Management Of Insulin-dependent Diabetes Research Articles

148-LB: Timely Administration of Rapid-Acting Insulin in Hospitalized Children with Diabetes: A Quality Improvement Project

Background: The preferred management of insulin-dependent diabetes (IDDM) for pediatric patients includes rapid-acting insulin analogs administered at mealtimes in conjunction with carbohydrate counting. Hospitalized children with IDDM are dependent on hospital personnel to administer rapid-acting insulin, which should occur within 15-30 minutes of the onset of eating. Delays in insulin administration can result in hyperglycemia, poor patient satisfaction, and inappropriate insulin regimen adjustments. At the Children’s Hospital at Montefiore (CHAM), we found that rapid-acting insulin is administered within 15 minutes of glucose check at breakfast time in only 18% of patients, and within 30 minutes of glucose check in only 40% of patients. Methods: We formed a multi-disciplinary team and used process mapping to identify barriers to timely insulin administration and implement interventions. We studied the time to rapid-acting insulin administration at breakfast for children with IDDM admitted to the 6th floor of CHAM from November 2018 to present before and after PDSA cycles, which have included nurse and resident education in carbohydrate counting, standardization of diabetes menus to include carbohydrate content, and standardization of communication method between nurses and residents. Results: As of December 2019, median time from blood sugar check to rapid-acting insulin administration at breakfast improved from 32.5 minutes at baseline to 26 minutes. The percentage of children with IDDM who receive rapid-acting insulin within 15 minutes of blood sugar check has not changed, but the percentage of children who receive rapid-acting insulin within 30 minutes of blood sugar check improved from 40% at baseline to 60%. Conclusions: Timely administration of rapid-acting insulin to hospitalized children with IDDM is a complex process involving coordination of care by multiple providers, and can be improved upon with a multidisciplinary team approach. Disclosure L. Eng: None. D. Duhame: None. L. Underland: None.

Unmet needs in children with diabetes: the role of basal insulin.

The goal of insulin therapy in people affected by type 1 diabetes mellitus consists in achieving an optimal metabolic control and so HbA1c levels below 7.5%, according to the conclusions of relevant scientific studies. In any case it seems that this target is far from being achieved, mostly in the pediatric population. However, many important pharmacological, technological and cultural milestones have been placed both in therapy and management of insulin-dependent diabetes even if the gap between growing knowledge in these fields and its application in daily clinical practice appears still too wide. A fundamental component of these advancements concerns the design of new insulin basal analogues; molecules used to realize a basal-bolus model of therapy with MDI scheme. Degludec insulin has been recently approved for the pediatric utilization (aged 1 to 17 years). A registration trial for pediatric population (aged 6 to 17 years) is in progress for glargine U-300 insulin. These two insulin types have different biochemical and pharmacological properties and they represent two different ways to achieve the ideal basal analogue. Insulin degludec and insulin glargine U-300 are the newest basal analogues and each of them has proper pharmacokinetic and pharmacodynamic characteristics. Their characteristics represent an effort to create the ideal solution. The aim of this review is to summarize the pharmacokinetic and pharmacodynamic properties of these new insulins, to list the most significant scientific findings regarding their pharmacology as well as clinical uses, with particular reference to the pediatric population in order to declare them to clinical experience and to report data on an initial experience with these analogues, especially with degludec insulin. Once again, evolution goes through the specialized training of the staff involved in the care of the diabetic patient and the constant education of the latter.

1673 Osteopathy in Insulin-Dependant Diabetes Mellitus; A Neglected Complication

The main aim of management of insulin dependent diabetes (IDDM) is to prevent the acute as well as the long term complications, Recent studies suggest that IDDM in children is...

Interference at work: a case report of a malfunctioning insulin pump

Insulin pumps operate almost universally in the work environment. Tubeless insulin pumps are a relatively recent development for management of insulin-dependent diabetes. This is the first report of location-dependent failure of insulin pump function, possibly due to external interference, occurring only in the setting of a medical center. A successful solution to this problem was designed and implemented. In conclusion, heightened awareness of this possibility in individuals who use tubeless insulin pumps in a medical environment would seem prudent, as when identified, it can be easily corrected.

