the level of knowledge and attitude on insulin therapy among patients with diabetes mellitus. 2. To find out the association between the knowledge and attitude on insulin therapy with the selected study variables.

Materials and Methods:

This is a nonexperimental, cross-sectional study. A total of 100 participants were recruited from the outpatients and inpatients attending the department of general medicine and general surgery. Adult male and female with diabetes mellitus receiving insulin injection and willing to participate in the study were included in the study. The data was collected using 20 structured questionnaires to assess the level of knowledge and modified 4 point Likert scale was used, which contains 10 statements to assess the level of attitude on insulin therapy by interview method.

Results:

It was observed from the results that the level of knowledge among the study participants was as follows: 4% of them had adequate knowledge, 44% had moderately adequate knowledge, and more than half (52%) of them had inadequate knowledge. The level of attitude among the study participants (27%) with diabetes mellitus had favorable attitude, more than half (69%) had moderately favorable attitude, and 4% had unfavorable attitude on insulin therapy. It is observed that there is no statistically significant correlation (r) =0.038, P = 0.707 between the level of knowledge and attitude on insulin therapy among patients with diabetes mellitus.

Conclusion:

This study showed that there was inadequate knowledge and unfavorable attitude among the diabetic patients regarding insulin therapy. The people with diabetes should receive ongoing need-based quality diabetic education by using innovative methods that is tailored to their needs, delivered by skilled healthcare providers.

BE-SMART (Basal Early Strategies to Maximize HbA1c Reduction with Oral Therapy): Expert Opinion

The past three decades have seen a quadruple rise in the number of people affected by diabetes mellitus worldwide, with the disease being the ninth major cause of mortality. Type 2 diabetes mellitus (T2DM) often remains undiagnosed for several years due to its asymptomatic nature during the initial stages. In India, 70% of diagnosed diabetes cases remain uncontrolled. Current guidelines endorse the initiation of insulin early in the course of the disease, specifically in patients with HbA1c > 10%, as the use of oral agents alone is unlikely to achieve glycemic targets. Early insulin initiation and optimization of glycemic control using insulin titration algorithms and patient empowerment can facilitate the effective management of uncontrolled diabetes. Early glucose control has sustained benefits in people with diabetes. However, insulin initiation, dose adjustment, and the need to repeatedly assess blood glucose levels are often perplexing for both physicians and patients, and there are misconceptions and concerns regarding its use. Hence, an early transition to insulin and ideal intensification of treatment may aid in delaying the onset of diabetes complications. This opinion statement was formulated by an expert panel on the basis of existing guidelines, clinical experience, and economic and cultural contexts. The statement stresses the timely and appropriate use of basal insulin in T2DM. It focuses on the seven vital Ts-treatment initiation, timing of administration, transportation and storage, technique of administration, targets for titration, tablets, and tools for monitoring.Funding: Sanofi.

Making inferior alveolar nerve block more comfortable via computer-controlled local anesthetic delivery: A prospective clinical study

Background

The fear of needle insertion and pain during anesthesia is a source of patient dissatisfaction in dentistry. Inferior alveolar nerve block (IANB) remains the most common type of block and is in itself painful. Computer-controlled local anesthetic delivery (CCLAD) has been proven to reduce the pain associated with injection of anesthetics in various blocks. However, the efficacy of CCLAD for IANB in adults remains unknown.

Methods

Sixty-four adult patients requiring bilateral IANB were selected and divided into two groups: group A (50 patients receiving IANB via CCLAD) and group B (50 patients receiving IANB using a conventional cartridge syringe). Pain perception and patient comfort were assessed using the visual analog scale and the 5-point semantic scale, respectively.

Results

The pain perception was compared between the two groups using the Mann-Whitney U-test, and the P value was 0.003. The patient comfort was also compared using the same test, and the P value was 0.484.

Conclusion

A significant difference was observed in the pain perception of the patients during CCLAD. The patient comfort was grossly equal for both techniques.

Correlation between muscle mass, nutritional status and physical performance of elderly people

OBJECTIVES

This study evaluated the relationship between the skeletal muscle mass (SMM), obtained by predictive equations, and the body composition, nutritional aspects, functionality and physical performance in elderly people.

METHODS

The sample consisted of adults aged 65 years or over from the cross-sectional study of the Brazilian Elderly Frailty Study Network, in Cuiabá, Mato Grosso State, Brazil. The anthropometric parameters, instrumental activities of daily living (IADL), Short Physical Performance Battery (SPPB), and handgrip strength (HGS) were evaluated. The SMM was estimated by 2 predictive anthropometric equations.

RESULTS

Both SMM equations correlated with age, anthropometric indices, SPPB, IADL, and HGS. However, only HGS and neck circumference strongly correlated in both equations, being higher in SMM II.

CONCLUSIONS

It seems that both equations are sensitive to obtain the SMM, contributing to the diagnosis of sarcopenia, nutritional status, and a physical performance condition.

Pediatric Insulin Injection Technique: A Multi-Country Survey and Clinical Practice Implications

INTRODUCTION

The 2015 Insulin Injection Technique Questionnaire survey involving 13,289 patients included 898 (6.8%) patients in the pediatric age range (≤ 18 years).

