Diabetes mellitus type I. Results of a European questionaire

An anonymous questionaire concerning diabetes type I was circulated through (Young) AEMIE members. Questions were asked regarding available facilities, diagnosis, follow-up and therapy. One hundred and six completed questionaires were available for study: most were from 5 countries, i.e. 20 from the Netherlands (NL), 26 from Great Britain (GB), 16 from France (F), 16 (+2) from Belgium (B) (+ Luxemburg = LUX) and 19 from Ireland (IRL). There was a preponderance of general internists and internist/diabetologists. In Great Britain significantly more participants were internist/diabetologists and they treated significantly more patients than other participants. They also had access to more facilities, especially diabetes nurses. Most patients appeared to perform bloodglucose measurements; only 10 p. 100 of the patients did not measure glucose in blood or urine at all. There is general acceptance that bloodglucose regulation should be as tight as possible. The allowance of sugar under certain conditions was mostly permitted in the Benelux countries. The use of insulin pens exceeded that of insulin pumps. The preference for pens was primarily related to convenience for patient and doctor and low cost. The main indication for their use was bad regulation. This study confirms the impression that there is an increased interest in patient education (i.e. diabetes nurses, educational programmes and home blood glucose monitoring) amongst European physicians and a trend towards using new devices such as insulin pens and pumps in an effort to achieve a tighter blood sugar control.     

Diabetic foot care: prevention is better than cure

Patients receiving renal replacement therapy especially haemodialysis (HD) are at high risk of foot ulcers which can lead to amputation. With the increasing numbers of patients with diabetes now presenting with renal failure, renal nurses are in a pivotal position to educate patients and initiate and oversee good foot care. This paper describes the risk factors for these patients and discusses general care for prevention and treatment of these factors. Factors such as regular screening which can be done easily and effectively in an HD setting where patients attend regularly is the first method towards prevention. Care and treatment of foot wounds based on results from the author's unit are discussed. The creation of a diabetes care programme for the author's HD unit have resulted in a more holistic approach to the care of the patient with diabetes and renal disease with special attention to foot care, which in turn has lead to an improved standard of care and better management of the patients' diabetes. This paper discusses information from this programme offering a summary of risks and treatments to assist those caring for these patients.     

Inpatient Diabetology

Tight glycemic control is now an imperative of outpatient diabetes care. The inpatient arena remains under the influence of an ineffective paradigm characterized by tolerance for hyperglycemia and a reluctance to use insulin intensively. This article is a call to action against the lip service paid to inpatient diabetes care. The compelling in vitro and in vivo evidence for the benefit of intensive insulin-mediated glycemic control is summarized. The linchpin of current inpatient care is a commonly used insulin sliding scale. This autopilot approach as the sole mode of treatment for inpatient hyperglycemia has been strongly condemned. Nevertheless, it continues to survive. The evidence supports the compelling argument that the adverse effect of hyperglycemia on hospital length of stay, morbidity, and mortality is substantial. Clinicians, nurses, administrators, and insurers ought to look critically at the prevailing paradigm and spearhead the much-needed revolution in inpatient diabetology. The issue of glycemic targets, the need for noninvasive blood glucose monitoring, and the role of nursing staff in this revolution are raised. We call for the banning of the insulin sliding scale use as the sole diabetes order. Also, the use of basal insulin via continuous intravenous insulin infusion or subcutaneous insulin analogs should be embraced. Educating nurses, house staff, and other frontline professionals in the adverse consequences of the current paradigm is essential. Inpatient glycemic control matters; clinical and financial outcomes are at stake. It behooves the health care system and the diabetic public to address the contemporary state of inpatient diabetology as soon as possible.     

