Andrea L Snyder

Accuracy of Perceiving Blood Glucose in IDDM

Type I (insulin-dependent) diabetic individuals and health professionals often assume that the symptoms of extremely low or high blood glucose (BG) levels can be recognized and, consequently, appropriate treatment decisions can be based on symptom perception. Because no research has documented the validity of these assumptions, this study tested the ability to perceive BG concentration. Nineteen type I adults, experienced in self-monitoring of BG (SMBG), estimated their BG 40–54 times just before measurement of actual BG. This procedure was repeated under two conditions: (1) in the hospital (hospital condition) while connected to an insulin/glucose infusion system that artificially manipulated BG, leaving subjects only symptomatic, or internal, cues and (2) in the natural environment (home condition), where both internal and external cues, e.g., food and insulin consumption, were available. Estimates significantly correlated with actual BG for 7 of 16 subjects in the hospital condition and for 18 of 19 subjects in the home condition. Believed ability to estimate BG did not predict documented ability in either condition. An evaluation of the treatment significance of estimation errors showed that the majority of errors were relatively benign. The most common error affecting clinical outcome was estimated euglycemia when actual BG was hypoglycemic or hyperglycemic.

Stress in Parents of Children With Diabetes Mellitus

The level of stress experienced in the parenting role by mothers of 49 children with insulin-dependent diabetes mellitus (IDDM) and its relationshipto glycemic control was examined with the parenting stress index (PSI). A subsample of the research group of 25 children with diabetes (≤11 yr old) was compared with an agematched control group (n = 21) drawn from the original study of the PSI on total stress, parent- and childdomain, and subdomain scale scores. The two groups differed on one child-domain subscale, whereby children with diabetes are perceived by their mothers as more demanding than healthy controls. Three parentsubscale differences existed between the two groups, with mothers of children with diabetes reporting less attachment to their children, less spousal support, and poorer health. Analysis of the diabetes sample demonstrated significant stress on several of the child- and parent-domain subscales in a large proportion of the sample. Stress, at levels s≥70th percentile of the control group, existed on the child scales of acceptability, mood, demanding behavior, and reinforcement for 51% of children with diabetes. Elevations associated with stress in the parenting role were evident on the scales associated with parental attachment, depression, and competence for 33% of parents. No differences in the level of glycosylated hemoglobin (HbA1) existed between children whose mothers reported high levels of stress in themselves and their children and those whose mothers reported little stress. Hierarchal regression analysis demonstrated a significant relationship between the child stress scale of distractibility, the use of self-monitoring blood glucose.

Evaluation of a new system for self blood glucose monitoring

A new combination reflectance meter/visually interpretable system (Glucometer II/Glucostix, Ames Division, Miles Laboratories, Elkhart, IN) has been designed for self blood glucose monitoring. Performance evaluation of this system demonstrates a linear relationship between meter-determined blood glucose values and laboratory-determined whole blood glucose values (y = 0.95x + 2.86, r = 0.97). In addition, 95% of visually interpreted blood glucose values are within one color block of YSI comparative values. Error grid analysis, a new method for determining the clinical accuracy of patient-determined blood glucose results, demonstrated that components of this new system produce clinically accurate blood glucose results.

Accuracy of blood glucose estimation by children with IDDM and their parents.

Objective To evaluate the accuracy of blood glucose symptom recognition and subjective blood glucose estimation in insulin-dependent diabetic (IDDM) children and their parents. Research Design and Methods Blood glucose estimation questionnaires were completed 4 times/day at home during routine activities. A sequential sample of 19 families, who attended a pediatric diabetes clinic, with IDDM children <2265; 12 yr old and IDDM duration of > or equal to 9 mo comprised the study. Results Error grid analysis showed that both children and parents demonstrated poor accuracy, making clinically significant errors as frequently as clinically accurate estimates. The most common error was the failure to detect extreme blood glucose levels, with a significant tendency to underestimate hyperglycemia. Children often reported hypoglycemia when blood glucose was hyperglycemic. Confidence in the ability to estimate blood glucose was unrelated to measured accuracy. Conclusions IDDM children and their parents demonstrated a higher rate of blood glucose estimation errors than IDDM adolescents and adults in previous studies. Even in families who use self-monitoring of blood glucose frequently, self-reported ability to recognize symptoms and estimate blood glucose should be viewed with caution. Families with IDDM children need more education about errors in symptom recognition and blood glucose estimation. They should also be encouraged to use self-monitoring of blood glucose before treating childrens reported hypoglycemic symptoms whenever possible.

