Context Newer insulin therapies, including the concept of physiologic basalprandial insulin and the availability of insulin analogues, are changing clinical diabetes care. The key to effective insulin therapy is an understanding of principles that, when implemented, can result in improved diabetes control. Objective To systematically review the literature regarding insulin use in patients with type 1 and type 2 diabetes mellitus (DM). Data Sources A MEDLINE search was performed to identify all English-language articles of randomized controlled trials involving insulin use in adults with type 1 or type 2 DM from January 1, 1980, to January 8, 2003. Bibliographies and experts were used to identify additional studies. Study Selection and Data Extraction Studies were included (199 for type 1 DM and 144 for type 2 DM, and 38 from other sources) if they involved human insulins or insulin analogues, were at least 4 weeks long with at least 10 patients in each group, and glycemic control and hypoglycemia were reported. Studies of insulin-oral combination were similarly selected. Data Synthesis Twenty-eight studies for type 1 DM, 18 for type 2 DM, and 48 for insulin-oral combination met the selection criteria. In patients with type 1 DM, physiologic replacement, with bedtime basal insulin and a mealtime rapid-acting insulin analogue, results in fewer episodes of hypoglycemia than conventional regimens. Rapid-acting insulin analogues are preferred over regular insulin in patients with type 1 DM since they improve HbA 1C and reduce episodes of hypoglycemia. In patients with type 2 DM, adding bedtime neutral protamine Hagedorn (isophane) insulin to oral therapy significantly improves glycemic control, especially when started early in the course of disease. Bedtime use of insulin glargine results in fewer episodes of nighttime hypoglycemia than neutral protamine Hagedorn regimens. For patients with more severe insulin deficiency, a physiologic insulin regimen should allow lower glycemic targets in the majority of patients. Adverse events associated with insulin therapy include hypoglycemia, weight gain, and worsening diabetic retinopathy if hemoglobin A 1C levels decrease rapidly. Conclusions Many options for insulin therapy are now available. Physiologic insulin therapy with insulin analogues is now relatively simple to use and is associated with fewer episodes of hypoglycemia.

This study documents the increasing use of longitudinal integrated clerkships and provides initial insights for institutions that may wish to develop similar clinical programs. Further study will be needed to assess the long-term impact of these programs on medical education and workforce initiatives.

These concepts introduce students to some of the positive and negative aspects of rural practice, as well as opportunities for rural practitioners to have a diverse practice, to become involved in all aspects of health and to initiate change. They provide an understanding of rurality from which health students can learn from their practical experiences during rural placements.

To assess physicians' use of and attitudes toward electronic mail (e-mail) for patient communication, we conducted a mailin survey of physicians who see patients in outpatient clinics affiliated with a large academic medical center (N = 283). Seventy-two percent of physicians reported using e-mail to communicate with patients, averaging 7.7 e-mails from patients per month. The lowest level of use was by communitybased primary care physicians (odds ratio, 0.22; 95% confidence interval, 0.08 to 0.59). Those physicians who reported using e-mail with patients reported high satisfaction with its use. Although physicians were concerned about the confidentiality of e-mail, few discussed this issue with patients.

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Understanding when to use insulin and how to apply the principles of physiologic insulin replacement using existing and new insulins is a key step to improving diabetes care. Insulin analogues and premixed insulins increase physicians' and patients' ability to lower hemoglobin A 1C levels with fewer episodes of hypoglycemia. Earlier use of insulin and more aggressive dose escalation are important steps in achieving treatment goals. This article discusses using bedtime insulin with oral agents, basal-prandial insulin strategies, and the new insulin analogues.