Using blood glucose meters: what you and your patient need to know, Part II.
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Blood Glucose Self-Monitoring↗
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Glucose acts in the CNS to regulate gastric motility during hypoglycemia.
Our purposes were to 1) develop an animal model where intravenously (iv) administered d-glucose consistently inhibited antral motility, and 2) use this model to assess whether iv glucose acts to inhibit motility from a peripheral or a central nervous system site and to elucidate the factor(s) that determine(s) whether stomach motor function is sensitive to changes in blood glucose. Rats were anesthetized with alpha-chloralose-urethane, and antral motility was measured by a strain-gauge force transducer sutured to the antrum. In some cases, antral motility and gastric tone were measured by monitoring intragastric balloon pressure. Increases in blood glucose were produced by continuous iv infusion of 25% d-glucose at 2 ml/h. Inhibition of antral motility and gastric tone was observed when gastric contractions were induced by hypoglycemia (subcutaneously administered insulin, 2.5 IU/animal). In contrast, no inhibition of gastric motor function was observed when glucose infusion was tested on gastric contractions that were 1) spontaneously occurring, 2) evoked by iv administered bethanechol in vagotomized animals, and 3) evoked by the TRH analog RX77368, microinjected into the dorsal motor nucleus of the vagus. Using the model of insulin-induced hypoglycemia to increase gastric motor activity, we found that neither sectioning the hepatic branch of the vagus (n = 5), nor treating animals with capsaicin to destroy sensory vagal afferent nerves (n = 5) affected the ability of iv d-glucose to inhibit gastric motor function. Our results indicate that an important factor determining whether stomach motor function will be sensitive to changes in blood glucose is the method used to stimulate gastric contractions, and that the primary site of the inhibitory action of iv glucose on gastric motility is the central nervous system rather than the periphery.
Animals↗
Intensified treatment and education of type 1 diabetes as clinical routine. A nationwide quality-circle experience in Germany. ASD (the Working Group on Structured Diabetes Therapy of the German Diabetes Association).
This contribution describes the nationwide implementation of an intensive treatment and education program for type 1 diabetic patients in the clinical routine of the German health care system. Based on the formation of a working group (Arbeitsgemeinschaft Strukturierte Diabetestherapie [ASD]) of presently 57 general internal medicine departments, mainly from secondary and tertiary care levels in city and country hospitals throughout the country, a peer-review quality circle was formed as an official working group of the German Diabetes Association. The participating institutions performed a structured program of intensive treatment and education in all type 1 diabetic patients referred to them on a routine basis. The program includes multiple daily insulin injections or continuous subcutaneous insulin infusion, several times daily blood glucose self-monitoring and self-adaptation of insulin dosages and other aspects of treatment by the patients, and a far-reaching liberalization of the nutrition regimen. The group has attempted to document and to improve the quality of the structure and process of type 1 diabetes care in its participating institutions by a system of peer supervision. Furthermore, all member institutions volunteered to collect outcome data based on systematic 1-1.3 years' follow-up examinations of consecutive type 1 diabetic patients. For the 1997 evaluation of 1,103 type 1 diabetic patients, significant decreases of GHb levels and of incidence rates of severe hypoglycemia (from 0.35 to 0.16 cases per patient-year) and ketoacidosis (from 0.08 to 0.02 cases per patient-year) are presented. The ASD quality circle represents a model to improve principal aspects of type 1 diabetes care on a nationwide basis.
Cohort Studies↗
A systems approach to capillary blood glucose monitoring. A joint nursing/patient education effort.
Capillary blood glucose monitoring was successfully instituted on the nursing units at a small community hospital using a systematic, goal-directed process. Through the efforts of the diabetes educator and the coordinator of nursing education, nursing staff are now able to detect fluctuations in patient blood glucose levels rapidly and to provide prompt treatment. The system was implemented on the nursing units with preceptors serving as instructor-trainers. The implementation required the close cooperation and collaboration of multiple hospital departments. The nurse educator and the diabetes educator conduct ongoing monitoring using data collected from the patient, the nurse, and the multidisciplinary team.
Blood Glucose Self-Monitoring↗
The use of a multidisciplinary team care approach to improve glycemic control and quality of life by the prevention of complications among diabetic patients.
In an effort to provide effective and efficient care to patients with chronic health conditions, the U.S. healthcare system is in the process of redesigning its delivery system. One approach to meet the high demands of patients and to best utilize resources is the use of a multidisciplinary team approach to provide better care when compared to an individual patient - physician care. When properly implemented, this team approach provides positive measurable outcomes. With a diverse group of healthcare professionals, such as physicians, nurses, pharmacists, dieticians, and health educators with the patient at the center of the team, the team can ensure treatment goals are maintained for chronic diseases. The team approach implements: patient satisfaction and self-management, development of a community support network, team coordination, team communication, patient follow-up, use of protocols and other tools, use of computerized information systems, and outcome evaluations. The goal of this paper is to demonstrate the benefits of utilizing this multidisciplinary approach with Type II diabetes through the improvement of glycemic control and improved quality of life. Cost effectiveness is also discussed.
