RESUMEN
The purpose of this study was to evaluate the efficacy of using a telecommunication system to assist in the outpatient management of pediatric patients with insulin-dependent diabetes. Metabolic control, patients' psychosocial status, family functioning, perceived quality of life, patterns of parental/child responsibility for daily diabetes maintenance, and nursing time-on-task were evaluated. One hundred six pediatric patients (mean age = 13.3 years) were randomly assigned to an experimental or control outpatient clinic for 1 year. Experimental subjects transmitted self-monitoring blood glucose data by modem to the hospital every 2 weeks. Transmitted data were reviewed by nurse practitioners who telephoned subjects to discuss regimen adjustments. Control subjects received standard care with regimen adjustments made by physicians. There were no significant between-group differences for metabolic control, rates of hospitalization or emergency-room visits, psychological status, general family functioning, quality of life, or parent-child responsibility. A significant decrease was noted in nursing time-on-task for experimental subjects.
Asunto(s)
Diabetes Mellitus Tipo 1/terapia , Servicio Ambulatorio en Hospital/organización & administración , Telecomunicaciones , Adolescente , Automonitorización de la Glucosa Sanguínea , Diabetes Mellitus Tipo 1/metabolismo , Diabetes Mellitus Tipo 1/psicología , Femenino , Humanos , MasculinoRESUMEN
OBJECTIVE: To test whether a two-injection regimen of HUL/R would improve FBG and metabolic control in pediatric IDDM patients with a dawn rise in FBG compared with our standard twice-daily therapy, HL/R. RESEARCH DESIGN AND METHODS: Seventy-seven patients with fasting hyperglycemia (prebreakfast mean FBG greater than or equal to 8.3 mM (150 mg/dl) during the preceding 2 wk) were evaluated with twice-weekly midsleep (0230-0330) FBG for 2 wk. Forty-seven patients (61%) had a mean dawn rise between midsleep and prebreakfast of greater than or equal to 2.8 mM (50 mg/dl). Patients continued on HL/R for an additional 4 wk, after which 31 patients were then randomized into a double-blind 12-wk trial of either HUL/R (n = 14) or HL/R (n = 17) administered before breakfast and the evening meal. Midsleep FBG was obtained twice weekly with weekly insulin adjustment as needed to optimize glycemic control. FBG was monitored and verified with memory glucometers (Glucometer M). HbA1c levels were measured at the time of physician visits at 0, 6, and 12 wk. RESULTS: Prebreakfast FBG was lower in the HUL/R-treated patients (10.6 +/- 0.6 vs. 12.6 +/- 0.6 mM [191 +/- 6.4 vs. 227 +/- 11.2 mg/dl], P less than 0.02). The dawn rise was diminished in the HUL/R patients (0.5 +/- 0.5 vs. 2.6 +/- 0.7 mM [9 +/- 8.3 vs. 46 +/- 11.7 mg/dl], P less than 0.02). FBG at lunch, dinner, bedtime, and midsleep were similar in both groups, and HbA1c did not differ between groups or change significantly in either group during the 12-wk trial. Insulin dose, percentage R, day-night dosage split, and episodes of hypoglycemia (FBG less than 3.3 mM [60 mg/dl]) were similar in both groups. CONCLUSIONS: A 12-wk trial of twice-daily HUL/R improved fasting glycemia in pediatric patients with a dawn rise but did not improve metabolic control as measured by HbA1c.
Asunto(s)
Diabetes Mellitus Tipo 1/tratamiento farmacológico , Hiperglucemia/prevención & control , Insulina de Acción Prolongada/administración & dosificación , Glucemia/metabolismo , Niño , Ritmo Circadiano , Diabetes Mellitus Tipo 1/sangre , Esquema de Medicación , Femenino , Humanos , Hiperglucemia/inducido químicamente , Insulina de Acción Prolongada/efectos adversos , Insulina de Acción Prolongada/uso terapéutico , Masculino , Proteínas Recombinantes/administración & dosificación , Proteínas Recombinantes/efectos adversos , Proteínas Recombinantes/uso terapéuticoRESUMEN
Nationwide, pediatricians provide a substantial portion of the health care of children with diabetes. Their beliefs and attitudes about diabetes and children with the illness have an important influence on their treatment decisions. The attitudes and beliefs of a 1988 sample of pediatrics residents were compared with data from a 1987 national survey of practicing pediatricians' beliefs and attitudes about children with insulin-dependent diabetes mellitus and about the disease itself. Pediatrics residents in their second and third years of training were considerably more negative about diabetes and diabetic children than were either the members of the national sample of practicing pediatricians or the residents' first-year colleagues.
