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Ragnar Hanas

Publications and source records attributed to Ragnar Hanas.

12 recordsLinked to original sources
PubMed2006

Insulin pumps in pediatric routine care improve long-term metabolic control without increasing the risk of hypoglycemia.

Although continuous subcutaneous insulin infusion (CSII) has been used in pediatric practice for >20 yr, the technique is not widely used in many countries. The aim of this non-randomized population-based study was to evaluate CSII in routine pediatric care. In a 1-yr cross-sectional evaluation, 27/89 patients (30.3%, age 7-21 yr) used pumps (two during the night only), the others 4-6 injections/day. In patients with >2 yr of diabetes, pump users had higher HbA1c (8.9+/-1.0 vs. 8.2+/-1.6%, p=0.04), less insulin/24 h (0.9+/-0.1 vs. 1.0+/-0.2 U/kg, p=0.002), and longer diabetes duration (p=0.02). The higher HbA1c is explained by 67% of pump patients having high HbA1c (>8.5%) as the major indication for CSII. The overall incidence of severe hypoglycemia was 31.5/100 patient years, 40.3 for injection therapy, and 11.1 for pump therapy (p=not significant). The incidence of severe hypoglycemia with unconsciousness was 12.9/100 patient years and with seizures 9.7 for injection therapy, whereas no children on pumps experienced these complications during the cross-sectional study year. We had no admissions for ketoacidosis in either group during this year. The pump patients were followed for 5 yr after pump start. Two stopped using the pump after 2 and 3 yr. For the patients with high HbA1c as indication, mean HbA1c the year before pump was 9.5%. Mean HbA1c during the first year with pump was lowered to 8.9% (p=0.019), the second year 8.6% (p=0.017), the third year 8.6 (p=0.012), the fourth year 8.7 (p=0.062), and the fifth year 8.9% (p=0.28). We found six cases of ketoacidosis corresponding to 4.7/100 patient years. In conclusion, we found a long-term lowering of HbA1c after starting CSII in a pediatric population, decreased frequency of severe hypoglycemia, and a low risk of ketoacidosis.

Adolescent↗
PubMed2006

Hypoglycemia and ketoacidosis with insulin pump therapy in children and adolescents.

This review deals with the two most serious side effects encountered with insulin pump therapy, severe hypoglycemia and diabetic ketoacidosis (DKA). Although clinical follow-up studies reported decreased rates of severe hypoglycemia, randomized studies have not confirmed this, showing no difference between the pump and injection groups. Less-severe hypoglycemia (mild/moderate/symptomatic hypoglycemia) was found to be more common with pump use. Some patients have inadvertently dosed or overdosed while awake or during sleep, causing fatal outcome in rare cases. Population-based or retrospective clinical studies reported a low rate of DKA in pump users that was still a higher rate than those using injection therapy, at least in some countries. In research settings and for patients with good compliance and adequate family support, the risk of DKA seems lower; many short-term studies report no DKA at all, possibly due to the increased attention given to participants. The use of continuous subcutaneous insulin infusion (CSII) seems to decrease the risk in patients who had recurrent DKA before pump start. Most episodes of DKA occur early after pump start, suggesting a learning curve occurs in all new forms of treatment. Increased teaching and awareness programs are vital to prevent severe hypoglycemia and DKA in children and adolescents using insulin pumps.

3-Hydroxybutyric Acid↗
PubMed2005

A cross-sectional international survey of continuous subcutaneous insulin infusion in 377 children and adolescents with type 1 diabetes mellitus from 10 countries.

OBJECTIVE: To document current practices using continuous subcutaneous insulin infusion (CSII) by downloading electronically the 90-d pump data held within the pump memory and relating that to clinical data from children and adolescents in different pediatric diabetes centers from Europe and Israel. METHODS: Data of patients (1-18 yr) treated with CSII in 23 centers from nine European countries and Israel were recorded with the encapture software (PEC International, Frankfurt, Germany). The number of patients who participated was 377 (48% female; mean diabetes duration +/- SD: 6.8 +/- 3.7 yr; age: 12.9 +/- 3.8 yr, preschool n = 33; prepubertal n = 95; adolescent n = 249; CSII duration: 1.6 +/- 1.2 yr; local HbA1c: 8.1 +/- 1.2%). RESULTS: The total insulin dose was lower than previously reported for injection therapy (0.79 +/- 0.20 U/kg/d). Covariance coefficient of daily total insulin was high in all age groups (adolescents 19 +/- 9%, prepubertal 18 +/- 8 and preschool 17 +/- 8). The distribution of basal insulin infusion rates over 24 hr (48 +/- 12% of total dose) varied significantly between centers and age groups. The number of boluses per day (7 +/- 3) was not significantly different between the age groups (average daily bolus amount: 0.42 +/- 0.16 U/kg). The rate of severe hypoglycemia (coma/convulsions) was 12.4 episodes per 100 patient-years and the number of diabetes-related hospital days was 124 per 100 patient-years. DISCUSSION: Pediatric CSII patients show a high variability in their insulin therapy. This relates both to age-dependent differences in the distribution of basal insulin as to the age-independent day-to-day variation in prandial insulin.

