Urban Rosenqvist

The effect of long-term intensified insulin treatment on the development of microvascular complications of diabetes mellitus

BACKGROUND A cause-and-effect relation between blood glucose concentrations and microvascular complications in patients with insulin-dependent diabetes mellitus has not been established. METHODS We randomly assigned 102 patients with insulin-dependent diabetes mellitus, nonproliferative retinopathy, normal serum creatinine concentrations, and unsatisfactory blood glucose control to intensified insulin treatment (48 patients) or standard insulin treatment (54 patients). We then evaluated them for microvascular complications after 18 months and 3, 5, and 7.5 years. RESULTS Mean (+/- SD) glycosylated hemoglobin values were reduced from 9.5 +/- 1.3 percent to 7.1 +/- 0.7 percent in the group receiving intensified treatment and from 9.4 +/- 1.4 percent to 8.5 +/- 0.7 percent in the group receiving standard treatment (P = 0.001). In 12 of the patients receiving intensified treatment (27 percent of those included in the analysis) and 27 of those receiving standard treatment (52 percent), serious retinopathy requiring photocoagulation developed (P = 0.01). Visual acuity decreased in 6 patients receiving intensified treatment (14 percent) and in 18 receiving standard treatment (35 percent) (P = 0.02). Nephropathy (urinary albumin excretion, > 200 micrograms per minute) developed in one patient in the group receiving intensified treatment, as compared with nine patients in the group receiving standard treatment (P = 0.01). No patient in the intensified-treatment group had nephropathy with subnormal glomerular filtration rates, as compared with six patients in the standard-treatment group (P = 0.02). The conduction velocities of the ulnar, tibial, peroneal, and sural nerves decreased significantly more in the standard-treatment group than in the intensified-treatment group. The odds ratio for serious retinopathy was 0.4 (95 percent confidence interval, 0.2 to 1.0; P = 0.04) in the intensified-treatment group as compared with the standard-treatment group. The corresponding odds ratio for nephropathy was 0.1 (95 percent confidence interval, 0 to 0.8; P = 0.04). CONCLUSIONS Long-term intensified insulin treatment, as compared with standard treatment, retards the development of microvascular complications in patients with insulin-dependent diabetes mellitus.

Intensified conventional insulin treatment retards the microvascular complications of insulin‐dependent diabetes mellitus (IDDM): the Stockholm Diabetes Intervention Study (SDIS) after 5 years

Abstract. Ninety‐six patients with insulin‐dependent diabetes mellitus (IDDM) and non‐proliferative retinopathy were randomized to intensified conventional treatment (ICT) (n = 44) or regular treatment (RT) (n = 52), and followed up for 5 years. HbA1c decreased from 9.5 ± 0.2% (mean value ± SEM) to 7.2 ± 0.1% in the ICT group, and from 9.4 ± 0.2% to 8.7 ± 0.1% in the RT group (difference between the groups, P < 0.001). Retinopathy increased in both groups (P < 0.001), but after 5 years it was worse in the RT group (P < 0.05). The urinary albumin excretion rate was higher in the RT group than in the ICT group after 5 years (239.9 ± 129.7 μg min−1 vs. 46.0 ± 26.1 μg min−1, P < 0.05). Eight RT patients developed manifest nephropathy, compared with none in the ICT group (P < 0.01). After 5 years the conduction velocities of the sural (P < 0.05), peroneal (P < 0.01) and tibial (P < 0.001) nerves were lower in the RT group. The respiratory sinus arrhythmia was 12.1 ± 1.2 beats min−1 in the RT group and 16.7 ± 1.4 beats min−1 in the ICT group at the end of the study (P < 0.01). The increases in retinopathy (P < 0.01), nephropathy (P < 0.01) and neuropathy (P < 0.001) were all related to the mean HbA1c value during the study. Smoking habits only influenced the progression of retinopathy (P < 0.05). Serious hypoglycaemia occurred in 34 ICT patients and 29 RT patients (242 and 98 episodes, respectively) (P < 0.05). Whereas weight was stable in the RT group, the body mass index increased by 5.8% in the ICT group (P < 0.01). In conclusion, microvascular complications of diabetes were retarded by intensified conventional insulin treatment. However, such treatment increased the frequency of serious hypoglycaemia, and led to an increase in body weight.