Screening for Type 2 diabetes: is it worthwhile? Views of general practitioners and practice nurses

AIMS: Screening for Type 2 diabetes does not meet all the criteria for screening, yet is increasingly proposed. The views of health care professionals towards screening for Type 2 diabetes are not known. We set out to explore the attitudes and beliefs held by general practitioners (GPs) and practice nurses towards screening for Type 2 diabetes. METHODS: Semistructured interviews with 10 GPs and nine practice nurses in eight general practices in North-east England. Data collection and analysis proceeded in an iterative manner in accordance with grounded theory. RESULTS: Practitioners who perceive themselves to be most aware of the evidence base surrounding screening for Type 2 diabetes are least likely to support its introduction. Those who support screening for Type 2 diabetes hold a 'common sense' viewpoint that earlier detection must be better and believe that patients demand and respect early diagnosis. Practitioners acknowledge a lack of knowledge and skills to promote lifestyle changes. This deficiency is combined with workload issues, contributing towards a medicalized view of diabetes screening. CONCLUSIONS: The belief that screening for Type 2 diabetes is worthwhile is based not on evidence for the effectiveness of screening, but rather on a complex interaction of factors including perceptions of patient desires and an interplay of previous experience and evidence from other sources. Increased resources would be most likely to promote screening in primary care.     

Management of elderly diabetic patients in the subacute care setting

Type 2 diabetes is a commonly encountered condition in the subacute care setting. The results of the landmark UK prospective studies have confirmed that aggressive glycemic and blood pressure control delayed diabetes-related microvascular and macrovascular complications and significantly improved diabetic outcomes. Within the past few years, new drugs have been developed to address both aspects of the type 2 diabetes syndrome: insulin resistance and insulin secretory defect. C-peptide analysis may be useful to predict a successful response to therapy with insulin sensitizers or the need to initiate therapy with insulin or insulin stimulators. The issues regarding the general approach to elderly diabetics and the strategies of dealing with diabetic complications encountered in the subacute care program are discussed and updated. It is hoped that diabetic management can be improved and that suggested alternate therapies can be used in the subacute care facilities.     

The scope of practice of diabetes educators in a metropolitan area.

A survey of 108 members of a local metropolitan AADE chapter was conducted to assess (1) current roles and responsibilities of diabetes educators with respect to medical management and patient education, and (2) the use of behavioral strategy techniques among diabetes educators. Nurses and dietitians specializing in diabetes care performed a range of responsibilities. Approximately 75% of the nurses performed standard patient education roles and 20% performed the majority of roles traditionally considered to be in the medical domain, including insulin adjustment. More than half of the respondents had not received formal training in the use of behavioral strategies. Formal training was positively associated with greater use of behavioral techniques. Training for diabetes educators should include behavioral intervention strategies. Nurses specializing in diabetes care may also need training regarding physical assessment for chronic complications, and knowledge regarding adjustment of insulin and oral hypoglycemic medications.     

Screening for type 2 diabetes in children with acanthosis nigricans

Acanthosis nigricans is a physical finding of the skin that appears to be a marker for insulin resistance. Because of the association of insulin resistance and type 2 diabetes, acanthosis nigricans may also be a marker for type 2 diabetes. Some states have recommended statewide screening for acanthosis nigricans. However, this has led to a large referral of children to pediatric endocrinologists. Presented is a schema for primary care physicians and school nurses to use as a guideline for referral of children with acanthosis nigricans.     

Iatrogenic brittle diabetes: the hold-the-insulin decision

Modern diabetes management often involves multiple daily insulin injections (MDII) for individuals with insulin-dependent diabetes mellitus (IDDM). Such insulin regimens are increasingly composed of a larger percentage of regular insulin and a smaller percentage of intermediate- and long-acting insulin. Withholding insulin in these individuals may precipitate acute metabolic catastrophe and attendant ketosis or, even worse, frank diabetic ketoacidosis. A comprehensive understanding of normal glucose metabolism and the principles of MDII by all health care professionals both in and out of the hospital setting will foster improved metabolic control in the individual with IDDM, reduce health care costs, and have a positive effect on decreasing diabetic complications.     

