| 1. |
- Abdelgadir, Moawia, 1965-
(författare)
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Clinical and Biochemical Features of Adult Diabetes Mellitus in Sudan
- 2006
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The high prevalence of diabetes mellitus among the Sudanese population is linked to obesity, poor glycaemic control and a high rate of complications. This study investigated 1/ Leptin hormone and its correlations with different biochemical characteristics in Sudanese diabetic subjects, 2/ The impact of glycaemic control on pregnancy outcome in pregnancies with diabetes, 3/ The glycaemic response to Sudanese traditional carbohydrate foods, 4/ The influence of glucose self-monitoring on the glycaemic control among this population, 5/ The health related quality of life in Sudanese subjects with diabetes-related lower limb amputation. Leptin was significantly lower in diabetic subjects compared with controls of same BMI in both females (P =0.0001) and males (P =0.019). In diabetic subjects, serum leptin correlated positively with the homeostatic assessment (HOMA) of both beta-cell function (P =0.018) and insulin resistance (P =.038). In controls, leptin correlated only with insulin resistance. Pregnancy complications were higher among diabetic compared with control women (P<0.0001) and varied with the type of diabetes. Infants of diabetic mothers had a higher incidence of neonatal complications than those of non-diabetic women (P<0.0001). In six Sudanese traditional carbohydrate meals over all differences in incremental AUCs were significant for both plasma glucose (P = 0.0092) and insulin (P = 0.0001). Millet porridge and wheat pancakes displayed significantly lower post-prandial glucose and insulin responses, whereas maize porridge induced a higher post-prandial glucose and insulin response. In type 2 diabetic subjects SMBG or SMUG was not related to glycaemic control. In type 1 diabetic subjects, SMBG was significantly associated with better glycaemic control, as assessed by HbA1c (P=0.02) and blood glucose at clinic visits (P=<0.0001), similar associations were found for SMUG respectively. Neither glycaemic control nor glucose self-monitoring was associated with education level. Diabetic subjects with LLA had significantly poorer HRQL compared to a reference diabetic group (P=<0.0001). Duration of diabetes and amputation had negative impact on HRQL in subjects with LLA (P=<0.0001) respectively. Diabetic subjects with LLA had decreased sense of coherence and high presence of symptoms. Improving health services at the primary level is important to reduce the complications and burden of disease in the Sudanese population.
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| 2. |
- Amsberg, Susanne, et al.
(författare)
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A cognitive behavior therapy-based intervention among poorly controlled adult type 1 diabetes patients : a randomized controlled trial
- 2009
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Ingår i: Patient Education and Counseling. - : Elsevier BV. - 0738-3991 .- 1873-5134. ; 77:1, s. 72-80
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE: To examine the impact of a Cognitive Behavior Therapy (CBT)-based intervention on HbA(1c), self-care behaviors and psychosocial factors among poorly controlled adult type 1 diabetes patients. METHODS: Ninety-four type 1 diabetes patients were randomly assigned to either an intervention group or a control group. The intervention was based on CBT and was mainly delivered in group format, but individual sessions were also included. All subjects were provided with a continuous glucose monitoring system (CGMS) during two 3-day periods. HbA(1c), self-care behaviors and psychosocial factors were measured up to 48 weeks. RESULTS: Significant differences were observed with respect to HbA(1c) (P<0.05), well-being (P<0.05), diabetes-related distress (P<0.01), frequency of blood glucose testing (P<0.05), avoidance of hypoglycemia (P<0.01), perceived stress (P<0.05), anxiety (P<0.05) and depression (P<0.05), all of which showed greater improvement in the intervention group compared with the control group. A significant difference (P<0.05) was registered with respect to non-severe hypoglycemia, which yielded a higher score in the intervention group. CONCLUSION: This CBT-based intervention appears to be a promising approach to diabetes self-management. PRACTICE IMPLICATIONS: Diabetes care may benefit from applying tools commonly used in CBT. For further scientific evaluation in clinical practice, there is a need for specially educated diabetes care teams, trained in the current approach, as well as cooperation between diabetes care teams and psychologists trained in CBT.
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| 3. |
- Amsberg, Susanne, et al.
