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Aim Canagliflozin is an SGLT2 inhibitor approved for the treatment of type-2 diabetes. A dynamic population pharmacokinetic–pharmacodynamic (PK/PD) model relating 24-h canagliflozin exposure profiles to effects on glycosylated haemoglobin was developed to compare the efficacy of once-daily and twice-daily dosing. Methods Data from two clinical studies, one with once-daily, and the other with twice-daily dosing of canagliflozin as add-on to metformin were used (n = 1347). An established population PK model was used to predict full 24-h profiles from measured trough concentrations and/or baseline covariates. The dynamic PK/PD model incorporated an Emax relationship between 24-h canagliflozin exposure and HbA1c-lowering with baseline HbA1c affecting the efficacy. Results Internal and external model validation demonstrated that the model adequately predicted HbA1c-lowering for canagliflozin once-daily and twice-daily dosing regimens. The differences in HbA1c reduction between the twice-daily and daily mean profiles were minimal (at most 0.023% for 100 mg total daily dose [TDD] and 0.011% for 300 mg TDD, up to week 26, increasing with time and decreasing with TDD) and not considered clinically meaningful. Conclusions Simulations using this model demonstrated the absence of clinically meaningful between-regimen differences in efficacy, supported the regulatory approval of a canagliflozin-metformin immediate release fixed-dose combination tablet and alleviated the need for an additional clinical study.

Rationale, aims and objectives This study aimed to evaluate the effect of a pharmacist–physician collaborative care model on clinical outcomes in patients with uncontrolled type 2 diabetes and determine characteristics that influence this effect. Methods A randomized controlled trial was conducted in a secondary care clinic for 80 patients with type 2 diabetes, aged 40–79 years and glycosylated haemoglobin (A1C) level ≥ 7.0%. The intervention group received individual, face-to-face pharmaceutical consultations and remote telephone support after a routine visit. The main measures were clinical outcomes (A1C, blood pressure, LDL cholesterol) and process indicators (medication adherence, medication regimen complexity, use of medicines). Multiple regression models were used to determine the variables that could explain the reduction and individualized control of A1C. Results From the initial sample of 80 patients, 73 completed this study. Compared with usual care, patients in the intervention group showed greater reduction in A1C (−0.79 vs. −0.16; P = 0.010); and an increase in the percentage of patients achieving the individualized goal of A1C (25.0% vs. 5.4%; P = 0.020). In addition, there was an increase in the percentage of adherent patients and in the average scores of medication adherence. Participation in the intervention group, higher baseline A1C levels and greater change in medication adherence were all significant predictors of improvement in A1C levels. Conclusions The results suggest that the collaborative care model proposed is feasible and more effective than the usual care in the reduction and individualized control of A1C levels in patients with uncontrolled type 2 diabetes.

AimsThe aim of this study was to identify factors that predict risk of obstructive sleep apnoea (OSA) in obese children, which could aid in prioritising sleep studies.MethodsA retrospective chart review was undertaken of obese children seen in the KOALA weight management clinic and Sleep clinic. Data collected included demographics, clinical history, examination findings, biochemical markers, and polysomnogram results.ResultsTwo hundred seventy-two obese children were seen in the KOALA clinic out of which 54 (20%) were also seen in the Sleep clinic because of snoring. Thirty-two were referred by the KOALA clinic; the remaining 22 were referred by other medical practitioners prior to being seen in the KOALA clinic. Thirty-nine had polysomnograms. The time from referral to Sleep clinic ranged from 10 days to 1.5 years with 50% seen within 6 months; with similar time gap between the blood tests and time of polysomnograms. Thirty-six percent (14/39) were reported to have OSA. Six children were Aboriginal/Torres Strait Islander (ATSI) and all had OSA, which was statistically significant (P = 0.004). There was a statistically significant correlation between high-sensitivity C-reactive protein (hs-CRP) and obstructive event index (OEI) in rapid eye movement (REM) sleep. (r = 0.50, P = 0.04). Correlation between low-density lipoprotein (LDL) and OEI in REM was r = 0.36, P = 0.06, which approached significance.ConclusionsEthnicity was a significant factor with more obese ATSI children having OSA. The significant correlation between hs-CRP with OEI is consistent with findings of previous studies. Several factors (glycosylated haemoglobin, LDL) approached significance.

