Bibbi Smide

Missed bolus doses: devastating for metabolic control in CSII-treated adolescents with type 1 diabetes

Objective:  To investigate the management of continuous subcutaneous insulin infusion (CSII) in adolescents with type 1 diabetes including their administration of bolus doses and to study relationships between insulin omission and metabolic control, body mass index, daily frequency of self‐monitoring of blood glucose (SMBG) and bolus doses, health‐related quality of life (HRQOL), the burden of diabetes and treatment satisfaction.

Clarifying responsibility for self-management of diabetes in adolescents using insulin pumps--a qualitative study.

AIM To gain insight into and generate theoretical knowledge about the processes involved when insulin pump-treated adolescents take or miss taking their bolus doses. BACKGROUND Insulin pump treatment is considered the most physiological way to imitate the healthy bodys insulin profile in adolescents with diabetes. Despite insulin pump treatment, it is hard to maintain near-normal glucose control in adolescents; one reason for this is missed bolus doses with meals. METHOD In this qualitative interview study, the grounded theory method was chosen as a model for the collection and analysis of data. Twelve adolescents (five boys and seven girls, mean age: 14·4 years, range: 12-19 years) from different Swedish paediatric diabetes clinics, four parents and one paediatric diabetes nurse were interviewed during 2008 and 2009. Two adolescents and two parents were re-interviewed after approximately 10 months. Data from clinical visits and diabetes camps were used to verify emerging categories. FINDINGS Responsibility in the context of taking or missing bolus doses emerged as the core category. It is elaborated and explained through three subcategories: distribution of responsibility, transfer of responsibility and clarification of responsibility. The findings describe the need to clarify the responsibility for diabetes self-management in continuous negotiations between adolescents and parents to avoid missed doses. CONCLUSION Negotiations to clarify the responsibility for diabetes self-management must be a continuous process between adolescents and parents. Diabetes care teams can facilitate and encourage these negotiations.

Does patient education facilitate diabetic patients' possibilities to reach national treatment targets? A national survey in Swedish primary healthcare.

Objective. To describe how patient education is arranged in Swedish primary healthcare (PHC) and to assess whether the type of patient education and individual goal setting have an impact on diabetic patients’ possibilities of reaching national treatment targets. Design. A Swedish national survey. Setting. Swedish PHC. Subjects. Data from 485 primary healthcare centres (PHCCs) and 91 637 diabetic patients reported by the PHCCs to the National Diabetes Register in 2006. Main outcome measures. Description of how patient education is arranged, HbA1c, body mass index, cholesterol, blood pressure, and physical activity. Results. Of the PHCCs that reported how they performed the individual counselling, 50% reported checklist-driven counselling and 8% individualized counselling based on patients’ needs. A total of 105 PHCCs reported that they arranged group education. Of these, 67% used pre-planned programmes and 9% individualized the programme to the patients’ needs. The majority of PHCCs (96%) reported that they set individual goals (HbA1c, blood pressure, lipids, and lifestyle). A minority of the PHCCs (27%) reported that the patients were involved in the final decision concerning their goals. Individual goal-setting facilitated patients’ possibilities of reaching treatment targets. Goal-setting, list size of PHCCs, and personnel resources explained a variance of 2.1–5.7%. Neither individual counselling (checklist-driven or individualized to patients’ needs) nor group education had an impact on patients’ possibilities of reaching the targets. Conclusion. The current study indicates that improvement is needed in patient education in PHC to facilitate diabetic patients’ possibilities of reaching national treatment targets.

Outcome of clinical foot examination in relation to self-perceived health and glycaemic control in a group of urban Tanzanian diabetic patients

Diabetic foot complications were studied in 153 patients at the university clinic in Dar es Salaam (56 insulin treated, 77 treated with oral agents and 20 with diet only). Neuropathy disability and symptoms scores were used to diagnose peripheral neuropathy (PN). Peripheral vascular disease (PVD) was classified as ankle/brachial pressure index less than one. The degree of metabolic control was assessed by glycated haemoglobin (HbA1c) and self-perceived health was measured with SF-36. PN was present in 28.1% of patients and 12.5% had PVD. Patients with PN had higher age and later onset of diabetes in comparison with patients without food complications. Patients with PVD had longer duration of diabetes and higher systolic and diastolic blood pressure compared with those free from PVD. HBA1c and body mass index did not seem to influence the occurrence of PN or PVD. Patients with PN had significantly poorer self-perceived health, whilst PVD-patients had health scorings equal to patients without any foot complications. PN, but not PVD, appeared to have a negative influence on patients self-perceived health. In comparison with studies from the industrial world, foot problems are as common in diabetic patients living in a developing country.