Blood Glucose↗
[Your reflectance meter results. To avoid doubt].
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Blood Glucose Self-Monitoring↗
User-friendly computerized quality assurance program for regionalized neonatal care.
In October 1983 a computerized data base system was implemented to perform quality assurance in the neonatal referral region of the University of Michigan. This system was customized to match and expand forms and reports already in use. It is menu driven, requires only rudimentary skills, and is compatible with existing computer equipment. To assess the effectiveness of the program in monitoring and improving neonatal care within the region, data from the first full year (1984) were compared with data from the last full year (1990). Statistically significant changes were found for referring physician presence at transfer, a greater assumption of initial stabilization procedures by community hospital personnel (continuous cardiorespiratory monitoring, orogastric tube placement, provision of respiratory support, blood glucose screening, blood gas evaluation, blood culturing, and antibiotic therapy), and an overall improvement in patient status before transfer. Review of reports generated by data analysis enables design of educational programs that are hospital specific and that focus on problems or deficiencies determined during quality assurance conferences. The chief benefit of this system is the provision of an objective basis for constructive criticism, which leads to both cognitive and behavioral changes in care providers and ultimately improves the delivery of care to neonates.
Data Display↗
B-G-T-E-S-T: a basic review.
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Blood Glucose Self-Monitoring↗
Metabolism and distribution of [14C]glucose in rats treated with 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD).
Male Sprague-Dawley rats were given a single, usually lethal, dose of 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD, 125 micrograms/kg ip in corn oil), or vehicle alone. Twenty-four hours after ip administration of TCDD the animals received an ip injection of 14C-labeled glucose, and the time course and amount of exhalation of 14CO2 were monitored for 8 h continuously and once daily for 20 min for the subsequent 5 d. TCDD treatment reduced the amount of 14CO2 exhaled within 8 h after the injection of [14C]glucose by 33%, as compared to pair-fed controls. Blood levels of radioactivity were affected by TCDD accordingly. No particular organ appeared to act as a sink for the radioactivity not exhaled during these 8 h by the treated animals. TCDD (125 micrograms/kg) induced significant changes in the disposition of radioactivity in heart and brown adipose tissue between 25 and 125 min after the iv injection of [14C]glucose. The areas under the curve of [14C]glucose-derived radioactivity were the same after either iv or ip injection in the blood of TCDD-treated rats, allowing a direct comparison of experiments with iv or ip injection of [14C]glucose. The half-lives of radioactivity in the exhaled air and in feces of treated animals were greatly elevated during the 5 d following administration of [14C]glucose. These results indicate that TCDD induces in rats, within 24 h after dosing, alterations in the metabolism of glucose that preceded changes in insulin homeostasis, because hypoglycemia and hypoinsulinemia in rats do not occur until about a week after TCDD treatment. Since overt signs of acute toxicity (reduced feed intake and body weight loss) are also not noticeable until several days after a lethal dose of TCDD, it is probable that this earlier disturbance of glucose metabolism is part of the biological changes that result in wasting away and eventually in death.
Animals↗
Microdialysis probe for transcutaneous monitoring of ethanol and glucose in humans.
A heated (42 degrees C) microdialysis probe and its application for continuous transcutaneous sampling of ethanol and glucose through cellophane-stripped forearm skin are described. Ethanol and glucose concentration in the dialysate were measured on-line with continuous-flow analysis and compared with blood values in human volunteers after ethanol consumption (n = 4) and oral glucose testing (n = 5), respectively. For ethanol and glucose, the dialysate and blood concentrations were linearly related in each subject (r > or = 0.91, P < 0.005), although the dialysate-to-blood ratio varied among subjects. The recovery in vivo was 22.4 +/- 22.7 and 4.7 +/- 2.3% (SD) of the recovery in vitro for ethanol and glucose, respectively. The dialysate glucose concentration was independent of blood flow. When the probe temperature was increased from 32 to 42 degrees C, the dialysate-to-blood glucose ratio increased, with 2.4 +/- 1.4%/degrees C (SD) in fasting subjects (n = 4), which was similar to an increase of 2.1 +/- 0.045%/degree C in dialysate-to-medium ratio in vitro. The present approach for transcutaneous sampling may possibly be used for other substances of low molecular weight as well.