Stability of Reacted Chemstrip bG

Reacted Chemstrip bG glucose reagent strips have been reported to retain their color changes for up to 7 days. Thus, patients could theoretically measure their blood glucose and mail their reacted test strips to their physicians for reanalysis. To test the stability of reacted Chemstrip bG blood glucose measurements, 268 Chemstrip bG test strips were reacted with blood obtained from 67 insulin-dependent diabetic patients, stored in desiccator vials, and read daily for 5 consecutive days with an Accu-Chek II blood glucose meter. Although Chemstrip bG blood glucose values significantly correlated with initial reference Beckman glucose analyzer glucose determinations for all 5 days, a steady significant decay in blood glucose readings over time was observed, and clinically accurate strip readings declined from 94% to 68%. Because this decay appeared consistent, correction factors were calculated with regression analyses. The correction factor for day 5 Accu-Chek II readings reduced measurement error by 77%. When applied to a different validation sample, this correction factor decreased day 5 error by 73%. Hence, it seems that correction factors may be applied to delayed readings of Chemstrips obtained with Accu- Chek II that would correct for the observed reduction in blood glucose readings. From these results, we conclude that delayed readings of Chemstrip bG test strips with the Accu-Chek II are not sufficiently accurate for clinical decision making or research purposes unless mathematically corrected.

Outpatient pediatric diabetes—I. Current practices

A survey of pediatric diabetologists in the U.S. was made in an attempt to define current outpatient practices in diabetes subspecialty clinics. Survey questions addressed clinic organization, health care team members, content of histories and physical examinations, use of laboratory studies, patient education, therapeutic recommendations, self-management practices and screening procedures used to identify early diabetes-related complications. The results of the survey suggested similar clinic organization and operation in most settings; a high degree of reliance on glycosylated hemoglobin determinations; a preference for the use of NPH insulin; and a lack of credence given urinary glucose determinations. Additionally, screening tests for the development of complications are not performed with regularity.

Hypoglycemia: Can the School Respond?

Severe hypoglycemia, characterized by loss of consciousness and/or seizures, occurs with an alarming frequency (4-31% incidence) in school-aged children with insulin-dependent diabetes mellitus (IDDM; 1-3). Most of these hypoglycemic episodes are reported to occur during the daytime and are related to inappropriate food intake or failure to adjust insulin or consume more food to compensate for exercise. Children may spend more than half their daytime hours within the care of the school system, yet little is known about how well school systems are prepared to assist the child who is experiencing hypoglycemia. This study was designed to survey the preparedness of the school systems in Virginia to respond to a hypoglycemic emergency. Surveys requesting 7) the number of students within the system known to have IDDM, 2) the person in each school responsible for treating a students hypoglycemia, and 3) who within the schools has the authority to administer an injection were mailed to health coordinators in each school district in the state. Eighty-four (62.6%) school systems representing 57% of all schoolaged children replied. Responses were evenly spread throughout rural areas, small towns, and large metropolitan cities. Seven hundred fifty-two (0.13%) of the total number of students in these school systems were known to have IDDM. Eight systems representing >40,000 students failed to identify any children with IDDM. Thus, there may be a significant number of children with IDDM who have not been identified within their school system. In 39% of the school systems, a nurse was responsible for treating a childs hypoglycemic episode. However, principals, teachers, secretaries, and cafeteria workers were also given that responsibility. In eight systems (9.5%), the child was the primary person responsible for treating his/her hypoglycemia, whereas two school systems stated that no one had been designated to provide this care. Half of the school systems permitted the administration of an injection by school personnel. In schools that authorize a school nurse to administer an injection, less than half (45.8%) reported that school nurses were present in each school. Forty-nine systems (58.3%) stated that a rescue squad was called before the initiation of any therapy. Children with IDDM ride school buses, eat one or two meals and snacks during the school day, attend school parties, and participate in strenuous physical activities. Academic performance cannot be optimal in the child who is experiencing either hypoor hyperglycemia (4). Thus, the maintenance of near-normal blood glucose levels should be an important issue for the schools. Unfortunately, the data we collected suggest that school systems may not be aware that a student has IDDM, and may not have developed a plan to assist the student with IDDM in achieving his/her health and academic potentials. Although this survey does not define the full extent of the relationship between the school systems and their students with IDDM, the results suggest areas for further research and education. If near-normal blood glucose control is to be a treatment goal for the child with IDDM, then hypoglycemia may be expected to occur during the school day (5). Parents must be encouraged to inform the schools of their childs diabetes and assist them in learning to help care for their children. School nurses are not always available; therefore, other members of the school staff need to be educated about diabetes, and protocols for preventing and/or treating hypoglycemia need to be established. Health-care providers need to ensure that pertinent educational material is provided to all school personnel who have contact with children with diabetes. Designated personnel should be allowed to administer injectable glucagon with standing orders from a physician and parental permission (6). Children must be permitted to carry their own source of rapid-acting glucose and be allowed to consume it when needed. The data presented above were obtained in only one state, and its educational system may not be representative of the rest of the country. However, the risks of severe hypoglycemia for the child with IDDM while attending school are not unique to this state. Diabetes care providers need to carefully assess the resources available to their patients in each school district. In addition, school administrators need to be reminded of their legal responsibilities and the needs of the child with diabetes.