Treatment with CSII in two infants with neonatal diabetes mellitus.

This article reports the case studies of two children with neonatal onset of diabetes who were treated with continuous subcutaneous insulin infusion (CSII) from within 4 d to 3 wk of the diagnosis. The aim was to describe diabetes‐related and insulin‐pump‐specific data in relation to growth and various feeding patterns when using CSII in infants with diabetes during their first year of life. The two children’s medical records were scrutinized. The results showed that both children had good metabolic control [median hemoglobin A1c (HbA1c) 5.3 and 5.7%, high performance liquid chromatography (HPLC) method, reference: 3.4–5.0%. Compared with the Diabetes Control and Complications Trial (DCCT) HbA1c units, Swedish units give approximately 1% point lower results]. No episodes of severe hypoglycemia or diabetic ketoacidosis have been demonstrated. The children had normal growth patterns, as they followed a normal feeding regime for their age. The meal doses of insulin were given over 12 min to 3 h. The children had diluted Humalog® insulin 10 U/mL (Eli Lilly & Co, Indianapolis, IN, USA) in their pumps. Different types of insulin pumps were used, namely, the Minimed 507C and 508 (Medtronic, Minneapolis, MN, USA), and a Disetronic H‐tron V100 (Roche Diagnostics, Basel, Switzerland). The children used different types of infusion sets. Neither family reported any technical problems with their pump system. CSII was an effective and safe treatment for the two children suffering from neonatal diabetes. This offers an alternative for other infants with a similar diagnosis.

Check your health validity and reliability of a measure of health and burden of diabetes

Check Your Health was constructed as four-two-sided vertical thermometers (0-100) measuring physical and emotional health, social well-being and quality of life today and before onset of diabetes. Burden of diabetes was calculated as the difference between the two scores (today and before onset of diabetes). The aim was to examine concurrent and discriminant validity and reliability of Check Your Health in a convenience sample of 180 people with diabetes, who visited the diabetes clinic during a 3-month period. A randomly selected subsample of 43 of the 180 patients responded to the questionnaire twice (test-retest). Besides Check Your Health, three additional questionnaires were mailed to the patients, the EVGFP scale (EVGFP stands for Excellent-Very good-Good-Fair-Poor health) for measuring concurrent validity, the Diabetes Empowerment Scale (Swe-DES-23) and an attitude measure, Semantic Differential in Diabetes (SDD) for calculation of discriminant validity. There was significant agreement between Check Your Health and the five EVGFP health groups. The instrument discriminated well between patients with and without late diabetic complications. The measure on burden of diabetes showed that the higher the burden of diabetes, the lower the quality of life. The same pattern was found for both Swe-DES 23 and SDD; the higher the burden, the lower the sense of empowerment and the lower the burden, the more positive the attitudes towards diabetes. Check Your Health showed good stability (0.88-0.68). The results indicate that Check Your Health can be used as an acceptable and sufficiently accurate method for detecting health distress in people with diabetes.

Diabetes self-care and educational needs in Tanzanian and Swedish diabetic patients: a cross-cultural study

The aim was to compare self-care and perceived educational needs in adult Tanzanian and Swedish diabetic patients. One hundred and fifty Tanzanians were matched with Swedes (n=150). All 300 patients filled in questionnaires about their self-care and educational needs. The comparison indicated the Tanzanians were almost as satisfied with their self-care as the Swedes, but Tanzanians were dissatisfied with the lack of drugs and wanted more diabetes education while the Swedes were more dissatisfied with their own self-care behaviour. None of the Tanzanians monitored their own blood glucose, whereas half the patients in the Swedish group did so weekly or monthly. The findings suggest that diabetes education in Tanzania should concentrate more on basic diabetes knowledge. In Sweden, however, the main points to be stressed should be life style and psychology.