METHODS

The younger patients included in the questionnaire survey were grouped according to age: Group 1 (G1), 0-6 years, n = 85; Group 2(G2), 7-13, n = 423; Group 3 (G3), 14-18, n = 390. The injection technique was evaluated by means of a questionnaire and nurse assessment.

RESULTS

Nurses found lipohypertrophy at injection sites in 41.3, 45.2, and 47.3% of patients in G1, G2, and G3, respectively. Unexpected hypoglycemia was common, ranging from 23.8 to 48.1% of patients, and glucose variability was even more common (61.0% in G1, 45.9% in G2, and 52.5% in G3); both conditions were associated with lipohypertrophy. While increasing numbers of patients were using the recommended 4-mm needles, large percentages still used longer ones (33.3% in G1, 45.9% in G2, and 61.5% in G3). The reuse of needles was also common, ranging from 21.1 to 32.5% in the three age groups. Excessive reuse, defined as using a single needle more than five times, was reported by 9.4-21.8% of patients in the three age group. The percentages of patients who had not received any injection training in the last 12 months ranged from 21.2 to 26.8% in the three groups.

CONCLUSION

Implications of our study are as follows: (1) pediatric patients should use 4-mm pen needles or 6-mm syringes (inserted at a 45° angle); (2) patients aged ≤ 6 years should always inject into a raised skin fold regardless of which device is used; (3) all patients should rotate sites and use needles only once to avoid lipohypertrophy.

FUNDING

Becton-Dickinson (BD) diabetes care.

Handling Insulin-Related Emotions

This article discusses a simplified, yet comprehensive approach to handle complex varieties of emotions related to insulin injections prescribed to patients with diabetes. Diabetes management requires balancing of biomedical and psychosocial complexities, so that varied emotions faced by individuals with diabetes which lead to undesirable reactions/behavior are understood and managed. This realization has inspired useful mnemonics such as OPEN OUT, SHAKTI, ASHA/HOPE, SHANTI/SHALOM, and LISTEN. These, if used in diabetes care practice, will make insulin acceptable and well tolerated.

A Comparison of Insulin Pen Devices and Disposable Plastic Syringes - Simplicity, Safety, Convenience and Cost Differences

Context: Managing diabetes efficiently demands a simple, safe, convenient and economical therapy. This study was done to understand the simplicity, safety, convenience and cost effectiveness of using pen versus syringe devices in patients on long-term insulin therapy. Design: This prospective observational study was conducted at the endocrine outpatient department of a universityaffiliated teaching hospital in North India. The investigator interviewed patients using a self-made questionnaire after obtaining consent; patients were scored based on their answers. A high score represented a poor response. A total of 90 completed questionnaires (45 from each group) were obtained. Results: Mean simplicity, safety and convenience score among the pen users was 5.31 ± 0.51, 5.4 ± 0.89 and 4.13 ± 1.04 respectively, as compared to 9.78 ± 1.43, 8.09 ± 2.02 and 8.67 ± 0.56 in syringe users respectively. The difference in these scores was statistically significant (p=0.0001). All patients felt that treatment using pen device was costlier when compared to using syringes, with pen users spending Rs1,756 per month on their insulin therapy, as compared to syringe users, who spent Rs590 per month. Among insulin pen users, 22.2% had optimal glycated haemoglobin levels (6-7.5%) as compared to 2.2% among syringe users, and this difference was statistically significant (p=0.007). Conclusions: An insulin pen is simple, safe and convenient to use, and may provide better glycaemic control. Treatment with a pen device is costlier, which may be due to the higher use of analogue insulin among pen users.

Diabetes in the Elderly

The elderly are an important and distinct yet heterogeneous group of persons living with diabetes. The elderly have a unique biomedical, psychological, and social constitution. Their needs are different from those of younger adults. This implies that special care must be taken while evaluating and planning their nursing and management. Diabetes management in the elderly should focus on prevention and limitation of geriatric syndromes (medical conditions encountered in elderly persons), hypoglycemia (low blood glucose), and neurocognitive dysfunction (impairment in the functioning of the nervous system and brain). This review takes a practical approach to the assessment, nursing care, and medical treatment of diabetes in the elderly. It highlights major challenges and suggests solutions to these commonly encountered clinical problems.

Lipocrinology - the relationship between lipids and endocrine function

While lipids are an integral part of the endocrine clinic, the opposite is not necessarily true. The lipocrinology framework addresses this lacuna, by highlighting the similarities and multiple relationships between lipid and endocrine function. It reinforces the need to screen (clinically or biochemically) all dyslipidemic patients for endocrine disease and appropriate endocrine patients for dyslipidemia. Thus, it aims to improve clinical care for persons with lipid abnormalities as well as endocrine disease.

Insulin Distress

Diabetes distress (DD) is a commonly encountered adjustment disorder among persons living with diabetes. This article discusses insulin distress, a subtype of DD, which has distinct characteristics. Insulin distress can be defined as an emotional response to a suggestion to use insulin; characterized by extreme apprehension, discomfort, dejection, or denial; due to a perceived inability to cope with the requirements of insulin therapy. We describe the etiopathogenesis, clinical features and management of insulin distress. They highlight the clinical challenges that insulin distress poses in some persons. Pragmatic suggestions are shared regarding the addressing of insulin distress before or in parallel with insulin prescription.