Asunto(s)
Actitud del Personal de Salud , Diabetes Mellitus Tipo 1/terapia , Internado y Residencia , Pediatría/educación , Niño , Humanos , Encuestas y Cuestionarios , Estados UnidosRESUMEN
General pediatricians provide comprehensive care for many children with insulin-dependent diabetes mellitus. To assess and improve our ambulatory training program, we first evaluated diabetes-specific care behaviors by residents in their continuity clinics and then introduced a structured visit encounter form. Based on established guidelines provided to the residents, a chart audit indicated appropriate measurement of glycosylated hemoglobin 40% of the time, cholesterol 90% of the time, urine protein 50% of the time, and thyroxine 66.7% of the time. Height was plotted 23% of the time, blood pressure was noted 66% of the time, and ophthalmologic referrals were documented 60% of the time. Requests for assistance from nonphysician members of a multidisciplinary diabetes team were minimal. After introduction of the structured visit encounter form, care behaviors did not improve. New training approaches to prepare general pediatric residents to provide excellent diabetes care are needed.
Asunto(s)
Diabetes Mellitus Tipo 1/terapia , Internado y Residencia , Pediatría/educación , Instituciones de Atención Ambulatoria , Niño , Humanos , Registros Médicos , Grupo de Atención al Paciente , Derivación y ConsultaRESUMEN
Many pediatric diabetes patients are cared for by community-based pediatricians. Training for pediatricians in optimal diabetes care should be based on both the recommendations of pediatric endocrinologists regarding optimal care and the practices of general pediatricians. Pediatric endocrinologists, general pediatricians, and pediatric residency coordinators were surveyed to assess the consonance of current recommendations, practices, and training in pediatric diabetes care. Not surprisingly, pediatric endocrinologists recommended more subspecialty care than pediatricians reported practicing. A major difference between endocrinologists and pediatricians emerged in the area of psychosocial support. A total of 85% of endocrinologists answered that there should be a mental health diabetes team member, but only 37% of pediatricians reported often or sometimes working with one to develop care plans. Pediatricians who provide complete diabetes care for most of their patients measure frequent glycosylated hemoglobin levels, obtain yearly lipid measurements marginally less often, and use urinary glucose measurements more often than recommended by pediatric endocrinologists. According to the descriptions of most pediatric residency training programs, multidisciplinary teams include a pediatrician, an endocrinologist, and a dietician. However, 25% do not include a social worker or nurse and 70% do not include a psychologist. Although most training programs operate on the assumption that their trainees will ultimately share responsibility with a subspecialist for diabetes care, in 26% of programs residents saw no diabetics in their continuity clinics. Most residents do not participate in providing diabetes education.(ABSTRACT TRUNCATED AT 250 WORDS)
Asunto(s)
Diabetes Mellitus Tipo 1/terapia , Endocrinología/métodos , Pediatría/métodos , Glucemia/análisis , Niño , Diabetes Mellitus Tipo 1/diagnóstico , Diabetes Mellitus Tipo 1/psicología , Endocrinología/educación , Glucosuria/orina , Humanos , Internado y Residencia , Pediatría/educación , Apoyo Social , Encuestas y Cuestionarios , Estados UnidosRESUMEN
The Glucometer M Diabetes Management System includes a glucose-reflectance meter with memory that can interface with a microcomputer for data manipulation and analysis. We evaluated the system in a short-term randomized control trial to determine its impact on metabolic control, self-monitoring of blood glucose (SMBG) testing behaviors, regimen self-adjustment, understanding of insulin-dependent diabetes mellitus (IDDM) treatment, attitudes about SMBG, and perceived quality of patient-physician interaction. Twenty-nine adolescent subjects (experimental) with IDDM were randomly assigned the Glucometer M system for 4 mo. Twenty-eight control subjects used meters without memory. All subjects returned twice to the clinic at 2-mo intervals during the study. At clinic visits, both groups reviewed their SMBG data with their physician. Reviews on experimental subjects were conducted with computer-generated data formats. Control subject reviews used traditional logbooks. Both groups showed a significant drop in glycosylated hemoglobin during the study period (P less than .001); however, there were no between-group differences. There were also no differences in SMBG testing behavior or self-reported regimen self-adjustment between groups or within groups compared with baseline. Compared with control subjects, experimental subjects indicated a significant increase in self-reported understanding of IDDM treatment (P = .002), perceived importance of testing (P = .006), and the quality of interaction with their physician (P less than .001). These data suggest that use of computer-assisted SMBG systems in the outpatient setting does not improve metabolic control over 4 mo. It may, however, contribute to improving communication between the patient and health-care providers.