It has been questioned whether aiming at near-normoglycaemia by intensified insulin treatment regimens is feasible and safe for the majority of patients with insulin-dependent diabetes. In this study, intensified insulin injection therapy (including blood glucose self-monitoring and multiple insulin injections) based upon a 5-day inpatient group teaching programme was evaluated in Type 1 (insulin-dependent) diabetes mellitus in the centralised health care system of Bucharest. One hundred patients (group A, initial HbA1 12.5%) were followed for 1 year on their standard therapy (individual teaching, no metabolic self-monitoring), and thereafter for 1 year on intensified therapy. Another 100 patients (group B, HbA1 12.3%) were followed for 2 years on intensified therapy. A third 100 patients (group C, HbA1 11.7%) were assigned to a basic 4-day inpatient group teaching programme with conventional insulin therapy (including self-monitoring of glucosuria and acetonuria) and followed for 1 year. Mean HbA1 remained unchanged after standard treatment (group A: 12.8% at 12 months), but decreased during intensified therapy (group A: 10.1% at 24 months; group B: 9.3% at 12 months, 9.5% at 24 months; p less than 0.0001). In group C, no change was found compared to standard treatment (i.e. group A at 12 months). Incidence rates of ketoacidosis were 0.16 episodes per patient per year during standard treatment, 0.01 during intensified treatment (p less than 0.01) and 0.04 in group C (p less than 0.025). Hospitalisation rates were reduced by 60% during intensified therapy and by 40% in group C. Frequency of severe hypoglycaemia was not significantly different between the three treatment regimens. Thus, under the condition that insulin treatment is based upon a structured and comprehensive training of the patient, intensified insulin injection therapy performed as routine treatment of Type 1 diabetes significantly lowers HbA1 levels without increasing the risk of severe hypoglycaemia.
In two hospitals an identical diabetes teaching and treatment programme (in-patient, Monday to Friday, group teaching) was set up. Seventy-eight consecutive, conventionally treated Type 1 diabetic patients (duration of diabetes 10 +/- 6 years), referred during a certain period, were reinvestigated after 1 year, and again (for assessment of metabolic control only) 22 months after the teaching and treatment programme. Initially, mean glycosylated haemoglobin was 2.6%, after one year 1.0%, and after 22 months 1.5% above the upper limit of the normal range (p less than 0.001). Hospital admissions were reduced from a mean of 10 to a median of 1 day per patient per year (p less than 0.001). The long-term quality of diabetes care achieved by the diabetes teaching and treatment programme was unrelated to intelligence quotient, diabetes duration, or diabetes-related knowledge. Patients with normal levels of glycosylated haemoglobin on follow-up (33% of all patients) had particularly good compliance rates, and significantly lower initial values of glycosylated haemoglobin than patients with glycosylated haemoglobin levels greater than or equal to 10%. The data indicate that the diabetes teaching and treatment programme resulted in a substantial long-term improvement of metabolic control and a striking reduction of hospital admissions. The study substantiates the feasibility of applying this teaching and treatment programme on a large scale to other hospitals, so as to improve the quality of diabetes care and decrease health care costs.
This paper describes systematic studies on the absorption kinetics of exogenous insulin from its subcutaneous tissue depot in 52 male nonobese volunteers (age 20-30 yr). Five experimental protocols were used: effect of changing injection site, effect of temperature change and local massage, effect of aprotinin and human serum, effect of mixing regular insulin with long-acting insulin preparations, and effect of temperature change, muscular exercise, and local massage on the absorption of long-acting insulin preparations. The fastest absorption of insulin occurred at the abdominal injection. Absorption after arm injection was faster than after thigh injection. A hot bath and local massage dramatically increased serum insulin levels in the first 90 min after injection; in contrast, a cold bath delayed absorption substantially. Both aprotinin and the subjects' own blood serum mixed with insulin caused a marked acceleration of the insulin absorption process. Absorption kinetics of two neutral regular insulins (Actrapid and Leo Regular) were virtually identical. Mixing Actrapid with Monotard caused higher serum insulin levels than the mixture of Leo Regular with NPH. A time lag of 5 min between the mixing of Actrapid and Monotard and the injection caused a delayed rise of serum insulin levels; in contrast, this delay could not be observed when Leo Regular and NPH were mixed. Volunteers performed bicycle exercise, applied a hot water bottle to the injection site, or rubbed the injection site 2 1/2 h after injection of long-acting insulin. Accelerated absorption of insulin was only observed after local massage of the injection site of Monotard, Leo NPH, and Mixtard. Local heat had no effect. Exercise caused only an increased absorption of insulin after the Mixtard injection but not after Monotard or NPH injection. These findings have clinical significance and should not be without potential benefit in the attempt to improve metabolic control in insulin-treated diabetic patients.
Despite the obvious improvements made in the field of diabetes therapy during this century [1] the quality of diabetes care has, in general, remained poor. The widespread failure to acknowledge the impact of patient education appears to evolve as the primary reason for this unsatisfactory situation. Despite the firm and well founded recommendations put forward by some of the pioneers of modem diabetology, e.g. Drs. E.P.Joslin and R.D. Lawrence in the 1920s, it has taken almost 50 years for the beneficial effects of patient education to have finally and unequivocally been proven. The recently developed strategies for a global approach to diabetes therapy which combines biomedical, psychosocial and educational elements represents an exemplary therapeutic model for the care of many chronic diseases. The complexities of diabetes and of diabetes careThe metabolic manifestations of diabetes mellitus oscillate from hypoglycaemia to hyperosmolar or ketoacidotic decompensation and coma. The long-term complications of the disease may involve almost all organs with disabling consequences from benign dysaesthesia of the legs to the total loss of pain sensation with the severe risk of foot lesions; from background diabetic retinopathy without any impairment of visual function to proliferative diabetic eye disease leading to blindness; from potentially reversible microproteinuria to endstage kidney failure; and from minor arterial insufficiency of the lower limbs to gangrene and amputations. The threat of acute and long-term complications as well as the need for daily monitoring (blood or urine glucose levels, foot care, blood pressure, etc.) represent a considerable psychological stress to diabetic patients and their families.Treatment of metabolic disturbances and care of diabetic patients are not simple. There are numerous factors involved in the control of blood glucose levels. Although the underlying cause of the disease is an endocrine disorder (i. e. the absolute or relative lack of insulin secretion and/or the insensitivity to insulin at the level of the liver and some peripheral tissues), many additional factors play important roles in regulating the level of glycaemia in diabetic patients. These include the nutritional status of the patients, their dietary habits, their emotional constitution and way of coping with the disease, their familial, professional and social environment and many others. There is a constant interaction between these factors, most of which keep fluctuating extensively even within the same day. Thus, physicians and patients often find it difficult to identify the factor(s) which might have been responsible for a deterioration of metabolic control. Because the majority of these factors are closely related to the patients' behaviour, it appears evident that the achievement of longterm metabolic control is the consequence of a complex process simultaneously involving psychosocial, endocrine, and pharmacological factors. Obtaining (near)normalization of glycaemia may require the patient to perform ...
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