Adolescent↗
PubMed2004

Reducing injection pain in children and adolescents with diabetes: a review of indwelling catheters.

Most children and adolescents find the pain when injecting insulin quite minimal but still significantly more painful than a placebo injection. However, injection pain and needle phobia are major problems for a small number of patients, even after many years of diabetes. Needle diameter is of less importance for the experienced pain. The use of indwelling catheters (Insuflon, Unomedical, Lynge, Denmark) for introducing insulin injections at the onset of diabetes results in an evident relief of preinjection anxiety, injection problems, and the procedural pain of repeated injections. The average indwelling time is 3-5 d. Fixation problems and local redness at the insertion site are the most frequent side effects. However, the frequency is low and they can be dealt with effectively. Needles of 8-10 mm should be used for injecting to avoid penetration of the tubing of the catheter. Using indwelling catheters for up to 4-5 d does not affect the absorption of insulin, when the catheter is inserted in an area free from lipohypertrophies. The long-term (measured by hemoglobin A1c) and short-term metabolic control (measured by blood glucose profiles and serum-free insulin) is not altered. Using this type of injection aid may decrease the risk of future injection problems, such as needle phobia, in very select patients. In conclusion, indwelling catheters can safely be used from the onset of diabetes to lessen injection pain in children and adolescents, and may facilitate the use of intensive insulin therapy in this age group.

Adolescent↗
PubMed2003

Continuous subcutaneous glucose monitoring improved metabolic control in pediatric patients with type 1 diabetes: a controlled crossover study.

OBJECTIVE: To improve metabolic control and prevent complications, both acute and late, we need to adjust treatment on the basis of the blood glucose (BG) profile, as not even the most active BG self-monitoring gives sufficient information. DESIGN: We have used Continuous Glucose Monitoring System (CGMS; Medtronic MiniMed, Northridge, CA) in a controlled crossover study including 27 diabetic patients aged 12.5 +/- 3.3 (mean; standard deviation; range: 5-19) years. All patients were treated with intensive insulin therapy, 14 with multiple injections, and 13 with pumps. The patients were randomized into an open or blind study arm. Both arms wore the CGMS sensor for 3 days every 2 weeks. CGMS profiles were used in the open study arm to adjust insulin therapy at follow-up visits every 6 weeks. Both the patients and the diabetes team were masked to the CGMS profiles in the blinded arm, and insulin therapy adjustments were based solely on 7-point BG profiles performed by the patients. At 3 months the 2 study arms were crossed over. RESULTS: Despite initial problems with a device new to both patients and the diabetes team, hemoglobin A(1)C decreased significantly in the open arm (from 7.70%-7.31%) but not in the blind arm (7.75%-7.65%). A total of 26/27 patients experienced daytime low subcutaneous glucose (<3.0 mmol/L;.8 episodes/day; duration 58 +/- 29 minutes; 5.5% of total time), and 27/27 patients had at least 1 nocturnal episode of low subcutaneous glucose (.4 episodes/night; duration 132 +/- 81 minutes; 10.1% of total time). CONCLUSIONS: Use of CGMS facilitated an improved treatment, and patients received new insight and increased motivation. In this study, we found CGMS to be a useful tool for education and improving metabolic control.

Adolescent↗
PubMed2002

Indwelling catheters used from the onset of diabetes decrease injection pain and pre-injection anxiety.

