Diabetes Patients' Experiences With the Implementation of Insulin Therapy and Their Perceptions of Computer-Assisted Self-Management Systems for Insulin Therapy

Background

Computer-assisted decision support is an emerging modality to assist patients with type 2 diabetes mellitus (T2DM) in insulin self-titration (ie, self-adjusting insulin dose according to daily blood glucose levels). Computer-assisted insulin self-titration systems mainly focus on helping patients overcome barriers related to the cognitive components of insulin titration. Yet other (eg, psychological or physical) barriers could still impede effective use of such systems.

Objective

Our primary aim was to identify experiences with and barriers to self-monitoring of blood glucose, insulin injection, and insulin titration among patients with T2DM. Our research team developed a computer-assisted insulin self-titration system, called PANDIT. The secondary aim of this study was to evaluate patients’ perceptions of computer-assisted insulin self-titration. We included patients who used PANDIT in a 4-week pilot study as well as patients who had never used such a system.

Methods

In-depth, semi-structured interviews were conducted individually with patients on insulin therapy who were randomly recruited from a university hospital and surrounding general practices in the Netherlands. The interviews were transcribed verbatim and analyzed qualitatively. To classify the textual remarks, we created a codebook during the analysis, in a bottom-up and iterative fashion. To support examination of the final coded data, we used three theories from the field of health psychology and the integrated model of user satisfaction and technology acceptance by Wixom and Todd.

Results

When starting insulin therapy, some patients feared a lifelong commitment to insulin therapy and disease progression. Also, many barriers arose when implementing insulin therapy (eg, some patients were embarrassed to inject insulin in public). Furthermore, patients had difficulties increasing the insulin dose because they fear hypoglycemia, they associate higher insulin doses with disease progression, and some were ignorant of treatment targets. Patients who never used a computer-assisted insulin self-titration system felt they had enough knowledge to know when their insulin should be adjusted, but still believed that the system advice would be useful to confirm their reasoning. Furthermore, the time and effort saved with automated insulin advice was considered an advantage. Patients who had used PANDIT found the system useful if their glycemic regulation improved. Nevertheless, for some patients, the absence of personal contact with their caregiver was a drawback. While guidelines state that adjustment of basal insulin dose based on fasting plasma glucose values is sufficient, both patients who had and those who had not used PANDIT felt that such a system should take more patient data into consideration, such as lifestyle and diet factors.

Conclusions

Patients encounter multiple obstacles when implementing insulin therapy. Computer-assisted insulin self-titration can increase patient awareness of treatment targets and increase their confidence in self-adjusting the insulin dose. Nevertheless, some barriers may still exist when using computer-assisted titration systems and these systems could also introduce new barriers.     

Coronary artery bypass surgery on small patients

Little research exists on the outcome of smaller patients who undergo coronary artery bypass graft surgery. The purpose of this study was to evaluate the outcomes of cardiac surgery in smaller patients (males with body surface area of 1.6 square meters or less, and women with 1.5 meters or less). A consecutive series of 4,358 patients undergoing bypass surgery was evaluated. Of these, 246 (5.6%) were classified as small patients. Smaller patients were more likely to be women, older and of Asian ethnicity. They were less likely to have undergone a prior cardiac surgery. Smaller patients were less likely to receive an arterial conduit (74% versus 99%; p<0.00001). Rates of post-surgery complications differed between small and normal size patients, with smaller patients more likely to require prolonged ventilator support (p <0.05), more likely to have acute renal failure (p<0.0001), more transfusions and re-operation for bleeding (p<0.05), higher death rate (5.7% versus 2.6%; p<0.01) and longer length of hospital stay (11.4 versus 8.3 days; p<0.00001). In multivariate analyses evaluating factors related to death, emergent surgery, poor ejection fraction and older patient age were independently related to mortality. Small body surface area was not an independent predictor. The results of this study indicate that smaller patients do have poorer outcomes associated with coronary artery bypass surgery. However, 90% of the smaller patients did have an event-free surgery. Surgeons may need to monitor these patients more closely and anticipate the increased risk and cost that is associated with this group.     

灰色数列预测模型在成骨细胞体外培养中的应用

目的：灰色模型是运用一定的数学方法使信息不完全明确的系统经数据处理后能得到较明确结果的一种数学预测模型，体外细胞培养的影响因素较多，属于信息不完全明确的灰色系统，故运用灰色GM（1，1）模型对成骨细胞增殖、分化的变化规律进行预测，验证模型在体外细胞培养中的可应用性。方法：实验于2005—11／2006—03在广东医学院药理教研室完成。①实验过程：应用酶序列消化分离培养法培养新生大鼠颅骨成骨细胞；用MTT法测定体外培养成骨细胞在不含血清培养液A值，以了解成骨细胞的增殖情况；对硝基苯磷酸盐法观察体积分数为0．01的胎牛血清培养液对体外培养成骨细胞分泌碱性磷酸酶活性的影响，代表成骨细胞的分化情况。②灰色GM（1，1）模型建立：运用灰色系统理论，通过SAS8．1软件对体外培养成骨细胞MTT值和碱性磷酸酶OT值进行分析和预测。结果：运用灰色系统理论的后验差检验方法对模型进行检验，MTT这一指标的平均相对误差为4．4％，碱性磷酸酶这一指标的平均相对误差为7．04％，后验差比值为0．048和0．315，综合评定该模型为“好”。结论：灰色GM（1，1）模型对体外培养成骨细胞MTT值和碱性磷酸酶的OT值变化的预测精度高，结果可靠。体外培养成骨细胞MTT值和碱性磷酸酶的OT值的变化可用灰色GM（1，1）模型进行预测。     