Pediatric primary care for children with IDDM.

1. Rubin RR, Peyrot M, Saudek CD: Effect of diabetes education on self-care, metabolic control, and emotional wellbeing. Diabetes Care 12:673-79, 1989 2. Mazzuca SA, Moorman NH, Wheeler ML, Norton JA, Fineberg NS, Vinicor F, Cohen SJ, Clark CM Jr: The diabetes education study: a controlled trial of the effects of diabetes patient education. Diabetes Care 9:1-10, 1986 3. Swedo SE, Rapoport JL, Leonard H, Lenane M, Cheslow D: Obsessive-compulsive disorder in children and adolescents: clinical phenomenology of 70 consecutive cases. Arch Cen Psychiatry 46:335-41, 1989 4. American Psychiatric Association Committee on Nomenclature and Statistics: Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. Washington, DC, Am. Psychiatr. Assoc, 1980 5. Pollock SE: Human response to chronic illness: psychologic and psychosocial adaptation. Nurs Res 35:90-95, 1986 6. Williams G, Pickup J, Keen H: Psychological factors and metabolic control: time for reappraisal? Diabetic Med 5:211-15, 1988

Cold Weather and CSII

pared by dilution of Squibb Regular mixed beef-pork U-100 insulin (E. R. Squibb &. Sons, Princeton, New Jersey) with 0.9% saline. After about 2 mo of therapy, he began to get firm, indurated, painful, red nodules at the site of the indwelling needle (Figure 1), which came after about 24 h of infusion at a single site, and lasted several days after the needle was moved to another site. The pain necessitated moving the needle about once every 24 h. Several nodules were present at once, making it difficult to find suitable abdominal injection sites. The patient was afebrile; there were no signs of cellulitis, and erythromycin, prescribed by his general pediatrician, had no effect. His insulin preparation was changed to Iletin I U-40 insulin (Eli Lilly and Company, Indianapolis, Indiana), which he then used without further dilution. The nodules resolved, and no new ones have occurred. The diluted insulin he had been using appeared slightly cloudy; when cultured, it grew a moderate number of Klebsiella oxytoca. The specific cause of the nodules is not firmly established. Possible causes are the saline dilution and the bacterial contamination. The latter is of interest because of the recent report by Schade and Eaton documenting the bactericidal property of U.S.P. insulin. Evidently, this property is lost on saline dilution. The brand of insulin was also changed, and this may have been a factor in the clinical improvement. Because the patient was a child who had greatly suffered from the skin nodules, we did not rechallenge him to determine the specific cause of the untoward reaction. This case does, however, present an argument for avoiding use of diluted insulins in insulin pumps.