Aim: The aim of this study is to determine if parental hypoglycaemia fear is associated with worse glycaemic control and increased resource utilisation and to identify risk factors for increased hypoglycaemia fear. Methods: Parents of children with diabetes completed a modified Hypoglycaemia Fear Survey. Demographic data, phone contacts and mean glycosylated haemoglobin A1c (HbA1c) were also recorded ove ra1y earstudy period. Results: A total of 106 parents participated. Mean patient age was 11.1 years, and duration of diabetes was 4.8 years. Fifty-two per cent were male, and 48% were on insulin pump therapy. Fear of hypoglycaemia was highest among parents of 6- to 11-year-olds. Parents of children with HbA1c less than 7.5% had less hypoglycaemia fear. Previous seizures and increased frequency of phone calls to the diabetes team were not associated with increased fear. Conclusion: Fear of hypoglycaemia is associated with worse glycaemic control. It is highest among parents of 6- to 11-year-olds but is not affected by previous severe hypoglycaemia or associated with increased contact with the diabetes team.

Aim To assess patient-reported outcomes associated with initiating insulin glargine among insulin-naive patients with type 2 diabetes mellitus (T2DM). Methods This was a pooled analysis of patient-level data from Phase 3, randomized controlled trials evaluating once-daily insulin glargine vs. comparator treatment for ≥24 weeks in previously insulin-naive adult patients with T2DM and poor glycaemic control. Eligible studies utilized strict, predefined insulin titration algorithms with weekly dose-adjustment to achieve fasting plasma glucose (FPG) levels of ≤5.6 mmol/l. Treatment satisfaction was measured using the Diabetes Treatment Satisfaction Questionnaire (DTSQ) change (c) and status (s) versions. Results A total of 1577 patients from four studies were included; 830 patients treated with insulin glargine and 747 with comparators. At week 24, DTSQc scores improved in both groups with a significantly higher increase in treatment satisfaction for insulin glargine vs. comparators (13.5 vs. 12.1; p

Summary This study analysed the effects of consuming 30 g per day of ‘Jijona turron’, a traditional Spanish Christmas nougat-type confection, on the circulating lipid parameters. Turron is made of toasted almonds, honey and sugar. To make this product more appealing to consumers who need to control their lipid or glucose levels, a new product containing inulin was developed. Macro- and micronutrient contents were similar in both turron with (JTI) or without (JT) inulin. A study with thirty-two volunteers was conducted, with a daily consumption of 30 g of either inulin-containing or not-inulin-containing turron for a total of 5 weeks. At the beginning and at the end of the study, the circulating lipid parameters were quantified. The volunteers consuming both types of products maintained their circulating cholesterol within normal levels; however, consumers of JT presented a slightly but significant 8% decrease in LDL cholesterol level. On the other hand, the group consuming JTI maintained the levels of glycosylated haemoglobin, while volunteers consuming JT presented low but significantly higher levels of glycosylated haemoglobin.

Objective: To compare efficacy of intravitreal bevacizumab versus triamcinolone in the treatment of diffuse diabetic macular oedema (DME). Methods: This retrospective nonrandomized study includes 60 patients with diffuse DME treated with at least one intravitreal triamcinolone injection (ITA) or intravitreal bevacizumab injection (IBe). Regression analysis was performed for pretreatment, glycosylated haemoglobin level, visual acuity (VA) at baseline and central macular thickness (CMT) at baseline. Results: After 1-, 3-, 6- and 9-month follow-up, there was no significant change in either VA or CMT treatment in the ITA and IBe groups. There was no statistically significant difference between the two treatment groups. Changes in CMT and VA in the subgroups were not significant. Only predictive factor independent of HbA1c level and VA was CMT at baseline in both treatment groups. The thicker CMT at baseline, the higher was reduction in CMT. After 1 month, the IBe group had a significantly higher decrement than the ITA group. Conclusion: In our study collective, neither IBe nor ITA treatment was able to improve VA during follow-up, significantly. CMT was reduced in both treatment groups, however not significantly. Our data demonstrates that reduction in CMT with either IBe or ITA treatment was significantly influenced by degree of CMT at baseline.

Aims. To explore the effects of exercise programme on glycosylated haemoglobin and peak oxygen uptake in children and adolescents with type 1 diabetes mellitus. Background. Regular exercise has been shown to be effective in blood glucose control, which includes improving glucose tolerance and insulin sensitivity, decreasing glycosylated haemoglobin levels and improving cardiorespiratory fitness. Design. Quasi-experimental design with a twelve-week home-based aerobic exercise programme. Method. Twenty-eight participants completed the study: 12 in the home-based exercise group, 11 in the non-exercise control group and five in the self-directed exercise group. A mixed model was used to capture longitudinal change in glycosylated haemoglobin levels. Results. The home-based aerobic exercise group showed no significant effect on glycemic control and peak oxygen uptake in this study across assessment times. However, a group difference in glycosylated haemoglobin levels at the nine-month follow-up was significant (general linear model: F = 4·06, p = 0·03). A Bonferroni test indicated that glycosylated haemoglobin levels in the home-based exercise group were higher than in the self-directed exercise group (p

Forty pregnant non-diabetics and 35 pregnant diabetics were studied in the antenatal period and followed till confinement. Glycosylated haemoglobin (GHb) and plasma glucose values (fasting and post load) were estimated at specific time periods. Various analyses showed GHb to have no significant correlation with glucose values (P>0.05). The diagnostic ability of GHb was significant at cut-off values of 6lt;% and 7% (P 0.05). At 7%, sensitivity (65.62%) and specificity (60.71%) were close; the positive predictive value was 65.62%. In pregnant diabetics, monitoring the response to therapy with GHb yielded no significant change in the diabetic status.