Heavy users of an emergency department: Psycho-social and medical characteristics, other health care contacts and the effect of a hospital social worker intervention

A small proportion of the patients coming to emergency departments of general hospitals account for a substantial share of the departments resources by making repeated visits. Repeater behaviour is a complex product of many, sometimes concurrent factors. This study has focused on the medical and psycho-social factors. A group of patients with repeated visits to an emergency department of a middle-sized Stockholm hospital was studied in 1980. The repeater group had a heavier load of psycho-social problems than the source population. The repeater behaviour profile included: feeling of loneliness, living alone, contacts with social agency, disability pension, high sick absenteeism from work and alcoholism. The repeater group had numerous contacts with health-care providers outside the emergency department. Some of the repeaters needed and received help by a social hospital worker. Of those that received such help 80% significantly decreased their emergency department visiting rate.

Heavy users of an emergency department—A two year follow-up study

Persons who repeatedly turn to emergency departments (ED) for medical services often have an unfavourable social situation. Very little is known about how their situation and utilization of ED services change with time. In the present study, 232 persons who had made 4+ visits to an ED during the previous year were followed for two years. In the first year 31% and in the second 19% of the original group remained heavy users of the ED. Patients diagnosed as having bronchial asthma remained heavy ED users to a greater extent than others. The mortality in the whole group was high, the standardized mortality rate (SMR) was 590% for the men and 740% for the women during the first follow-up year and 380% respectively 350% during the second. A sub-sample of the patients was interviewed both in the beginning and at the end of the study period with regard to psycho-social factors. The follow-up analysis showed that number of previous visits, contact with psychiatric care, living alone and perceived loneliness were predictive factors for continued ED use. Twenty-two percent of the variation in ED use could be accounted for by changes in the social network over time. The present study supports the hypothesis that the quality of the social network is related to the use of medical services, here expressed in ED use. The findings raise the question of how to handle the variety of psycho-social problems found among these ED users.

Hypoglycaemic episodes during intensified insulin treatment: increased frequency but no effect on cognitive function

Abstract. Ninety‐seven patients with insulin dependent diabetes mellitus (IDDM) were randomized to intensified conventional treatment (ICT, n = 44) or regular treatment (RT, n = 53). The mean HbA1c level (± SEM) was reduced from 9.5 ± 0.2% to 7.4 ± 0.1% in the ICT group (P < 0.001), and from 9.4 ± 0.2% to 9.0 ± 0.2% (P < 0.01) in the RT group. The difference between the groups was significant (P < 0.001). During a period of 3 years, 57% of the ICT patients (95% confidence interval 44‐73%) and 23% of the RT patients (95% CI, 11‐34%) (P < 0.001) had at least one episode of serious hypoglycaemia, with the need for third‐party assistance or resulting in coma. Eighteen of the 32 ICT patients who initially had adrenergic symptoms during hypoglycaemia changed to predominantly neuroglycopenic symptoms. This was the case with only 8 of 38 RT patients (P < 0.01). The change in symptoms was related to the increased frequency of serious hypoglycaemia, but neither symptoms nor frequency of hypoglycaemia bore any relationship to insulin dose, body mass index, duration of diabetes or autonomic nerve function. The results of several neuropsychological tests did not differ between the groups at baseline, and did not change during the study. There were no signs of deteriorating cognitive function in the patients with serious hypoglycaemic episodes.

Metabolic control and complications over 3 years in patients with insulin dependent diabetes (IDDM): the Stockholm Diabetes Intervention Study (SDIS).

Abstract. In a planned 5‐year study, 97 patients with insulin dependent diabetes mellitus (IDDM), non‐proliferative retinopathy and unsatisfactory blood glucose control were monitored for 3 years. The patients were randomized to an intensified conventional treatment (ICT, n=44) or a regular treatment (RT, n=53) group. HbA1c (normal range 3.9‐5.7%) was reduced from 9.5 ± 0.2 (mean value±SEM) to 7.4 ± 0.1% in the ICT group (P=0.0001), and from 9.4 ± 0.2 to 9.0 ± 0.2% in the RT group (P=0.004). Nerve conduction velocities in the sural and peroneal nerves (P=0.01‐0.0001) were impaired in the RT group, but not in the ICT group. Retinopathy increased in both groups. The condition of 22 ICT patients (50%, 95% confidence interval 34‐66%) and 37 RT patients (73%, 61‐84%) deteriorated with regard to at least one microvascular complication (retinopathy, nephropathy, neuropathy) (P=0.024). Lower HbA1c levels during the study significantly reduced the risk of deterioration (P=0.01). In total, 57% of the ICT patients had at least one episode of serious hypoglycaemia, compared with 23% in the RT group (P=0.001). The patients in the ICT group also gained weight (P=0.0001). Improved blood glucose control slowed down the progression of microangiopathy during a 3‐year period in patients with non‐proliferative retinopathy, but at the price of an increased frequency of serious hypoglycaemic episodes, and some gain in body weight.