(författare)
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Experience from a behavioural medicine intervention among poorly controlled adult type 1 diabetes patients
- 2009
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Ingår i: Diabetes Research and Clinical Practice. - : Elsevier BV. - 0168-8227 .- 1872-8227. ; 84:1, s. 76-83
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Tidskriftsartikel (refereegranskat)abstract
- Aim To describe experience from a behavioural medicine intervention among poorly controlled adult type 1 diabetes patients, in terms of feasibility, predictors and associations of improved glycaemic control. Methods Data were collected on 94 poorly controlled adult type 1 diabetes patients who were randomised to a study evaluating the effects of a behavioural medicine intervention. Statistics covered descriptive and comparison analysis. Backward stepwise regression models were used for predictive and agreement analyses involving socio-demographic and medical factors, as well as measures of diabetes self-efficacy (DES), diabetes locus of control (DLOC), self-care activities (SDSCA), diabetes-related distress (Swe-PAID-20), fear of hypoglycaemia (HFS), well-being (WBQ), depression (HAD) and perceived stress (PSS). Results The participation rate in the study was 41% and attrition was 24%. Of those patients actually participating in the behavioural medicine intervention, 13% withdrew. From the regression models no predictors or associations of improvement in HbA1c were found. Conclusions The programme proved to be feasible in terms of design and methods. However, no clear pattern was found regarding predictors or associations of improved metabolic control as the response to the intervention. Further research in this area is called for.
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| 4. |
- Amsberg, Susanne
(författare)
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Health Promotion in Diabetes Care : Studies on Adult Type 1 Diabetes Patients
- 2008
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Introduction: A landmark report has shown that improving glycaemic control among type 1 diabetes patients markedly reduces diabetes-related complications. In clinical practice, however, many patients have problems in adhering to the treatment, and thus remain in poor glycaemic control. Research suggests a more behaviour-oriented approach to diabetes, but there is a lack of evidence on the efficacy of interventions, especially for those adult type 1 diabetes patients who are in poor glycaemic control. Diabetes-related distress has been associated with poor adherence to treatment and poor glycaemic control. There is a need for validated measures in this area, to identify patients who experience diabetes-related distress. Additionally, injection technique is crucial for the management of diabetes, and lipohypertrophy is a common side effect which deserves further attention.Objectives: The overall aim of this thesis was to evaluate a behavioural medicine intervention among poorly controlled adult type 1 diabetes patients, and to gain a deeper knowledge in an area of diabetes self-management.Methods: Quantitative design was used for the studies, and the clinical settings comprised two diabetes care units in Stockholm, Sweden. Study I: The Swedish version of the Problem Areas in Diabetes (Swe-PAID-20) scale was evaluated regarding its psychometric properties by type 1 diabetes patients, as well as by an expert panel of diabetes specialist nurses. Study II: A behavioural medicine intervention based on Cognitive Behaviour Therapy (CBT) was evaluated in a randomised controlled trial among poorly controlled adult type 1 diabetes patients. Study III: Using the same sample as in study II, descriptive statistics were produced, and predictive and comparative analyses performed, in order to find predictors of or associations with improvements in glycaemic control as a response to the intervention. Study IV: In a randomised crossover trial insulin absorption in lipohypertrophic injection sites was investigated in type 1 diabetes patients.Results and conclusions: Study I: A three-factor solution of the scale was found, comprising sub-dimensions of diabetes-related emotional problems, treatment-related problems and support-related problems. Cronbach’s alpha for the total score was 0.94 and varied between 0.61 and 0.94 in the three subscales. The findings also supported the convergent and content validity. The Swe-PAID-20 seems to be a reliable and valid outcome for measuring diabetes-related distress in type 1 diabetes patients. Study II: Significant differences were observed with respect to HbA1c, well-being, diabetes-related distress, frequency of blood glucose testing, fear of hypoglycaemia, perceived stress, and depression, all of which improved more in the intervention group compared with the control group. The CBT based behavioural medicine intervention appears to be a promising approach to diabetes self-management. Study III: The participation rate in the study was 41% and attrition was 24%. Of those patients who actually participated in the intervention, 13% withdrew. From the regression models no predictors or associations were found with regard to improvement in HbA1c. The programme proved to be feasible in terms of design and methods. However, no clear pattern was found regarding predictors of or associations with improved metabolic control. Study IV: Impairment of insulin absorption from lipohypertrophic injection sites was also found with analogue insulins. It is suggested that patients should be advised to refrain from injecting insulin aspart into lipohypertrophic subcutaneous tissue.