Aim: To evaluate whether the metabolic status had been influenced by the longer interval between visits because of a strike at the diabetes outpatient clinic. Methods: During the strike from April 16 to June 15, 2008 all routine visits were cancelled. The HbA1c values from the last two visits prior to and the first two visits after the strike were compared with the values from the same periods the previous year. Danish speaking patients answered a questionnaire. Results: For 155 children included, the mean HbA1c values before the strike were 8.1 and 8.1 (p = 0.39), while the value increased to 8.5 at the first visit (p 0.05). Of the 152 questionnaires handed out, 113 (74.3%) were returned. Of these, 48 (42.5%) stated to have needed help, and 49 (43.3%) that their children’s diabetes had deteriorated because of the strike. Conclusions: In this unplanned study, the increase of 0.4% in mean HbA1c supports previous findings that the interval between visits at a diabetic clinic is important for ensuring an acceptable metabolic control in children with diabetes.

No correlation has been demonstrated between the elevated levels of plasma beta-thromboglobulin and glycosylated haemoglobin found in a group of 97 diabetic patients. The abnormality in diabetic platelets which is reflected by beta-thromboglobulin levels may not therefore be a direct result of poor metabolic control. The highest levels of beta-thromboglobulin were found in those patients with a raised blood urea. Glycosylated haemoglobin levels correlated with prevailing blood glucose and with the type of therapy employed, and were highest in the insulin dependent diabetics, intermediate in those on tablets and lowest in those on diet alone.

Glycosylated haemoglobin or HbA, is a valuable instrument and an objective method to evaluate the metabolic state in the management of diabetes mellitus. This paper summarizes the value of HbA1 analysis from the clinical point of view, discussing errors and indications. Only 20% of a group of type I diabetic patients had acceptable HbA1 niveau indicating that a lot of work has to be done to achieve normoglycaemia in ordinary diabetics outside the remission period and during pregnancy.

Insulin analogues were developed to try and achieve more physiological insulin replacement from injection in the subcutaneous site. Their pharmacokinetics and pharmacodynamics differ from human insulin when injected subcutaneously because of alterations in the amino acid sequence of the insulin molecule. The rapid-acting insulin analogues, lispro, aspart and glulisine, have a rapid onset of action and shorter duration of action because of changes to the B26-30 portion of insulin inhibiting formation of dimers and hexamers. They appear to improve postprandial glucose, incidence of hypoglycaemia and patient satisfaction and, when used in combination with basal insulin analogues, improve glycosylated haemoglobin in comparison to conventional insulin therapy. Additionally, they have been successfully used in children, pregnant women, in pump therapy and as part of premixed biphasic regimens. The two basal insulin analogues, glargine and detemir, developed by adjusting the isoelectric point and adding a fatty acid residue, respectively, have a protracted duration of action and a relatively smooth profile. Their pharmacokinetic and pharmacodynamic profiles have been assessed using euglycaemic clamp protocols. Both analogues have a longer duration of action, less of a peak of activity and a reduced variability with repeated injection. There is some evidence to suggest that detemir may have a slight hepatoselective effect. Clinical studies have shown a lower relative risk of hypoglycaemia and detemir appears to have a weight-sparing action. Insulin analogues represent a successful example of applied medical science.

Aim: Little is known about the dose–response relationships of rapid-acting insulin analogues in subjects with diabetes. This study compared the dose–exposure and dose–response relationships of insulin glulisine and regular human insulin (RHI) in subjects with type 1 diabetes. Methods: Eighteen male subjects with type 1 diabetes (mean glycosylated haemoglobin, HbA1c, 7.7%; body mass index 24.5 kg/m2) received subcutaneous injections of insulin glulisine followed by RHI (both at doses of 0.075, 0.15 and 0.3 U/kg) in the same three-way crossover, randomized order in a euglycaemic glucose-clamp study. Results: Insulin glulisine and RHI showed dose-proportional increases in exposure (INS-AUCtotal) and maximum serum concentration (INS-Cmax) in the dose ranges 0.075, 0.15 and 0.3 U/kg. At all doses, within 2 h after injection, about twice as much insulin glulisine was absorbed as RHI (INS-AUC0–2h: 3855, 6832 and 13237 vs. 2356, 3630 and 6231 μU.min/mL; p

