A cross-sectional study to assess home glucose monitoring practices was conducted in 200 non-insulin-treated diabetic patients consecutively attending our hospital clinic. Of the 200, 97 (48%) patients (Group 1) regularly monitored urine (n = 74), blood (n = 19) or both (n = 4); 103 (52%) patients (Group 2) performed no home monitoring. The two groups were similar in terms of age, sex, duration of diabetes and type of treatment. The prevalence of diabetic complications was also closely comparable and only peripheral neuropathy differed between the groups, being more common in Group 1 (n = 12) than Group 2 (n = 4); p < 0.05. There was also no significant difference between the HbA1 concentration (mean +/- SD) in Group 1 (9.7 +/- 2.2%) and Group 2 (9.4 +/- 2.0%). The mean frequency of home monitoring was four tests weekly, but only 21 (22%) kept a written record and 60 (62%) would never alter their treatment on the basis of their results. Almost a third of patients could not interpret the results of monitoring or give the normal range of values. Home glucose monitoring, particularly of urine, is widely practised in Type 2 diabetes, at considerable overall expense. However, convincing evidence of its value in helping patients improve their blood glucose control or preventing the complications of the disease is lacking.
Insulin-treated diabetic patients with poor glycaemic control are frequently referred to diabetes specialist nurses, but little data exist as to the effectiveness of this practice. We therefore analysed the progress of 43 prospectively referred insulin-treated patients with glycosylated haemoglobin (HbA1c) levels > 7.5%. Diabetes nurse intervention involved re-education, dietary advice and insulin dose adjustment. Improvement in control was defined as a final HbA1c < 7.0% or a fall of HbA1c of > 1.0% at 6 months post-intervention. Almost two-thirds (63%) of patients achieved improvement status, with no increase in body weight or hypoglycaemic episodes. Disappointingly, however, the 'non-improver' group (37%) showed a mean deterioration in HbA1c. In conclusion, diabetes nurse intervention for poorly controlled insulin-treated diabetic patients is generally effective, but intervention may be best targeted to responsive patients. The factors which influence diabetic patients' 'responsiveness to change' require further investigation.
In order to assess the outcome of hospitalized diabetic patients in an urban health district the notes of a cohort identified from a survey of all inpatients on a single day in spring 1990 were reviewed. One hundred and ten cases were reviewed (8.4% of all inpatients); median age 73 years (range 26-99), 59 female. Fifty-five percent were medical patients (general or geriatric) and 16% were general surgical. Six remained inpatients after 6 months. Sixteen died, of whom 10 had macrovascular disease. Median length of stay was 22 days (2-300), significantly above the district average in all specialties (< 10 days). Of 15 patients with foot problems, 5 died and 3 had major amputations. Only 23% of all patients had documented evidence of screening for diabetic complications. The discharge diagnoses failed to acknowledge diabetes in 54 cases (including 10 deaths). Only 10% had formal advice from the diabetes team and subsequent audit revealed that metabolic management was commonly suboptimal in non-physician units. These data suggest that inpatient diabetes is costly and carries a high mortality. The incidence is substantially underestimated by conventional episode statistics. The evidence from this cohort of diabetic inpatients suggests that improved communication and recognition of the importance of diabetes could usefully contribute to the quality of care achieved.
The case is presented of a 31-year-old woman who developed florid clinical and biochemical Cushing's syndrome due to metastatic hepatic carcinoid tumour from a probable pancreatic primary. Hypercortisolaemia was controlled with metyrapone and ketoconazole, but high doses of octreotide failed to affect plasma cortisol and urinary 5-hydroxyindole acetic acid (5HIAA) levels, or prevent rapid tumour growth. Hepatic polystyrene embolisation failed, and she was treated by liver transplantation with initial excellent results, and normalisation of cortisol and 5HIAA levels. Ten months later, however, she relapsed with bony and pelvic tumour recurrence, and high and symptomatic levels of cortisol and 5HIAA. At this time, octreotide in similar doses to those used previously appeared to normalise her biochemically, although she died soon after. This variable responsiveness to octreotide could be related to somatostatin receptor changes, or cyclical tumour secretion patterns.
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