Investigation of the Effect of Aqeous Mistletoe Leaf Extract on Glucose and Cholesterol Levels in Alloxan-Induced Diabetic Rabbits

Aqueous leaf extract of the mistletoe was investigated for hypoglycaemic and hypocholesterolaemic effect in diabetic rabbits. Diabetes mellitus was induced in rabbits in groups I-II by a single intraperitoneal injection of alloxan monohydrate at 100mg/kg body weight. Following confirmation of hyperglycaemia, groups I and II were treated with the extract at 1.32 and 2.64g/kg body weight for three consecutive days. After the last treatment, rabbits were fasted for 12 hours and bled at 0, 2, 6 and 24 hours. Serum glucose levels were determined by the glucose oxidase method and cholesterol levels by Liebermann-Buchard method. The results showed statistically significant decreases (P 0.05), when compared to control group III. Aqueous leaf extract of the mistletoe (an epiphyte of lemon trees) may be recommended for frequent consumption in the management of insulin-dependent diabetes. Keywords : Mistletoe Extract, Glucose, Alloxan-Induced Diabetic Rabbits Journal of Medical Laboratory Sciences Vol. 14 (1) 2005: pp. 28-32

DIAS—the diabetes advisory system: an outline of the system and the evaluation results obtained so far

The present paper gives a description of the Diabetes Advisory System (DIAS), and the evaluation results obtained so far. DIAS is a decision support system for the management of insulin dependent diabetes. The core of the system is a compartment model of the human carbohydrate metabolism implemented as a causal probabilistic network (CPN or Bayesian network), which gives it the ability to handle the uncertainty, for example, in blood glucose measurements or physiological variations in glucose metabolism. The evaluation results suggest that, at least in our hands, DIAS can generate advice that is safe and of a quality that is at least comparable to what is available from experienced clinicians.

Management of insulin-dependent diabetes: hypoglycaemia and the eye.

The treatment of type 1 (ketosis-prone) or insulin-depend­ ent diabetes has not changed radically since the introduc­ tion of insulin into clinical practice in the 1920s. Modifications and improvements in the purity , supply , for­ mulations and regimens of insulin have provided signifi­ cant progress in diabetic management, but the presently available range of insulins and methods of delivery are still far removed from simulating the normal physiology of insulin secretion and action. The loss of the normal homeostatic mechanisms which maintain blood glucose within a narrow physiological range, render the diabetic individual susceptible to wide excursions in blood glucose and the intermittent hazard of metabolic extremes. This occurs with chronic hyperglycaemia and diabetic ketoaci­ dosis, which is fortunately now relatively infrequent, and acute hypoglycaemia which is an exceedingly common therapeutic side effect of insulin. Hypoglycaemia will be addressed in more detail here because of its potential effects on the diabetic eye.

Clinical review 38: Intensive management of insulin dependent diabetes: risks, benefits, and unanswered questions.

Clinical review 38: Intensive management of insulin dependent diabetes: risks, benefits, and unanswered questions.

Clinical review 38: Intensive management of insulin dependent diabetes: risks, benefits, and unanswered questions

Clinical review 38: Intensive management of insulin dependent diabetes: risks, benefits, and unanswered questions

Membrane Bioreactors as Hybrid Artificial Pancreas: Experimental Evaluation

Results of cultured islet transplantation in the management of insulin-dependent diabetes are still unsatisfactory. The main problem preventing success is the swift and resolute host immune rejection. To obviate this we designed and experimented a model of bioartificial pancreas, made of polymeric hollow fibers, put into the blood circulation as an artero-venous bypass to immunoisolate endocrine tissue from leucocytes and immunoglobulins. We tested four different membrane bioreactors (BR1-4). BR1 and 2 had seven hollow fibers, the others more than 6,000 smaller fibers. In BR4 a connecting tube with a high-permeability membrane was inserted between the islet compartment and the bioreactor outlet to improve the ultrafiltration flow. In vitro, the islets inside the bioreactor perfused with glucose solutions (300 mg%) showed a rapid, high insulin secretory response, related to the glucose stimulation. The use of the outside connection allowed a twofold increase of insulin production.