Aim: The present study aimed to investigate the effect of the number and intensity of visits to the More Allied Health Services (MAHS) clinics and a change in glycosylated haemoglobin (HbA1c) levels in people with type 2 diabetes. Methods: Data on subjects accessing diabetes clinics in rural southern New South Wales were analysed retrospectively. Data included age at the end of the data collection period, sex, number and dates of visits to the MAHS dietitian and diabetes educator, weights and heights, HbA1c and cholesterol levels. Results: Sixty-four patient records were analysed. The median period of clinic attendance was 32.5 months; median number of combined visits to MAHS dietitian and diabetes educator was three. Older subjects were significantly more likely to show a reduction in HbA1c than younger subjects. Subjects visiting the MAHS program more regularly than once every eight months were significantly more likely to achieve a reduction in HbA1c than those who were seen by MAHS staff once every eight months or more. Sixty per cent of those subjects with four or more visits to the MAHS program showed a reduction in HbA1c, while 38% of those with fewer than four visits showed a reduction in HbA1c, but this association did not reach significance. Conclusions: Older subjects and those attending the MAHS diabetes clinics more intensively were significantly more likely to show a reduction in HbA1c than younger subjects and those attending the clinic once every eight months or more. Future, larger studies using additional outcome measures will allow for an improved evaluation of interventions by dietitians and diabetes educators for those with type 2 diabetes.

Glycosylated haemoglobin levels are a key monitoring tool for diabetes control and the basis for targets in the QOF for diabetes. The first article in this occasional series discusses how the targets are best achieved in various patient groups. Copyright © 2007 Wiley Interface Ltd

glycosylated haemoglobin (HbA1c) has been recommended by the American Diabetes Association (ADA), the World Health Organisation and subsequently by many other professional bodies as a diagnostic tool for diabetes mellitus. However, the cut-off values suggested vary between these groups and uncertainties remain regarding the limitations of this test and its effectiveness as a diagnostic tool. We wished to assess the effect of HbA1con detection rates for dysglycaemia in a high risk cohort of 200 patients with possible acute coronary syndrome not previously known to have diabetes. Anthropometric as well as HbA1c, oral glucose tolerance tests (OGTT), random and fasting plasma glucose (RPG and FPG) concentrations, fasting lipids and high sensitivity C-reactive protein data were obtained during admission. We examined each of the recommended cut-off values for HbA1c. Test accuracy was assessed by the degree of misclassification (both under- and over-diagnosis) of patients into normal glycaemic control, impaired glucose tolerance and diabetes mellitus based on OGTT data using WHO criteria. A predictive index (PI) was generated using stepwise ordinal regression models (incorporating FPG, HbA1c, HDL-C, triglycerides, age and gender). HbA1calone, using the International Expert Committee cut-off values, had unacceptably high misclassification rates (49.0% under- and 2.5% over-diagnosed). This did not improve when ADA criteria were examined, despite their lower cut-off values for normoglycaemia (44.4% under- and 7.1% over-diagnosed). FPG was marginally better, misclassifying 44.4% (mostly under-diagnosis; 41.4%). The PI had the lowest misclassification rate (35.9%; with 22.7% under- and 13.1% over-diagnosed). In conclusion, our data suggest that HbA1calone offers little advantage over FPG in detecting dysglycaemia in this high risk population. Our approach using a predictive index to combine HbA1c with other test data will enhance its performance. Copyright © 2012 John Wiley & Sons. Practical Diabetes2012; 29(1): 29-31

Measurement of glycosylated proteins such as fructosamine and haemoglobin A1c (HbA1c) can be used to assess glycaemic control in canine diabetic patients. Two point-of-care analysers, designed for human diabetics, were evaluated for use in dogs. Blood samples were collected from 50 normoglycaemic dogs, 100 diabetic patients and five dogs with insulinoma and tested using the In Charge fructosamine meter and the Haemaquant/Glycosal HbA1c meter. Readings were obtained in all cases except for 21 of 50 diabetics, which were above the upper limit of the In Charge meter. Diabetic dogs had higher fructosamine and HbA1c concentrations compared to controls. However, there was poor agreement between the In Charge meter readings and serum fructosamine concentrations, suggesting that there are problems associated with the use of this device in dogs. HbA1c concentrations showed a high degree of correlation with glycosylated haemoglobin measured at an external laboratory, suggesting that the Haemaquant/Glycosal meter warrants further evaluation for veterinary use.