Inpatient diabetology

Tight glycemic control is now an imperative of outpatient diabetes care. The inpatient arena remains under the influence of an ineffective paradigm characterized by tolerance for hyperglycemia and a reluctance to use insulin intensively. This article is a call to action against the lip service paid to inpatient diabetes care. The compelling in vitro and in vivo evidence for the benefit of intensive insulin-mediated glycemic control is summarized. The linchpin of current inpatient care is a commonly used insulin sliding scale. This autopilot approach as the sole mode of treatment for inpatient hyperglycemia has been strongly condemned. Nevertheless, it continues to survive. The evidence supports the compelling argument that the adverse effect of hyperglycemia on hospital length of stay, morbidity, and mortality is substantial. Clinicians, nurses, administrators, and insurers ought to look critically at the prevailing paradigm and spearhead the much-needed revolution in inpatient diabetology. The issue of glycemic targets, the need for noninvasive blood glucose monitoring, and the role of nursing staff in this revolution are raised. We call for the banning of the insulin sliding scale use as the sole diabetes order. Also, the use of basal insulin via continuous intravenous insulin infusion or subcutaneous insulin analogs should be embraced. Educating nurses, house staff, and other frontline professionals in the adverse consequences of the current paradigm is essential. Inpatient glycemic control matters; clinical and financial outcomes are at stake. It behooves the health care system and the diabetic public to address the contemporary state of inpatient diabetology as soon as possible. Editor’s Note: The American College of Endocrinology and the American Association of Clinical Endocrinologists released a position statement on “Inpatient Diabetes and Metabolic Control” calling for aggressive and tight glycemic control in the inpatient arena and setting target blood glucose levels for hospitalized diabetics. This is a happy development and lends a great deal of support to our call to action limned in our paper. The position statement can be accessed at http://www.aace.com/pub/ICC and will be published in the January/February 2004 issue of Endocrine Practice.     

Physiologic insulin replacement in type 2 diabetes: optimizing postprandial glucose control

PURPOSE: The purpose of this article is to review physiologic insulin replacement using a basal-prandial approach and focus on the role of postprandial glucose control. In addition, therapeutic options for optimizing glycemic control are described, including diabetes education, currently available agents, treatment regimens, and strategies. METHODS: This article reviews the benefits of treating with a basal-prandial insulin approach and focuses on post-prandial glucose-targeted therapies, including rapid-acting insulin analogs. RESULTS: Data from landmark clinical trials in type 2 diabetes suggest that intensive glycemic control can reduce the frequency and severity of diabetes complications. A basal-prandial insulin regimen combines a long-acting insulin analog with a rapid-acting insulin to mimic normal physiologic insulin secretion, providing a flexible tool to enhance patient self-management. CONCLUSIONS: Strategies that include patient education, improved health care provider/patient communication, and basal-prandial insulin treatment can help patients achieve good glycemic control. The optimal setting for successful diabetes treatment is a team approach with the health care provider, nurse/certified diabetes educator, and patient as essential members.     

Continuous quality improvement in rural health clinics

AIM: Continuous quality improvement has been shown to work in urban and suburban clinics. The objective of this project is to test whether continuous quality improvement would improve the quality of care for patients with diabetes mellitus and/or hypertension in a rural health clinic. SETTING: Rural health clinic with 3 providers and two and half full-time registered nurses. Patients were mostly older adults with Medicare health insurance. PROGRAM DESCRIPTION: Health care providers and nursing staff agreed on the quality improvement project. The intervention included providing quarterly feedback to health care providers, empowering the nurses to remind patients of diabetes care, and flagging the charts to remind providers. PROGRAM EVALUATION: The proportions of diabetic patients who had ophthalmologic exam, pneumococcal vaccine and lipid screening significantly improved over 12-month period. The proportions of patients with hypertension who had blood pressure less than 140/90 and patients who were taking aspirin also significantly improved over 12-month period. CONCLUSION: The quality of care for patients with diabetes and patients with hypertension could be improved in rural health clinics using repetitive cycles of measurements, implementation of interventions and evaluation of outcomes. This process could be used as the backbone for translation of evidence into practice and improving quality of care.     