Doctors' beliefs and the management of insulin dependent diabetes: implications for sharing care.

There have been many studies of the health beliefs of patients but relatively few have considered the beliefs of doctors and the influence these have on the management of a disease. This paper reviews the evidence that such beliefs are important and reports a preliminary study examining differences in the beliefs of doctors as a function of their experience and chosen specialty. Thirty four general practitioner teachers responded to a questionnaire measuring beliefs about diabetes and its management. The results were compared with those of a previous study among hospital doctors with an interest in diabetes. In comparison with hospital doctors, general practitioner teachers had a more pessimistic outlook on diabetes, perceiving that the disease carried more risks and having less confidence that achieving goals of treatment would reduce these risks. In accord with these beliefs their approach to treatment was less rigorous than that of hospital-based doctors. These results have implications for shared care; such differences between groups of doctors are likely to be a barrier to the effective sharing of patient care. The results also add further strength to the view that doctors' beliefs about a disease and its management need to be considered alongside those of the patient to explain more of the variance in patient health outcomes.

すい切除後発症する糖尿病の病態と管理 すい再生因子からの検討

すい切除後発症する糖尿病の病態と管理 すい再生因子からの検討

Insulin infusion therapy

A mass of evidence favors the concept of euglycemic management of insulin-dependent diabetes, despite significant potential complications. Patients with advanced nephropathy and/or autonomic neuropathy are very poor risks, and infusion therapy does not reverse well-established complications. To well-motivated, educated patients, infusion therapy offers the conveniences of more flexible timing of meals and of having a premeal bolus infusion rather than a premeal injection. With improvement in the technology of continuous glucose monitoring and closed-loop systems, as well as basic improvements in immunologic techniques for islet transplantation, the future may offer a choice of excellent euglycemic therapies for insulin-dependent diabetes. Meanwhile, infusion therapy, which was once only a research tool, is now widely available and is appropriate for near-euglycemic management of diabetes in selected patients.

The Management of Insulin Dependent Diabetes During Cardiopulmonary Bypass and General Surgery

Two groups of insulin dependent diabetic subjects have been studied: six undergoing general surgical procedures and six undergoing hypothermic cardiopulmonary bypass surgery for coronary artery vein grafting. Intravenous glucose insulin mixtures were infused from the onset of surgery in both groups of patients, supplying 0.4 units of insulin per gram of glucose per hour, and 0.6 units of insulin per gram of glucose per hour in general and cardiac surgical patients respectively. Postoperatively diabetes was controlled carefully with an insulin syringe pump regulated by venous blood glucose monitoring. In cardiac surgical patients far more insulin was required to control diabetes postoperatively than in the general surgery patients (at 1 hour 1.6 units, SEM 0.4 compared to 0.7 SEM 0.1, p less than 0.05; and at 4 hours 2.0 units SEM 0.3 compared to 0.8 units SEM 0.1, p less than 0.02). Five non-diabetic subjects who underwent surgery for coronary artery venous bypass grafting were also studied. They developed significant postoperative hyperglycaemia (5.0, SEM 0.2, mmol/litre pre-operatively, compared with 8.8, SEM 0.7, mmol/litre p less than 0.03 at 1 hour and 10.2, SEM 1.7, mmol/litre, p less than 0.02 at 4 hours after bypass terminated).

Human insulin.

Two methods of synthesis of human insulin have been developed to the stage of commercial production. One entails synthesis of human insulin by bacteria ("biosynthetic" human insulin) and one entails the conversion of pork insulin into human insulin by an amino acid substitution ("semisynthetic" human insulin). Both forms of human insulin have been shown to be safe, and to have similar efficacy and pharmacokinetics to purified pork insulin. Human insulin given by subcutaneous injection has been shown to elicit antibody formation in man, although the extent of this may be slightly less than in the case of purified pork insulin, and is certainly less than in the case of beef insulin and beef-pork combinations. The clinical significance of these differences in immunogenicity is doubtful. However there are rare defined situations, such as allergy to pork insulin and antibody-mediated insulin resistance where human insulin has been shown to have advantages over purified pork insulin. Bacterial synthesis of insulin provides an assured supply for the world's future needs, and it is conceivable that further technological refinement may make bacterial synthesis cheaper than extraction and purification of animal insulins. However, current evidence provides no basis for recommending human rather than purified animal insulin for the routine management of insulin dependent diabetes.