Summary • Insulin-treated diabetic patients with poor glycaemic control are frequently referred to diabetes specialist nurses, but little data exist as to the effectiveness of this practice. • We therefore analysed the progress of 43 prospectively referred insulin-treated patients with glycosylated haemoglobin (HbA1c) levels > 7.5%. • Diabetes nurse intervention involved re-education, dietary advice and insulin dose adjustment. Improvement in control was defined as a final HbA1c 1.0% at 6 months post-intervention. • Almost two-thirds (63%) of patients achieved improvement status, with no increase in body weight or hypoglycaemic episodes. Disappointingly, however, the ‘non-improver’ group (37%) showed a mean deterioration in HbA1c. • In conclusion, diabetes nurse intervention for poorly controlled insulin-treated diabetic patients is generally effective, but intervention may be best targeted to responsive patients. • The factors which influence diabetic patients' ‘responsiveness to change’ require further investigation.

Background: Patients with type 2 diabetes have abnormal endothelial function but it is not certain whether improvements in glycaemic control will improve endothelial function. Aims: To examine the effects of short-term improved glycaemic control on endothelial function in patients with inadequately regulated type 2 diabetes mellitus. Methods: Forty-three patients with type 2 diabetes and glycosylated haemoglobin (HbA1c) > 8.9% were randomized to either improved glycaemic control (IC) n = 21 or usual glycaemic control (UC) n = 22 for 20 weeks. Using high-resolution B-mode ultrasound, brachial artery flow-mediated dilatation (FMD) and glyceryl trinitrate-mediated dilatation (GTN-D) were measured at baseline and 20 weeks later. Results: After 20 weeks, HbA1c was significantly lower in IC versus UC (IC 8.02 ± 0.25% versus UC 10.23 ± 0.23%, P < 0.0001) but changes in FMD and GTN-D were not different between the groups (FMD at baseline and week 20 IC 5.1 ± 0.56% versus 4.9 ± 0.56% and UC 4.2 ± 0.51% versus 3.1 ± 0.51%; P = 0.23: GTN-D IC 12.8 ± 1.34% versus 10.4 ± 1.32% and UC 13.7 ± 1.2% versus 12.7 ± 1.23%; P = 0.39). In the IC group weight increased by 3.2 ± 0.8 kg after 20 weeks compared to 0.02 ± 0.70 kg in UC (P = 0.003). Blood pressure and serum lipid concentrations did not change in either group. Conclusions: Short-term reduction of HbA1c levels did not appear to affect endothelial function in patients with type 2 diabetes and previously poorly regulated glycaemic control. (Intern Med J 2001; 31: 322–328)

A method for assaying canine glycosylated haemoglobin was evaluated. The method is a turbidimetric inhibition immunoassay and the final reaction is bichromatically measured using a multichannel automatic analyser. Within-run coefficients of variation (2.07 to 4.46 per cent) were permissible, but between-run coefficients of variation (2.10 to 8.25 per cent) were slightly more elevated. The detection limit of this assay is 0.052 per cent. A sample dilution of 10 microliters of sample and 500 microliters of haemolysing reagent is recommended for routine analysis of canine blood samples. A normal reference interval of 1.39 +/- 0.70 per cent was obtained from the glycosylated haemoglobin analysis in 82 healthy dogs and no statistically significant differences in relation to age or gender were observed. Some changes in glycosylated haemoglobin concentrations were noted throughout the ovarian cycle, although differences between dogs were evident. Since this assay specifically measures the glycosylated haemoglobin content in canine blood samples, it could be very useful for monitoring diabetic dogs.

In anaemia with reduced erythrocyte survival and/or excess production of new young erythrocytes, a reduced concentration of HbA 1c is to be expected. We studied 8 patients with acute haemolytic anaemia, 28 patients with a heart valve prosthesis, 10 patients with iron-deficiency anaemia, 10 patients with vitamin B-12 deficiency anaemia and 10 control patients having no diabetes or haematologic disease

A simple method for collecting capillary blood for measurement of glycosylated haemoglobin (HbA1c) was developed that allows samples to be obtained at home and then mailed to the laboratory 2 weeks before a hospital visit. A single drop of blood is collected into a 2 ml plastic tube and sent for HbA1c assay on the Diamat HPLC system which has inter- and intra-assay coefficients of variation < 2.6 and < 1.2%, respectively. Results of simultaneously obtained venous and capillary samples in 32 diabetic children agreed well with each other. A separate study of 25 patients was performed to determine whether transport conditions affected the samples. Posted samples were compared with venous samples; again the values were in good agreement. This method is now used routinely in the diabetic clinic. Its value was determined by questionnaire in 40 children with age range 4-17 years. No family experienced difficulty collecting samples and all samples received were suitable for analysis. Children preferred this method to blood collection in the clinic as they felt it was less traumatic and more convenient. Seventy-nine percent of them understood its value in the long-term control of diabetes. In 40.5% of visits changes to management were made at the clinic due to the availability of the results.