Intensified conventional insulin treatment and neuropsychological impairment.

OBJECTIVE--To assess whether intensified insulin treatment, with an increased frequency of hypoglycaemic episodes, leads to cognitive deterioration. DESIGN--Prospective randomised trial of intensified conventional treatment and standard treatment. SETTING--Outpatient clinic for patients with insulin dependent diabetes. SUBJECTS--96 patients with insulin dependent diabetes, high blood glucose concentrations, and non-proliferative retinopathy were randomised to intensified conventional treatment (n = 44) or standard treatment (n = 52). MAIN OUTCOME MEASURES--Glycated haemoglobin concentration (metabolic control); the number of hypoglycaemic episodes reported by patients at each visit; results of computerised neuropsychological tests performed at entry and after five years. RESULTS--Mean glycated haemoglobin concentration during the study was 7.2% (SE 0.1%) with intensified conventional treatment and 8.7 (0.1%) with standard treatment (p less than 0.001). During five years 34 (77%, 95% confidence interval 53% to 100%) of the patients given intensified treatment and 29 (56%, 36% to 75%) of the others had at least one episode of serious hypoglycaemia (p less than 0.05). The intensified conventional treatment group had a mean of 1.1 episodes of serious hypoglycaemia per patient per year compared with 0.4 episodes in the standard treatment group. Results of the neuropsychological tests were similar in the two groups after five years. CONCLUSIONS--Intensified conventional insulin treatment led to lower blood glucose concentrations and a higher frequency of hypoglycaemic episodes, but patients showed no signs of cognitive deterioration.

An ecological study of the relationship between risk indicators for social disintegration and use of a somatic emergency department

During the last decade a number of studies have been dedicated to the relationship between social support and ill health. In this study the relationship between risk indicators for social disintegration in defined geographical areas and the utilization of a hospital somatic Emergency Department (ED) by the inhabitants of these areas was analyzed. Six socio-demographic variables were used as risk indicators for social disintegration. To measure illness behaviour a register of 57,481 ED visits, made by 34,915 individuals, to the General Adult ED at St Görans Hospital was utilized. The proportions of immigrants, of adult unemployed and of persons moving into the areas were significantly related to the illness behaviour of seeking care at the ED. The results also showed a significant correlation between the sum of the six risk indicators and use of ED services for three of the four studied subgroups.

Capillary Loss and Leakage after Five Years of Intensified Insulin Treatment in Patients with Insulin-dependent Diabetes Mellitus

Ninety-six patients with insulin-dependent diabetes mellitus were randomized to intensified conventional treatment (n = 44) or regular treatment (n = 52) programs and followed for 5 years. Hemoglobin A1c was reduced from 9.5% +/- 0.1% to 7.2% +/- 0.1% in the intensified conventional treatment group and from 9.4% +/- 0.2% to 8.7% +/- 0.1% in the regular treatment group (mean +/- standard error) (P less than 0.001). Capillary loss and leakage of fluorescein as evaluated with fluorescein angiography increased significantly in the regular treatment group (P less than 0.05; P less than 0.01) but not in the intensified conventional treatment group. Capillary loss (P less than 0.01) and leakage (P less than 0.001) were related to metabolic control as measured by Hb A1c but not to duration of diabetes or smoking habits. Capillary loss (P less than 0.05) but not leakage was related to the initial diastolic blood pressure.

Clashes between understanding and doing – leaders’ understanding of management in intensive care during a period of reorganisation

The objective was to elucidate hospital leaders’ understanding of the organisational structures and processes and their understanding of their leading role during an intensive period of reorganisation. From a qualitative exploratory study using semi‐structured interviews and thematic analysis four themes were identified: understanding the function of leadership and management, understanding organisational structures and processes, their own role as leader, and the outside world. The results indicate that the organisation is characterised by disintegration and erratic structures. The leaders perceive that they lead a learning organisation but in practical care work the organisation functions more like an organisation streamlined for mass production. This discrepancy between their understanding and practical daily care work led to dissatisfaction and existential chaos among the leaders. Our findings show an example of “clashes with the individual attractor pattern”, an urgent, but not yet very clear problem in health‐care organisations of today.