Adult↗
Health professional training for multi-disciplinary care of elderly patients with type II diabetes.
With funding support from the Northern Wisconsin Area Health Education Center, we conducted a survey to assess continuing education needs of health care professionals providing diabetes self-care management and nutrition therapy to patients with Type II diabetes in rural northern Wisconsin and conducted a conference to address the identified needs. Of the topics surveyed, respondents ranked themselves lowest in knowledge and experience in the following areas: 1) application of revised guidelines for medical nutrition therapy, 2) considering patients, differing cultural needs, and 3) team management of diabetes. They were most comfortable with the technical aspects of care, e.g., insulin administration and blood glucose monitoring. One hundred seven health care professionals attended a one-day continuing education conference sponsored by the Eau Claire Family Practice Residency and the University of Wisconsin-Eau Claire School of Nursing, to address the topics identified by the needs assessment survey.
Aged↗
Effect of an intensive glucose management protocol on the mortality of critically ill adult patients.
OBJECTIVE: To assess the effect of an intensive glucose management protocol in a heterogeneous population of critically ill adult patients. PATIENTS AND METHODS: This study consisted of 800 consecutive patients admitted after institution of the protocol (treatment group, between February 1, 2003, and January 10, 2004) and 800 patients admitted immediately preceding institution of the protocol (baseline group, between February 23, 2002, and January 31, 2003). The setting was a 14-bed medical-surgical intensive care unit (ICU) in a university-affiliated community teaching hospital. The protocol involved intensive monitoring and treatment to maintain plasma glucose values lower than 140 mg/dL. Continuous intravenous insulin was used if glucose values exceeded 200 mg/dL on 2 successive occasions. RESULTS: The 2 groups of patients were well matched, with similar age, sex, race, prevalence of diabetes mellitus, Acute Physiology and Chronic Health Evaluation II scores, and distribution of diagnoses. After institution of the protocol, the mean glucose value decreased from 152.3 to 130.7 mg/dL (P<.001), marked by a 56.3% reduction in the percentage of glucose values of 200 mg/dL or higher, without a significant change in hypoglycemia. The development of new renal insufficiency decreased 75% (P=-.03), and the number of patients undergoing transfusion of packed red blood cells decreased 18.7% (P=.04). Hospital mortality decreased 29.3% (P=.002), and length of stay in the ICU decreased 10.8% (P=.01). CONCLUSION: The protocol resulted in significantly improved glycemic control and was associated with decreased mortality, organ dysfunction, and length of stay in the ICU in a heterogeneous population of critically ill adult patients. These results support the adoption of this low-cost intervention as a standard of care for critically ill patients.
APACHE↗
Quantitative on-line monitoring of cellular glucose and lactate metabolism in vitro with slow perfusion.
An on-line in vitro perfusion technique is described that allows the continuous quantification of cellular glucose metabolism in vitro. Using biosensor technology, we measure glucose and lactate metabolism at a minute-to-minute time resolution for periods up to several days. The application of our perfusion-detection technique for in vitro monitoring is demonstrated in a wide variety of cells, including primary neuronal and astroglia cultures, yeast cells, and human lymphocytes. The method shows that variations in oxygen delivery or exposure to a noncompetitive pseudosubstrate (here 2-deoxyglucose) affects normal glucose metabolism. The innovative advantage of the present system is that, in contrast to other devices including a recently described system, metabolism per cell can be quantified. The potential of in vitro on-line monitoring is discussed for application in studying normal and abnormal metabolism, toxic and nontoxic drug effects, and human tissue biopsies.
Animals↗
Interaction of sympathomimetics and insulin with hepatic glucose production by isolated perfused rat livers: effects of continuous versus pulsatile infusion.