Scoparia dulcis L. commonly known as 'Sweet Broomweed' is widely used in Indian folk medicine for the treatment of diabetes mellitus. Oral administration of 0.15, 0.30 and 0.45 g/kg body weight of the aqueous extract of the Scoparia dulcis leaves (SLEt) for 45 days resulted in a significant reduction in blood glucose, glycosylated haemoglobin and an increase in total haemoglobin but in the case of 0.45 g/kg body weight the effect was highly significant. The aqueous extract also prevented a decrease in the body weight. An oral glucose tolerance test was also performed in experimental diabetic rats, in which there was a significant improvement in glucose tolerance in animals treated with SLEt and the effect was comparable to that of glibenclamide.

The compliance of young patients with diabetes regimens is explored by means of a questionnaire filled in by both the patients and their nurses and compared with the patients' glycosylated haemoglobin (HBA1) levels. The structured questionnaire was completed by 47 diabetics aged between 15 and 17 years. The adolescents had very similar views to the specialist nurse on their compliance with health regimens, and these assessments were also in line with the HBA1 values. One-third of the young patients showed a high degree of compliance with diabetes regimens, while just under a half showed average compliance; the remainder failed to comply adequately. Compliance was highest in the case of insulin treatment, self-care and co-operation with the nursing staff, and poorest in following dietary and home monitoring instructions.

The effect of altering the frequency of self-monitoring of blood glucose upon blood glucose control was assessed in 25 Type 1 diabetic patients. Patients entered a balanced, crossover study in which they were randomly allocated to three 12-week periods. During each period the frequency at which patients self-monitored their blood glucose was: (1) four-point profiles on 2 days per week; (2) four-point profiles on 1 day per week; (3) two-point profiles on every day of the week. There were no significant differences in mean blood glucose concentration, fructosamine or glycosylated haemoglobin concentrations during the three periods. There was no correlation between the frequency at which patients altered insulin doses and measures of metabolic control. Altering the frequency of blood glucose self-monitoring had a variable and uncertain influence upon the frequency at which patients altered insulin doses. Some patients felt unsafe monitoring blood glucose only four times per week. There was however no patient consensus on the best-liked regimen.

The within-clinic use of glycosylated haemoglobin (HbA1) and plasma fructosamine results in assessing blood glucose control and clinical management was compared in 1030 diabetic patients. The physician initially reviewed the patient with one randomly allocated measure (HbA1 or fructosamine) and completed a questionnaire concerning perception of blood glucose control, alteration to diet, alteration to medication, referral for diabetes education, and follow-up interval. The patient was then re-assessed using the second measure and the questionnaire repeated. Discordance rates for the study end-points, judged as binary outcomes, were: blood glucose control 15%; alteration to diet 7%; alteration to medication 9%; referral for education 3%; follow-up interval 4%. A significantly greater number of patients were rated as poorly controlled with HbA1 than with fructosamine (p less than 0.001) and were, in consequence, more frequently recommended alteration to diet and medication, referral for education and shorter follow-up interval; the rate of discordance for at least one of the management decisions was 16%. Multifactorial analysis showed that discordant management was dependent on the reviewing physician (p less than 0.001) and a history of cardiovascular disease (p less than 0.01); but neither type of diabetes, nor presence of nephropathy or variant haemoglobins, nor plasma glucose concentration, significantly influenced the likelihood of a discordance. Replacing HbA1 with fructosamine in the diabetic clinic may result in significant differences in the physician's perception of blood glucose control and in the management of patients.

Thirty diabetic individuals in Austria were included in this study about health locus of control and glycosylated haemoglobin in implantable insulin pump recipients. Multidimensional Health Locus of Control (MHLC) scores were generally consistent with the optimal values identified for other populations with chronic conditions. Little relationship was found between MHLC scores and glycosylated haemoglobin values. Areas for further research are identified.