Managing diabetes in cystic fibrosis

Cystic fibrosis related diabetes (CFRD) is the most common co-morbidity in persons with cystic fibrosis (CF). As the life expectancy of persons with CF continues to increase, the need to proactively diagnose and aggressively treat CFRD and its potential complications has become more apparent. CFRD negatively impacts lung function, growth and mortality, making its diagnosis and management crucial in a population already at high risk for early mortality. Compared to type 1 and type 2 diabetes, CFRD is a unique entity, requiring a thorough understanding of its unique pathophysiology to facilitate the creation and utilization of an effective medical treatment plan. The physiology of CFRD is complex, likely consisting of a combination of insulin deficiency, insulin resistance and a genetic predisposition towards the development of diabetes. However, the hallmark of CFRD is insulin deficiency, necessitating the use of exogenous insulin as the mainstay of therapy. Insulin administration, in combination with a multidisciplinary team of health professionals with expertise in the care of patients with CF and CFRD, is the cornerstone of the care for these patients. The goals of treatment of the CFRD population are to reverse protein catabolism, maintain a healthy weight, and reduce acute and chronic diabetes complications. Creating a partnership between the treatment team and the patient is the ideal way to accomplish these goals and is essential for successful diabetes care.     

US nurses' perceptions of their role in diabetes care: results of the cross-national Diabetes Attitudes Wishes and Needs (DAWN) study

PURPOSE: The purpose of this study was to examine nurse and physician perceptions of nurse involvement and roles in diabetes care. METHODS: The study used a cross-sectional design with face-to-face or telephone interviews of diabetes health care professionals in 13 countries from Asia, Australia, Europe, and North America. This article focuses on the data from US health care providers. The US sample included 51 generalist nurses, 50 diabetes specialist nurses, 166 generalist physicians, and 50 diabetes specialist physicians. RESULTS: Nurses and physicians agreed that nurses should take a larger role in managing diabetes. Most common differences identified between nurses and physicians were that nurses provide better education, spend more time with patients, were better listeners, and knew their patients better than physicians. All nurses had a high perceived need for better understanding of psychosocial issues and were more likely than physicians to suggest helping patients to take responsibility for their care. Nurses more than physicians also said better communication was needed. Generalist nurses report that they act as intermediaries and facilitate patient appointment keeping. Specialist nurses talk to patients about self-management, teach medication management, have a higher level of involvement in medication prescribing, and are more willing to take on additional responsibilities than generalist nurses. CONCLUSIONS: There is an increased need for more involvement by nurses, particularly specialist nurses, in diabetes care.     

AN INTERNATIONAL SURVEY ON ATTITUDES OF RENAL NURSES TOWARDS OLDER PEOPLE

Background: Previous studies have indicated that healthcare providers do not enjoy taking care of older people, because of poor attitudes towards the elderly. Aim: The purpose of this cross‐sectional study is to identify and describe the attitudes of a worldwide sample of renal nurses towards older people. Method: A convenience sample composed of renal nurses worldwide completed a socio‐demographic questionnaire and the Kogan's Attitude towards Old People Scale (KOAP). Results: We received 1,061 completed questionnaires from nurses in 12 countries. Participants were mainly female (81%), their average age being 42.69 (SD ± 8.70); 74% of nurses had older people in their families and 51% had lived with older people. The sample reported slightly positive attitudes towards the elderly [mean score (±SD) = 151.50 (±17.9)]. Attitudes were influenced by continent, country, religion, presence of older people in the family and level of nursing education (p < 0.0001). Conclusion: Our study has shown that renal nurses have slightly positive attitudes towards older people but attitudes could be improved with specific information being provided to renal nurses, to obtain better care.     

Pregnancy and labor in diabetes from the viewpoint of the obstetrician

Diabetes of all types is a known complication of pregnancy and is a risk for mother and foetus. Despite significantly improved care of pregnancies complicated by diabetes the perinatological results are still somewhat worse than in the healthy population. Therefore in the further improvement of perinatological indicators preconception care participates as well as systematic compensation of insulin dependent diabetes, preventive admission on hospital and correct timing of termination of pregnancy in pregestational as well as in gestational diabetes. All care of these pregnancies is shared by the obstetrician and diabetologist.     

