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Insulin therapy is only effective if it is delivered into the right tissue in the right way. Exogenous insulin is intended for the subcutaneous (SC) tissue, not the muscle or skin. If delivered into the latter, its absorption (pharmacokinetics (PK)) and action (pharmacodynamics (PD)) are unpredictable, which often leads to poor glucose control. Correct insulin therapy begins with matching the insulin to the site used. Typically, four sites are used for insulin injection or infusion: the abdomen lateral to the umbilicus all the way to the flanks, the anterior lateral upper half of the thigh, the deltoid region of the arm, and the upper outer quadrant of the buttocks. Regular insulin and neutral protamine Hagedorn (NPH) are both absorbed more rapidly from the arm and abdominal sites and more slowly from the thigh and buttocks. The newer insulin analogs, both rapid- and slow-acting, do not appear to be influenced by the site used for injection. In order to avoid intramuscular (IM) injections, patients should use the shortest needles currently available (the 4-mm pen needle and the 6-mm syringe needle). Very young children should raise a skin fold and inject into it even when using the 4-mm needle. Giving injections with the 6-mm needle at a 45° angle converts this needle into the equivalent of the 4 mm. Injection sites should be rigorously rotated, with the new injection being approximately 1 cm from previous injections. This measure helps prevent the most common complication of injection therapy, lipohypertrophy (LH). Injecting into LH leads to unstable PK and PD and deregulated glucose control, manifested as unexpected hypoglycemia, glycemic variability, and elevated HbA1c values. Comprehensive insulin deliver recommendations have recently been published.

Esophageal dysmotility and gastroparesis are common secondary complications in patients with diabetes mellitus. Patients with dysmotility express antibodies against gonadotropin-releasing hormone (GnRH) in serum. The aim of the present study was to scrutinize patients with diabetes mellitus with regard to the presence of GnRH antibodies, and to examine associations between antibodies and clinical findings.

Epidemiological studies have linked whole grain intake to the prevention of the metabolic syndrome, obesity and associated chronic diseases such as CVD and T2D. The Nutrition module within the HEALTHGRAIN project, included 10 partners and undertook in vitro, animal and human in vivo studies with the overall aims of elucidating the components and mechanisms underlying the health benefits of cereal grains. This review summarises the major outcomes of these studies, including yet unpublished findings.

QC 20120330

Background: Few studies evaluate patients' perspectives when a new drug is introduced to treat chronic diseases such as diabetes mellitus. The clinical role of a new insulin treatment, in terms of the relationship between higher cost and better treatment outcomes (as defined from the patient perspective) has been discussed. We sought to explore patient satisfaction with a new insulin treatment (insulin glargine). At its launch in 2002/3 it was purported to provide constant, peakless insulin release following once- or twice-daily administration, thus leading to fewer hypoglycaemic episodes while providing metabolic control equivalent to that achieved with NPH human basal insulin. Aims: To investigate the indications used for prescription of a new drug and its clinical effects on glycosylated haemoglobin (HbA1c) levels, perceived hypoglycaemic events and patient satisfaction. Methods: The Diabetes Treatment Satisfaction Questionnaire (Status Version, DTSQ-s), which measures satisfaction with treatment regimen, and perceived frequency of hyperglycaemia and hypoglycemia, was circulated to all living patients who had ever started treatment with insulin glargine at the Department of Endocrinology at Malmö University Hospital. Medical records of 913 patients were assessed for HbA1c levels at 0 and 12 months after starting insulin glargine therapy. Results: Completed questionnaires were returned by 615 of 960 patients (64%) who had ever started insulin glargine. The main indications for starting treatment were physicians' or nurses' initiatives, desire for fewer fluctuations and improved metabolic control. HbA1c levels fell by 0.41% for patients with type 1 diabetes and by 0.68% for those with type 2 diabetes. The mean DTSQ-s score was 28.45 for satisfaction, whereas the mean perceived hypoglycaemic/hyperglycaemic events score was 3. Conclusion: Treatment satisfaction was very high and perceived frequency of hypoglycaemia/hyperglycaemia was very low. The indications for tre

[Reply on new drugs against type 2 diabetes: important to gain experience and knowledge]

The overall goals for the treatment of diabetes are to prevent acute and long-term complications and maintain a good quality of life. The St Vincent Declaration and the Swedish National Guidelines for the Treatment of Diabetes Mellitus describe patient education in self-treatment as a prerequisite for the achievement of these goals. This survey aimed to evaluate the presence of structured patient education (in advance planned education), its organisation, staffing and goals, and the results in out-patient diabetes care in Sweden.A questionnaire consisting of 35 open and closed questions was mailed to 1250 diabetes educated nurses working in hospitals and primary health care in the entire country.Responses were received from 583 (47%) nurses. Structured diabetes patient education was performed by 486 nurses. It was usually organised by nurses and performed in co-operation with doctors (55%), dietitians (38%), chiropodists (36%), and social workers (9%). The sessions took place individually at pre-scheduled visits (80%), or as group education (26%). Fifty-one percent described explicit goals for the education, most commonly: general knowledge about diabetes, improved metabolic control and increased safety. The structured education was evaluated by 51% of which the HbA[1]c level at the next scheduled visit was the most frequently used evaluation method (44%), followed by home monitored blood glucose values (37%) and a structured evaluation form (17%). The goals had been achieved to a great or quite great extent by 67% of the responding nurses.To the extent that structured patient education takes place, nurses are usually responsible for its performance. It takes place individually as well as in groups. Many nurses lack evident goals for the education and sufficient evaluation methods.It was concluded that there is confusion about the content of structured education vs information activity.