Purpose: To evaluate the degree of macular function disturbances in patients with diabetes mellitus and high glycosylated haemoglobin (HbA1c). Methods: 11 patients with type II diabetes were included in our study. In 6 patients a clinically significant macular edema was detected; other 5 patients showed slight vascular changes and absence of macular pathology. All patients had much too high (8-10%) or extremely high (above 10%) levels of HbA1c and underwent a chromatic macular ERG test to red, green and blue stimuli (MBN, Russia). A RETIScan system for multifocal ERG was also used (Roland Consult, Germany). Results: Patients with macular edema and long duration of the disease had significant reduction of a- and b-wave amplitudes of macular ERG, whereas those with short duration of diabetes showed slight decrease of macular ERG amplitude. The density of photoreceptors in multifocal ERG and amplitudes of N1 and P1 components were analyzed in area of 15° of visual angle: the mean of 3 central rings’ values was calculated. Correlation between mf-ERG data and macular ERG amplitudes were found. In patients without macular edema and duration of the disease from 7 to 10 years who had background diabetic retinopathy no significant changes of function testing of the macula were revealed. The amplitude values were close to lower normal data. Conclusions: Macular function in diabetic patients is mainly safe in spite of high levels of glycosylated haemoglobin. The complexity of pathogenetic mechanisms of diabetic retinopathy along with functional tests is still the subject of an investigation.

Two hundred and seventy-six consecutive pregnancies among 186 women with diabetes mellitus from 1980–90 were studied. Diabetic offspring were a mean of 652g (124%) overweight compared with our reference population regardless of maternal White classification or gestational age. Glycosylated haemoglobin values below 10 SD above the reference value in a nondiabetic population did not correlate to fetal macrosomia. HbA1c is therefore considered an insensitive predictor of fetal macrosomia.

The long-term glycaemic control, assessed by the mean of three successive levels of glycosylated haemoglobin (HbA1c) achieved in a special clinic for insulindependent diabetics aged 12–40, was audited in 1984 and 1987. Clinic policy involved a twice-daily insulin regimen with infrequent blood glucose monitoring and little emphasis on dietary compliance or formal education. Overall levels of diabetic control were identical in 1984 and 1987; 34% of patients had HbA levels within three standard deviations of the mean and 60% within five standard deviations. There was no correlation between control and age or duration of diabetes. Diabetic control deteriorated in 24% of patients and improved in 20% between 1984 and 1987. There was no significant difference in the overall levels of control compared with other centres. It is concluded that frequent blood glucose monitoring, strict dietary compliance and formal education are not important factors in glycaemic control in insulin-dependent diabetes.

We have studied the effect of limiting plasma glucose estimations in a busy diabetic clinic. Forty nine patients recorded their time of arrival, the time they saw the doctor, and the time they left the diabetic clinic, before and after the implementation of a plasma glucose policy. At the first visit all patients had a plasma glucose estimation. This was repeated at the second attendance in 24 (48%) patients. The remaining patients had glycosylated haemoglobin and home blood monitoring results available. The mean waiting times to see the doctor and the time spent at the clinic at the second visit were reduced (p 12 mmol/l) did not alter patient management. We conclude that the traditional diabetic clinic blood test delays the clinic and rarely contributes to patient management.

The efficacy and safety of replacing doctors with nurse specialists in the routine care of diabetics was assessed in peripatetic diabetes clinics on the Isle of Wight. During the weekly clinic sessions biochemical control was monitored, and patients were educated about the disease. If a physical examination was required the patients were referred to a consultant clinic. The results of biochemical tests were noted in the patients records and copies were passed onto the doctors and consultants in charge. After one year questionnaires were sent to all general practitioners and patients involved in the study to assess their opinions of the nurse specialist clinics. Random blood sugar levels were similar when the clinics were run by both doctors and nurse specialists. However, glycosylated haemoglobin improved in the Type 1 diabetics controlled by the nurse specialists, and in both Type 1 and Type 2 diabetics the numbers of admissions to hospital from hyper- or hypoglycaemia decreased. The majority of GPs were in favour of the nurse run diabetes clinics; 68% felt that the nurse specialist clinics were beneficial for their patients. The patients were also in favour of the nurse specialist clincis, 97% said that they were confident in the nurse specialist system; and over half stated that they would prefer to have this kind of diabetes care in the future.

Aim. The purpose of this study was to evaluate whether the effect of the nurse's education using short message service of cellular phone varied according to the degree of the glycosylated haemoglobin at baseline with type 2 diabetes mellitus. Background. Nurse's education using telemedicine has a decrease glycosylated haemoglobin level in type 2 diabetic patients. Design. A control group pretest–post-test design was used to assess the effectiveness of nurse's education. Methods. Fifty-one subjects completed the entire study, 25 interventions and 26 controls. Intervention and control groups were then separated into two groups by baseline-glycosylated haemoglobin, a baseline-glycosylated haemoglobin ≥7·0% and a baseline-glycosylated haemoglobin

The relationships between daily insulin dose, body weight, age, sex and glycosylated haemoglobin (HbA1) were explored in a group of 198 insulin-dependent (IDDM) diabetics of at least five years' duration. Insulin dose was positively correlated with body weight (p