OBJECTIVES: To investigate the use of indwelling catheters as injection aids at diabetes onset to reduce injection pain and pre-injection anxiety. STUDY DESIGN: Forty-one patients aged 8.1 +/- 3.7 years (range, 1-15) participated in this open, controlled randomized study. A 10-cm VAS with faces was used for scoring. A local anesthetic cream was used before all insertions. The control group used insulin pens with standard needles. After one week, the indwelling catheter group could choose regular injections but were included in the "intention to treat" analysis. RESULTS: Injection pain and anxiety decreased from day 1 to 15 in both groups (average, 4.1 injections/day). Pain was significantly lower for indwelling catheter injections when scored by parents (median, 1.2 cm vs 2.7 cm; P =.002), children/teenagers (0.8 cm vs 1.5 cm; P =.006), and nurses (1.4 cm vs 3.0 cm; P =.002). Parental pre-injection anxiety was also lower (1.2 cm vs 2.9 cm; P =.016). Taking injections, including inserting catheters, was found to be less problematic with an indwelling catheter (1.6 cm vs 3.3 cm;P =.009). During the 6-month follow-up, injection pain and injection problems were significantly lower in the catheter group. Mean catheter indwelling time was 3.7 days. Median pain for catheter insertion was 2.1 cm and for glucose testing was 0.9 cm. Sixteen of 20 patients continued to use indwelling catheters after 2 weeks, and 9 of 20 after 6 months. CONCLUSIONS: We found an evident relief of pre-injection anxiety and injection pain when using indwelling catheters for introducing insulin injections at the onset of diabetes.

Adolescent↗
PubMed2002

How do we educate young people to balance carbohydrate intake with adjustments of insulin?

The dietary management of childhood diabetes is complex. Is it possible to educate young people to balance carbohydrate with their insulin? Can dietary knowledge be translated into lasting behaviour change? Do present teaching methods provide the skills necessary for children and parents to adjust their insulin therapy adequately? Evidence shows great variation in glycaemic control between centres and countries but the impact of dietary education methods is poorly evaluated and its links with clinical and psychosocial outcomes is virtually unknown. There is also little evidence to suggest cohesive teamworking with clear dietary targets for glycaemic control, lipids, incidence of hypoglycaemia, compliance, effect on peer and sibling relationships, and evaluation of individual dietary components, e.g. fibre, fat, antioxidants. There is wide variation in methods of dietary education, which are often based on historic practice. They include rigid counting of grams of carbohydrate, carbohydrate portion assessments, qualitative diets, low glycaemic index diets and the more recent 'intensified' carbohydrate measures with daily adjustments of insulin (the basis also of pump management). This last method has many benefits although it requires extensive nutrition education, it allows greater flexibility and variety of food intake, is sensitive to the varying daily energy expenditure of childhood and it addresses postprandial glycaemic excursions, all of which are inadequately managed by conventional therapy. However, one of the problems of overemphasizing carbohydrate measurement is that total carbohydrate intake may be suppressed, with a resulting increase in fat, this may contribute to an increase in cardiovascular risk. The ISPAD Consensus Guidelines 2000 contain dietary recommendations but scientific evidence is often lacking. Limited dietary studies show that some countries can meet guidelines more successfully than others. There are many reasons for this, such as food availability, types of food eaten, food preferences and family/cultural/religious influences. Educational methods must be adapted to local customs. Is there enough evidence to recommend a particular dietary education method? What outcomes do we hope to achieve? The workshop explored these issues in order to develop a deeper understanding of the complexity of dietary modification in childhood diabetes.

Behavior↗
PubMed2002

Selection for and initiation of continuous subcutaneous insulin infusion. Proceedings from a workshop.

Continuous subcutaneous insulin infusion (CSII) has been used in the paediatric age group for more than 20 years. The technique is not yet widely used in most countries but there has recently been increasing interest in pump therapy for young children and adolescents. In 1999, 7.5% of Swedish children and adolescents with diabetes used pumps, now the figure is approaching 12%. The indication for starting pump therapy has usually been a medical problem, but today quality of life issues are becoming increasingly important. One technique sometimes used is to start CSII by wearing the pump only at night. Daily insulin requirements are usually decreased compared with injection therapy. Studies have shown that it is possible to lower HbA1c when using an insulin pump and that the risk of severe hypoglycaemia can be lowered. The use of CSII has also been successful in preventing recurrent admission for diabetic ketoacidosis. While starting pump therapy does take an extra effort from both the diabetes team and the family, routine visits are generally no more time-consuming than for patients on multiple injection therapy. CSII can be initiated during admission to hospital but most pumps are started on an outpatient basis. Our department has the patients on the day care ward for 3-4 days of 'pump school'. Parents wear a saline pump for practice. The total daily insulin dose is usually lowered 15-20% compared with multiple injections; on average 40-50% (sometimes up to 60%) of the daily dose is given as basal rate. We start all pumps on rapid-acting analogues and use 40 IU/ml if the basal rate is <0.3 IU/h. In conclusion, the use of CSII in children and adolescents is well accepted and can be managed safely.

Child↗