Outcome of foot examinations in Tanzanian and Swedish diabetic patients, a comparative study

AIMS AND OBJECTIVES The aim of the current study was to present the outcome of clinical nurse performed foot examinations in a group of Tanzanian diabetic patients and make comparisons with matched Swedish patients. BACKGROUND Nurses working with diabetic patients in any country need to be familiar with foot problems in diabetic patients to educate patients about foot care. DESIGN A comparative study examining diabetic patients in Tanzania and Sweden with a quantitative approach. METHOD One hundred and forty-five diabetic patients in each country were examined. They were matched in gender and age. All patients responded verbally to questions about individual foot-care and underwent clinical foot examination concerning existing foot lesions, sensitivity testing using Semmes-Weinstein monofilament (5.07) and, vibratory perception using a tuning fork (128 Hz). RESULTS The Tanzanians had more reported foot problems than the Swedes. The latter reported problems due to poorly fitting footwear whilst the Tanzanians reported pain issues of the feet irrespective of footwear. In the Tanzanian group 37 patients presented with peripheral neuropathy (PN), 13 with peripheral vascular disease (PVD) and six had both PN and PVD. In the Swedish group of patients four had PN, three PVD, but none had both PN and PVD. Only 20 Tanzanians reported carrying out self-inspections of their feet, while 103 Swedes reported doing so. CONCLUSIONS Nurse performed foot examinations showed that the Tanzanian diabetic patients in this study had poorer foot status than the Swedish study sample. RELEVANCE TO CLINICAL PRACTICE Knowledge about foot problems in diabetic patients worldwide will hopefully improve education about self foot-care and therefore decrease incidence of foot lesions and other foot problems in this cohort.

Characteristics of nursing studies in diabetes research published over three decades in Sweden, Norway, Denmark and Iceland: a narrative review of the literature

Similarities and differences across borders of Nordic countries constitute a suitable context for investigating and discussing factors related to the development of diabetes nursing research over the last three decades. The present study reviewed the entire body of contemporary diabetes nursing research literature originating in four Nordic countries: Norway, Sweden, Denmark and Iceland. Our aims were (i) to catalogue and characterise trends in research designs and research areas of these studies published over time and (ii) to describe how research involving nurses in Nordic countries has contributed to diabetes research overall. The larger goal of our analyses was to produce a comprehensive picture of this research in order to guide future studies in the field. We conducted a narrative literature review by systematically searching Medline, Medline in process, EMBASE, CINAHL, PsycINFO and Cochrane databases. These searches were limited to studies published between 1979 and 2009 that had an abstract available in English or a Nordic language. Two researchers independently selected studies for analysis, leading to the inclusion of 164 relevant publications for analysis. In summary, Nordic nurse researchers have contributed to the development of new knowledge in self-management of diabetes in childhood, adolescence and adulthood, and to some extent also in the treatment and care of diabetes foot ulcers. Future research may benefit from (i) larger nurse-led research programmes organised in networks in order to share knowledge and expertise across national groups and borders, (ii) more multidisciplinary collaborations in order to promote patient-centred care and (iii) further research directed towards improving the dissemination and implementation of research findings. Using complex intervention designs and a mix of research methods will enrich the research.

Clarifying responsibility for self-management in adolescents with diabetes using insulin pumps : a qualitative study

AIM To gain insight into and generate theoretical knowledge about the processes involved when insulin pump-treated adolescents take or miss taking their bolus doses. BACKGROUND Insulin pump treatment is considered the most physiological way to imitate the healthy bodys insulin profile in adolescents with diabetes. Despite insulin pump treatment, it is hard to maintain near-normal glucose control in adolescents; one reason for this is missed bolus doses with meals. METHOD In this qualitative interview study, the grounded theory method was chosen as a model for the collection and analysis of data. Twelve adolescents (five boys and seven girls, mean age: 14·4 years, range: 12-19 years) from different Swedish paediatric diabetes clinics, four parents and one paediatric diabetes nurse were interviewed during 2008 and 2009. Two adolescents and two parents were re-interviewed after approximately 10 months. Data from clinical visits and diabetes camps were used to verify emerging categories. FINDINGS Responsibility in the context of taking or missing bolus doses emerged as the core category. It is elaborated and explained through three subcategories: distribution of responsibility, transfer of responsibility and clarification of responsibility. The findings describe the need to clarify the responsibility for diabetes self-management in continuous negotiations between adolescents and parents to avoid missed doses. CONCLUSION Negotiations to clarify the responsibility for diabetes self-management must be a continuous process between adolescents and parents. Diabetes care teams can facilitate and encourage these negotiations.