This longitudinal study compares serum fructosamine (SF) and glycosylated haemoglobin (HbA1) in assessing glycaemic control in 172 insulin-dependent diabetic outpatients over a 21 month period. Seven simultaneous measurements of SF and HbA1 were performed in sequential order at intervals of 10 to 12 weeks, during which patients received standard diabetic care. In common with other studies, the between-subject correlation of SF and HbA1 was confirmed to be satisfactory (r = 0.68, p

The dietary pattern of thirteen non-insulin-dependent diabetics during the Ramadan fast and the effect of Ramadan fasting on the metabolic control of these diabetics was studied. The dosage of oral hypoglycaemic drugs and insulin (in insulin-requring patients) was left unaltered during the fasting period. Patients ingested significantly less calories (p

The value of computer-linked “memory” blood glucose reflectance meters in the education and management of diabetic adolescents was assessed in a group cross-over study. Sixteen diabetic teenagers took part. After explanation of the new meters and instruction in their use, eight (Group A) were given memory meters while the remainder (Group B) continued to record blood glucose results in their logbooks as usual. After six weeks the memory meters were transferred from Group A to Group B. Glycosylated haemoglobin and blood test performance were recorded at the start, at 12 weeks and at 24 weeks. The results were discussed individually with the patients at routine clinic visits. The conclusions were; (1) blood glucose tests were accurately recorded; (2) use of the memory meter was associated with increased test frequency which continued for some weeks after the study; (3) there was a slight but definite improvement in glycaemic control; (4) most important, the computer printouts were of real help in demonstrating to diabetic adolescents the purpose and value of blood glucose monitoring.

In this cross-sectional study total glycosylated haemoglobin (Hb AIa+b+c) has been measured in 20 healthy non-pregnant women and in five groups of 20 healthy women at various times during pregnancy. A statistically significant decrease occurs in these minor haemoglobin fractions by about 20 weeks gestation and this reduced level is maintained throughout the rest of pregnancy. If diabetic patients are to have their control assessed during pregnancy by determination of these fractions this fact might be relevant.

Forty-two diabetic patients from a group practice were studied. Information relevant to their diabetes was extracted from the medical records, a questionnaire interview was conducted and glycosylated haemoglobin measured. Diabetics were frequent attenders at the surgery but their follow-up was haphazard and incomplete. Although patients had a generally poor understanding of diabetes, they were keen to learn more. Regular follow-up by general practitioner would be preferred to hospital care, by three out of four patients. To provide this care, we need to combine a systematic approach with the long-term encouragement of the diabetic person to play an active part in his own management.

Vibration perception threshold (VPT) has been measured before and 30 min after limb ischaemia in 17 newly diagnosed non-insulin-dependent diabetic patients and matched controls. Mean baseline VPT was higher in the diabetics than in controls (14 vs 11, p less than 0.01) while VPT at 30 min was lower (25 vs 30, p less than 0.05). The ischaemic index (VPT at 30 min/baseline VPT), calculated as a measure of nerve ischaemia-resistance, was lower in the diabetics compared with controls (p less than 0.01), and correlated with blood glucose (r = -0.53, p less than 0.03) but not glycosylated haemoglobin at the time of testing. The difference in ischaemic index persisted even when baseline VPT measurements, rather than patients, were matched. Ischaemic index was re-tested in 15 patients after a median interval of 17 months (range 6-19), at which time mean +/- SD glycosylated haemoglobin had improved significantly (12.2% +/- 0.4 versus 9.5% +/- 0.05, p less than 0.001), but this bore no relation to changes in ischaemic index. Peripheral nerve ischaemia-resistance is present at the time of diagnosis of non-insulin-dependent diabetes, even in the absence of other neurophysiological abnormalities, and is not explicable by glycaemic control alone.

Insulin-treated diabetic patients attending a busy diabetic clinic were approached to determine their interest in using continuous subcutaneous insulin infusion (CSII) via a portable pump. Three hundred and eighty-two patients were offered the choice of CSII, intensified conventional therapy (ICT) or continuation of less intensified treatment. One hundred and sixteen patients (30.4%) chose CSII, 169 (44.2%) chose ICT, 97 (25.4%) chose the less intensive regimen. Those choosing CSII represented a broad cross section of the clinic population, though older patients with a longer duration of diabetes tended to continue with less intensified therapy. There were no differences between groups in the level of blood glucose control or the prevalence of complications at the outset of the study. Of 104 patients not previously using CSII, 86 have so far commenced the therapy. Twenty-seven (32.6%) of these discontinued within one year, 23 doing so in the first three months of treatment. Metabolic control, assessed by glycosylated haemoglobin, was significantly improved in the CSII group after three months and in the other treatment groups by six months. Glycosylated haemoglobin levels achieved with CSII were significantly lower at three and six months when compared with the other treatments.