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| 5. |
- Amsberg, Susanne, et al.
(författare)
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The psychometric properties of the Swedish version of the Problem Areas in Diabetes Scale (Swe-PAID-20) : scale development
- 2008
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Ingår i: International Journal of Nursing Studies. - : Elsevier BV. - 0020-7489 .- 1873-491X. ; 45:9, s. 1319-28
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Considering the importance of psychological aspects in the management of diabetes, there is a need of validated measurements in this area. Such tools make it possible to screen patients for specific conditions as well as they serve as reliable measures when evaluating medical, psychological and educational interventions. OBJECTIVES: The current study was conducted to adapt the Problem Areas in Diabetes Scale for use among Swedish-speaking patients with type 1 diabetes and to evaluate the psychometric properties. DESIGN: Methodological research design was used in this study. SETTING AND PARTICIPANTS: A convenience sample of 325 type 1 diabetes patients was systematically selected from the local diabetes registry of a university hospital in Stockholm, Sweden. METHODS: Following the linguistic adaptation using the forward-backward translation method, the 20-item PAID was answered by the selected patients. Statistics covered exploratory factor analysis, Cronbach's alpha, convergent validity and content validity. RESULTS: In the factor analysis a three-factor solution was found to be reasonable with the sub-dimensions diabetes-related emotional problems (15 items), treatment-related problems (2 items) and support-related problems (3 items). Cronbach's alpha coefficient for the total score was 0.94 and varied between 0.61 and 0.94 in the three subscales. The findings also gave support for the convergent and content validity. CONCLUSIONS: The Swedish version of the Problem Areas in Diabetes Scale (Swe-PAID-20) seems to be a reliable and valid outcome for measuring diabetes-related emotional distress in type 1 diabetes patients.
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| 6. |
- Anderbro, Therese, et al.
(författare)
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Beliefs and Experiences of Fear of Hypoglycemia and Use of Uncooked Cornstarch before Bedtime in Persons with Type 1-Diabetes
- 2018
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Ingår i: Open Journal of Nursing. - : Scientific Research Publishing, Inc.. - 2162-5336 .- 2162-5344. ; 8:11
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Tidskriftsartikel (refereegranskat)abstract
- Among persons living with type 1-diabetes hypoglycemia and fear of hypoglycemia remain limiting barriers for achieving optimal glucose control and a good quality of life. Fear of hypoglycemia has been found stable over time if not treated. Uncooked cornstarch has been found to reduce the risk of hypoglycemia but has not been studied in relation to fear of hypoglycemia. The aims of this study were to through clinical data, self-reported measures and clinical interviews explore subjects’ experience of using uncooked cornstarch before bedtime and their beliefs and experiences of fear of hypoglycemia. Methods: Mixed methods with both quantitative and qualitative data were used. Self-reported measures of hypoglycemia and fear of hypoglycemia were compared to subjects’ responses during a clinical interview. The interviews were analyzed with a functional behavior analytical approach. Results: A total of five subjects took part in the study. One subject perceived the uncooked cornstarch helpful in reducing hypoglycemia. Several subjects could recall frightening hypoglycemic episodes triggering their fear. Three out of the five subjects reported avoidance behaviors such as excessive self-monitoring of blood glucose or overeating related to fear of hypoglycemia. Conclusions: The uncooked cornstarch was found appetizing but was not perceived as having an effect on BG or hypoglycemia frequency. The clinical interviews confirmed previous research regarding experience of hypoglycemia and fear of hypoglycemia.
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| 7. |
- Anderbro, Therese Carin, et al.