To elucidate the efficacy of continuous vs. intermittent exposure to epinephrine, phenylephrine, and insulin, hepatic glucose production was monitored in isolated perfused rat livers (means +/- SE, n = 6 each). To this end livers of fed rats were perfused with 5 mM glucose Krebs-Ringer buffer in a nonrecirculating system. Using this model it was shown that intermittent exposure (3 min on/off period, dose reduction -50%) to epinephrine (0.4 microM, alpha + beta-agonist) and phenylephrine (5 microM, alpha-agonist) elicited an almost identical rise in hepatic glucose production [epinephrine: 0.72 +/- 0.08 mmol/(86 min X 100 g BW); phenylephrine: 0.68 +/- 0.07 mmol/(86 min X 100 g BW) as their continuous administration (epinephrine: 0.78 +/- 0.06 mmol/(86 min X 100 g BW); phenylephrine: 0.74 +/- 0.09 mmol/(86 min X 100 g BW)]. Inhibition by insulin (100 mU/liter) given either continuously or intermittently (3 min on/off intervals; dose reduction -50%) was equipotent for epinephrine- and phenylephrine-stimulated hepatic glucose production. When the off period was doubled to 6 min, thereby reducing the total insulin dose to 33%, no significant suppression of epinephrine- and phenylephrine-stimulated hepatic glucose production was observed. From this we conclude that 1) the effect on hepatic glucose production of pulsatile (3 min on/off, dose reduction 50%) and continuous administration is equipotent for the respective action of epinephrine, phenylephrine as well as of insulin; and 2) insulin is more effective (P less than 0.02) in inhibiting hepatic glucose production stimulated by an alpha-agonist (phenylephrine; 5.0 microM) than in counteracting alpha + beta-agonist action (epinephrine; 0.4 microM). The characteristics of hepatic glucose release as stimulated by alpha- and/or beta-adrenergic agonists and its inhibition by continuously or intermittently infused insulin were simulated and described by a computer model. Thereby, no qualitative difference could be demonstrated in alpha- vs. beta-adrenergic agonists action on stimulated hepatic glucose production.
Animals↗
Enzyme electrodes as practical biosensors.
An enzyme can be combined with an electrochemical sensor to produce an electrode that will measure the substrate for that enzyme. Such electrodes, known as enzyme electrodes, have enabled assay of many compounds of biochemical interest. However, they remain largely unexploited in medical measurement. The review gives the basic principles and describes electrodes used in biological solutions, together with an outline of the problems. The development of enzyme electrodes for continuous in vivo monitoring is emphasised.
Blood Glucose↗
Intensive conventional and insulin pump therapies in adult type I diabetes. A crossover study.
We examined the relative efficacy of two modes of insulin therapy in five patients with insulin-dependent diabetes. Using a crossover protocol, therapy with multiple insulin injections was compared with the use of continuous subcutaneous insulin infusion (pump therapy); both therapies were regulated by home blood glucose monitoring. Although both therapies were equally effective during 2 to 4 days of inpatient management, pump therapy was clearly superior in the outpatient setting. Mean plasma glucose and hemoglobin A1c concentrations and the frequency of hypoglycemic reactions were significantly less with pump therapy despite apparently equal compliance with both therapies. We conclude that in compliant adult patients with type I diabetes continuous insulin infusion is more effective in achieving normalization of plasma glucose concentration than intensified conventional therapy in the outpatient setting. Although these patients found pump therapy preferable to intensive conventional therapy, the superiority of pump therapy is not explained by this bias. Whether these results are applicable in a more standard treatment setting remains to be established.
Adult↗
Improving glycemic control: the case for self-monitoring blood glucose levels.
Diabetes can be potentially identified, monitored, treated, and prevented more easily now than at any other time in history. Yet, the prevalence of diabetes continues to grow and the complications associated with it continue to afflict millions of Americans. Glycemic control, or the maintenance of appropriate levels of blood sugar, measured through the self-monitoring of blood glucose or a glycated hemoglobin test, represents the best opportunity for persons with diabetes to prevent complications by helping them understand the effect of their lifestyle choices and medications on their health. Despite the numerous advantages of glycemic control, a number of barriers prevent individuals from monitoring their blood sugar concentrations and achieving the health benefits that come with the proper understanding of their condition.
Blood Glucose↗
A patient with severe, recurrent hypoglycemia and glycemic lability who underwent islet transplantation.
BACKGROUND: A 48-year-old woman who was diagnosed with type 1 diabetes at 5 years of age presented to our Clinical Islet Transplant Program with severe, recurrent hypoglycemia and glycemic lability. She was diligent with her diet, used a continuous subcutaneous insulin infusion pump (32 U per day), and monitored her glucose levels typically eight times a day. The patient usually had one hypoglycemic reaction a day, experienced a severe reaction once a month, and had marked variability of her glucose values. On presentation, her HYPO score was 584 and her lability index was 868 mmol/l(2)/h per week. INVESTIGATIONS: HYPO score, lability index score, screening for diabetes complications, and routine pretransplant evaluation. DIAGNOSIS: Severe, recurrent hypoglycemia and glycemic lability associated with type 1 diabetes. MANAGEMENT: The patient underwent islet transplantation. Post-transplant, the problems with hypoglycemia abated and excellent stable glycemic control was attained, although some side effects from the immunosuppressive drug, sirolimus, were evident. Insulin was reinstituted 2.5 years after surgery, at lower doses than before the transplant because of deterioration in graft function. Occasional episodes of hypoglycemia have occurred and some glycemic lability has recurred, although endogenous insulin secretion is still preserved.
Blood Glucose↗