There are studies suggesting that fear of blood and injury is associated with less frequent self-testing; by reducing pain when measuring blood glucose the number of measurements can probably increase. The aim of this study was to investigate whether or not there were any differences regarding pain at different test sites in the palm. Twenty type 1 diabetes subjects pricked themselves at four different sites in the palm in the non-dominant hand in a randomised order with the Freestyle® punction device loaded with BD Microfine+ lancets. Pain was evaluated by the subjects using the Pain-O-Meter®. The result (n=80) showed no statistically significant difference in pain score between the investigated sites. The level of sensory pain was reported: shooting (n=36), no pain (n=27), searing (n=8), soaring (n=5), pressing (n=2), aching (n=1) and burning (n=1); 86% (n=69) of the pricked sites were experienced as no pain at all. This study shows that pain in connection with capillary blood test is low as measured by the Pain-O-Meter. There are no significant differences in the pain experienced at different sites in the palm. More studies need to be done using different punction devices and more sites need to be investigated

BACKGROUND: Milk products deviate from other carbohydrate-containing foods in that they produce high insulin responses, despite their low GI. The insulinotropic mechanism of milk has not been elucidated.OBJECTIVE: The objective was to evaluate the effect of common dietary sources of animal or vegetable proteins on concentrations of postprandial blood glucose, insulin, amino acids, and incretin hormones [glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide 1] in healthy subjects.DESIGN: Twelve healthy volunteers were served test meals consisting of reconstituted milk, cheese, whey, cod, and wheat gluten with equivalent amounts of lactose. An equicarbohydrate load of white-wheat bread was used as a reference meal.RESULTS: A correlation was found between postprandial insulin responses and early increments in plasma amino acids; the strongest correlations were seen for leucine, valine, lysine, and isoleucine. A correlation was also obtained between responses of insulin and GIP concentrations. Reconstituted milk powder and whey had substantially lower postprandial glucose areas under the curve (AUCs) than did the bread reference (-62% and -57%, respectively). Whey meal was accompanied by higher AUCs for insulin (90%) and GIP (54%).CONCLUSIONS: It can be concluded that food proteins differ in their capacity to stimulate insulin release, possibly by differently affecting the early release of incretin hormones and insulinotropic amino acids. Milk proteins have insulinotropic properties; the whey fraction contains the predominating insulin secretagogue.

BACKGROUND: To investigate which factors during gestational diabetes pregnancies correlate with the risk of developing impaired glucose tolerance or diabetes 1 year postpartum and to compare this risk in women with gestational diabetes and women with a normal oral glucose tolerance test during pregnancy. METHODS: Of 315 women with gestational diabetes, defined as a 2-hr blood glucose value of at least 9.0 mmol/l at a 75-g oral glucose tolerance test, who delivered in Lund 1991-99, 229 (73%) performed a new test 1 year postpartum. We compared maternal and fetal factors during pregnancy with the test value at follow up. A control group of 153 women with a 2-hr test value below 7.8 mmol/l during pregnancy were invited to a new test 1 year postpartum and 60 (39%) accepted. RESULTS: At 1 year follow up, 31% of the women with gestational diabetes but only one of the 60 controls showed pathologic glucose tolerance and one had developed diabetes. The following factors in women with gestational diabetes were identified as predicting impaired glucose tolerance or diabetes at 1 year follow up: maternal age over 40 and--in a multiple regression analysis, independent of each other--a high 2-hr value at oral glucose tolerance test during pregnancy and insulin treatment during pregnancy. CONCLUSION: The risk of developing manifest diabetes after gestational diabetes may be high enough to justify a general screening or diagnostic procedure in all pregnant women to identify women with gestational diabetes and a postpartum follow up program for them. This study did not identify any particular factor during pregnancy with enough precision to predict a later progression to diabetes.

Aim. To study different insulin pens regarding leakage from the tip of the needle after injection. Patients and method. Six pens were tested; Saline Pen 3.0 ml (Lilly), B-D Pen 3.0 ml, NovoLet 1.5 and 3.0 ml, NovoPen 1.5 and 3.0 ml. Twenty volunteers were injected with sterile saline and the needle was withdrawn after 1, 3, 5, or 7 s respectively. Any dribble was collected on a filter paper and weighed. The procedure was videotaped. Results. There was a minimum of dribbling from the 1.5 ml pens. Eight out of 20 NovoPen 3.0 ml and B-D Pen 3.0 ml, 16 out of 20 NovoLet 3.0 ml, and 19 out of 20 Saline Pen (Lilly) dribbled after a 7 s hold-in time. The 8 B-D Pen 3.0 ml had leaked 4.0 mg (2.4±18.8), the 8 NovoPen 3.0 ml 4.7 mg (3.8±6.7), the 16 NovoLet 3.0 ml 5.0 mg (3.1±16.6) and the 19 Saline Pen 3.0 ml had leaked 9.2 mg (4.9±19.1). Conclusion. There is a clinically significant leakage of fluid from the needle tip even after 7 s hold-in time. Patients should be taught to hold the needle in for at least 10 s to be assured they get the intended dose.