Diversity in diabetes: the role of insulin aspart

Diabetes management is changing not only with novel treatments but also in patient demography. This presents clinical challenges and influences our view of diabetes therapies. Insulin analogues have been developed to overcome some of the limitations of traditional human insulins, with the aim of providing a more physiological pharmacokinetic/pharmacodynamic profile. The rapid-acting insulin analogue insulin aspart has been investigated in many clinical trials over the past 10 years and the aim of this review is to present the insulin aspart clinical trial data from across the spectrum of patients with diabetes. Five studies have looked at insulin aspart use (including continuous subcutaneous insulin infusion) in children and adolescents, where the analogue was as effective and well tolerated as soluble human insulin. One large-scale, randomized, controlled trial in pregnant women with type 1 diabetes observed trends towards a reduction in major hypoglycaemia, fewer preterm deliveries and lower birthweight with insulin aspart compared with soluble human insulin. Two 6-month, randomized, controlled, multicentre, multinational, parallel-group, open-label trials reported significant reductions in haemoglobin A(1c) and major nocturnal hypoglycaemia with insulin aspart compared with soluble human insulins in patients with type 1 diabetes. There are fewer data involving insulin analogue use in hospitals and in elderly patients with diabetes, but some recent studies have investigated insulin aspart in the emergency department, intensive/non-intensive care setting and in a pharmacokinetic/pharmacodynamic study in patients aged ≥ 65 years. In summary, the evidence would suggest that insulin aspart is suitable for use in a variety of patients with diabetes.     

Non‐insulin treatments for Type 1 diabetes: critical appraisal of the available evidence and insight into future directions

Intensive insulin therapy is the mainstay of treatment for people with Type 1 diabetes, but hypoglycaemia and weight gain are often limiting factors in achieving glycaemic targets and decreasing the risk of diabetes‐related complications. The inclusion of pharmacological agents used traditionally in Type 2 diabetes as adjuncts to insulin therapy in Type 1 diabetes has been explored, with the goal of mitigating such drawbacks. Pramlintide and metformin result in modest HbA_1c and weight reductions, but their use is limited by poor tolerability and, in the case of pramlintide, by frequency of injections and cost. The addition of glucagon‐like peptide‐1 receptor agonists to insulin results in improved glycaemic control, reduced insulin doses and weight loss, but this is at the expense of higher rates of hypoglycaemia and hyperglycaemia with ketosis. Sodium‐glucose co‐transporter‐2 and dual sodium‐glucose co‐transporter‐2 and ‐1 inhibitors also improve glucose control, but with reductions in weight and insulin requirements potentiating the risk of acidosis‐related events and hypoglycaemia. The high proportion of people with Type 1 diabetes not achieving glycaemic targets, the negative clinical impact of intensive insulin therapy and the rise in obesity and cardiovascular disease and mortality, underline the need for individualized clinical care. The evaluation of new therapies, effective in Type 2 diabetes, as adjuncts to insulin therapy represents a promising strategy, particularly given the beneficial effects on cardiovascular and renal outcomes in people with Type 2 diabetes with or at high risk of complications that are also observed in patients with Type 1 diabetes. As the population with Type 1 diabetes ages, our mission is to evolve and provide better tools and improved therapies to excel, not only in glycaemic control but also in risk reduction and reduction of complications.     

The prevalence of diabetes mellitus and quality of diabetic care in residential and nursing homes. A postal survey

OBJECTIVE: to investigate the prevalence of known diabetes mellitus in care homes and the patterns of diabetes care in these institutions. DESIGN: a postal questionnaire sent to all 98 care homes in Sheffield. RESULTS: 70 care homes (71%) returned the questionnaire, indicating that 233 (8.8%) of 2648 residents were known to have diabetes. Of these, 76 (33%) were treated with diet alone, 105 (45%) with diet plus oral medication and 52 (22%) with insulin. Only seven registered nurses (2%) in the homes had certified diabetes training. Forty-two homes (60%) did not carry out a structured, diabetes-related assessment of residents on entry and only 29 (42%) had regular review of diabetic residents by a general practitioner or practice nurse. Most homes (89%) were visited by an optician, 56 (80%) also had a regular chiropody service, although 32 (46%) of these charged their residents for this service. CONCLUSIONS: the known prevalence of diabetes is similar to that reported previously. This study highlights the need for structured care with defined standards for care-home residents with diabetes.