The management of insulin dependent diabetes during cardiopulmonary bypass and general surgery.

Two groups of insulin dependent diabetic subjects have been studied: six undergoing general surgical procedures and six undergoing hypothermic cardiopulmonary bypass surgery for coronary artery vein grafting. Intravenous glucose insulin mixtures were infused from the onset of surgery in both groups of patients, supplying 0.4 units of insulin per gram of glucose per hour, and 0.6 units of insulin per gram of glucose per hour in general and cardiac surgical patients respectively. Postoperatively diabetes was controlled carefully with an insulin syringe pump regulated by venous blood glucose monitoring. In cardiac surgical patients far more insulin was required to control diabetes postoperatively than in the general surgery patients (at 1 hour 1.6 units, SEM 0.4 compared to 0.7 SEM 0.1, p less than 0.05; and at 4 hours 2.0 units SEM 0.3 compared to 0.8 units SEM 0.1, p less than 0.02). Five non-diabetic subjects who underwent surgery for coronary artery venous bypass grafting were also studied. They developed significant postoperative hyperglycaemia (5.0, SEM 0.2, mmol/litre pre-operatively, compared with 8.8, SEM 0.7, mmol/litre p less than 0.03 at 1 hour and 10.2, SEM 1.7, mmol/litre, p less than 0.02 at 4 hours after bypass terminated).

Outpatient Use of Intermediate- and Short-Acting Semisynthetic Human Insulins

To determine if semisynthetic human insulins are useful in the outpatient management of insulin-dependent diabetes, the conditions of eight patients were evaluated for three months using short- and intermediate-acting insulins. No complications of either insulin preparation were observed. Hemoglobin A1c levels were decreased from 8.4% to 6.9% during human insulin use, and, in addition, normal hemoglobin A1c levels were maintained in patients using portable insulin infusion pumps. These results were achieved because of the health care provision team and were not directly the result of human insulin. Semisynthetic human insulins were also associated with lower levels of circulating insulin antibody. These data indicate that both short- and intermediate-acting semisynthetic human insulins are effective in stringent diabetes metabolic control, provided adequate health care provision is available.

Glycosylated hemoglobin: A screening test for diabetes mellitus?

Glycosylated hemoglobin (GHb), or HbA, is now a popular test in the management of Insulin Dependent Diabetes (IDDM) as it provides an integrated measure of blood glucose concentrations over the preceding 1–3 months. In this report we evaluate its potential as an epidemiologic screening tool through its relationship to the standard diagnostic test—an Oral Glucose Tolerance Test (OGTT). Using data from over 400 relatives of IDDM patients, thought to be free of diabetes, we demonstrate that there was a significant correlation between GHb and glucose concentrations during an OGTT (maximum correlation, r = 0.27, P < 0.001). This was largely limited to adults. However, only 37% of the relatives who were found to have a diabetic OGTT also had a GHb above the normal range (mean ± 2 SD). Furthermore, only 25% of those with either diabetes or impaired glucose tolerance had an abnormal GHb. We thus conclude that GHb is too insensitive a measure to be used as a screening tool for the detection of diabetes mellitus as currently defined.

Improved metabolic profiles in insulin-treated diabetic patients given an alpha-glucosidehydrolase inhibitor.

An alpha-glucosidehydrolase inhibitor (acarbose; BAY g 5421) taken with food was compared with dummy tablets in seven insulin-treated diabetic patients over eight-hour periods that included breakfast, lunch, and two snacks. Acarbose diminished the postprandial increases in blood glucose, lactate, and pyruvate concentrations and may therefore be of value in the management of insulin-dependent diabetes.

Combined insulin-tolbutamide therapy in the management of insulin-dependent diabetes.

Combined insulin-tolbutamide therapy in the management of insulin-dependent diabetes.