Relaxin levels in ovum donation pregnancies

STUDY OBJECTIVE: To investigate the relative contributions of the corpus luteum (CL) and the placenta to the circulating levels of relaxin during pregnancy. PATIENTS: Forty-one patients in whom pregnancy had been achieved by ovum donation. RESULTS: Relaxin was not detected in the serum of 36 patients; in the remaining 5, although it was detectable, the levels were markedly reduced when compared with those in normal pregnancies. CONCLUSION: These results demonstrate that the CL is essential for the maintenance of normal circulating levels of relaxin during pregnancy.     

Serum Ornithine Carbamoyl Transferase as a Surrogate Marker in Malaria

Ornithine carbamoyl transferase (OCT) activity and other liver function tests were studied in a total of 50 patients of clinical malaria and 15 controls. They were grouped as group I (positive for malarial parasite on peripheral blood smear, n=18), group II (negative for malarial parasite on peripheral blood smear (PBS) but responded to antimalarials, n=17) and group III (peripheral blood smear negative and did not respond to antimalarial therapy, n=15). The mean OCT levels were significantly raised in group I (6.79 ± 1.84 IU/L, p value = 0.006) and group II (5.0 ± 1.15 IU/L, p value = 0.014) as compared to controls (2.5 ± 1.13 IU/L) and returned to normal after treatment In contrast, group III had normal levels except in a case of kala azar and septicemia where OCT levels were high and increased further on treatment. Taking PBS positivity as a gold standard of diagnostic criteria, OCT had a sensitivity of 83% and specificity of 86% with a high positive predictive value of 88% as compared to ALT which had a lower sensitivity of 55% and specificity of 80%. The clinical response rate in PBS negative cases of fever having high OCT level was 83% as compared to 35% in cases with normal OCT level, making OCT a good surrogate marker of malaria. OCT levels could also be of prognostic significance as 2 cases of cerebral malaria had high OCT levels of 11.1 UAL and 10.7 IU/L, respectively.Key Words: Malaria, Ornithine carbamoyl transferase     

Effects of oxygen and nitric oxide in oxygen on pulmonary arterial pressures of children with congenital cardiac defects

Inhaled nitric oxide is a specific pulmonary vasodilator. This study was undertaken to assess the effect on pulmonary arterial pressure of administering 100% oxygen compared with nitric oxide in oxygen. Thirteen mechanically ventilated children undergoing routine cardiac catheterization for the investigation of congenital heart disease were studied. Pulmonary arterial pressures were measured during inhalation of 30% oxygen (baseline), 100% oxygen, and nitric oxide (40 parts per million) in oxygen. In addition, in six children the pulmonary/systemic blood flow ratio and pulmonary vascular resistance were calculated using oxygen content, an assumed value for oxygen uptake, and the Fick principle. Results were compared using analysis of variance and the Wilcoxon signed-rank test. Pulmonary arterial pressure decreased from a mean value of 29.5 mmHg (SD 15.1) to 25.6 mmHg (SD 9.3), p= 0.048, after increasing the inspired oxygen fraction from 0.3 to 1.0. The addition of nitric oxide caused a further reduction to 22.9 mmHg (SD 7.9), p= 0.0001. There was no change in systemic arterial pressure or heart rate during the study period, but a small increase occurred in the mean methemoglobin level (1.1% to 1.3%) p= 0.039. Changes in the pulmonary/systemic blood flow ratio and pulmonary vascular resistance (n= 6) were not significant. Nitric oxide in oxygen appears to be a more potent pulmonary vasodilator than oxygen alone in pediatric patients with congenital cardiac defects.     

Plasma amino acid and protein concentrations in infants fed human milk or a whey protein hydrolysate formula during the first month of life

The aim of the study was to compare growth parameters, biochemical indices of protein metabolism and plasma amino acid concentrations in infants fed either human milk ( n = 12) or a whey protein hydrolysate formula ( n = 13) during the first month of life. Growth and gain in skin fold thickness were similar in both groups whereas serum protein concentration was significantly decreased (57.4 ± 3.9 versus 61.2 ± 2.9 g/l) in the infants fed the whey hydrolysate formula. The discrepancies between the plasma amino acid pattern of the whey hydrolysate formula group and that of the human milk group lessened during the first month. Nevertheless, at a mean age of 33 days the plasma threonine concentration remained twice as high and the plasma tyrosine, phenylalanine and proline concentrations were Significantly lower in the whey hydrolysate formula group than in the human milk group. Thus, compared with breast-fed infants, growth and most of the biological indices of protein metabolism were satisfactory in infants fed during the first month of life on a whey protein hydrolysate formula. Nevertheless, the decrease in total plasma protein concentration needs to be confirmed in a larger cohort of infants. In addition, further research is necessary to investigate the possible ways of reducing the hyperthreoninemia and preventing other plasma amino acid disturbances since it would be desirable to obtain plasma amino acid levels similar to those of breast-fed infants.