(författare)
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A longitudinal study of fear of hypoglycaemia in adults with type 1 diabetes
- 2018
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Ingår i: Endocrinology, Diabetes & Metabolism. - : Wiley. - 2398-9238 .- 2057-3316. ; 1:2
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Tidskriftsartikel (refereegranskat)abstract
- Aims: To investigate fear of hypoglycaemia (FoH) longitudinally in a cross‐sectional study of adult patients with type 1 diabetes. Specifically, we investigated two subgroups of patients who over 4 years either showed a substantial increase or decrease in level of FoH to identify factors associated with changes in FoH.Methods: The Swedish version of the Hypoglycaemia Fear Survey (HFS) along with a questionnaire to assess hypoglycaemia history was sent by mail to 764 patients in 2010. The responders in 2010 (n = 469) received another set of the same two questionnaires in 2014. HbA1c, insulin regimen, weight and creatinine from 2010 and 2014 were obtained from medical records. Those with an absolute difference in HFS scores ≥ 75th percentile were included in the subgroup analyses. Statistical analyses included one‐sample t tests, chi‐square and McNemar's test.Results: The absolute difference in the HFS total score (n = 347) between 2010 and 2014 was m = ±7.6, SD ± 6. In the increased FoH group, more patients reported a high level of moderate hypoglycaemic episodes as well as impaired awareness of hypoglycaemia in 2014 compared with the decreased FoH group. There were more subjects in the increased FoH group with insulin pumps in 2014 and in 2010. In the decreased FoH group, more patients had a high frequency of daily self‐monitoring of blood glucose (SMBG) in 2010 and in 2014.Conclusions: Fear of hypoglycaemia is stable across time for most patients. Changes in fear level are associated with changes in hypoglycaemia frequency. Thus, asking patients about changes in hypoglycaemia experiences is of great importance.
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| 8. |
- Anderbro, Therese, et al.
(författare)
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Fear of hypoglycemia : relationship to hypoglycemic risk and psychological factors
- 2014
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Ingår i: Acta Diabetologica. - : Springer Science and Business Media LLC. - 0940-5429 .- 1432-5233.
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE: The major aims of this study were to examine (1) the association between fear of hypoglycemia (FOH) in adults with type 1 diabetes with demographic, psychological (anxiety and depression), and disease-specific clinical factors (hypoglycemia history and unawareness, A1c), including severe hypoglycemia (SH), and (2) differences in patient subgroups categorized by level of FOH and risk of SH.RESEARCH DESIGN AND METHODS: Questionnaires were mailed to 764 patients with type 1 diabetes including the Swedish translation of the Hypoglycemia Fear Survey (HFS) and other psychological measures including the Perceived Stress Scale, Hospital Anxiety and Depression Scale, Anxiety Sensitivity Index, Social Phobia Scale, and Fear of Complications Scale. A questionnaire to assess hypoglycemia history was also included and A1c measures were obtained from medical records. Statistical analyses included univariate approaches, multiple stepwise linear regressions, Chi-square t tests, and ANOVAs.RESULTS: Regressions showed that several clinical factors (SH history, frequency of nocturnal hypoglycemia, self-monitoring) were significantly associated with FOH but R (2) increased from 16.25 to 39.2 % when anxiety measures were added to the model. When patients were categorized by level of FOH (low, high) and SH risk (low, high), subgroups showed significant differences in non-diabetes-related anxiety, hypoglycemia history, self-monitoring, and glycemic control.CONCLUSION: There is a strong link between FOH and non-diabetes-related anxiety, as well as hypoglycemia history. Comparison of patient subgroups categorized according to level of FOH and SH risk demonstrated the complexity of FOH and identified important differences in psychological and clinical variables, which have implications for clinical interventions.
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| 9. |
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| 10. |
- Anderbro, Therese, et al.
(författare)
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Psychometric evaluation of the Swedish version of the Hypoglycaemia Fear Survey
- 2008
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Ingår i: Patient Education and Counseling. - : Elsevier BV. - 0738-3991 .- 1873-5134. ; 73:1, s. 127-31
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE: The objective of this study was to evaluate the psychometric properties of the Swedish version of the Hypoglycaemia Fear Survey (Swe-HFS) for use among Swedish-speaking patients with type 1 diabetes. METHODS: The HFS was translated using the forward-backward translation method and was thereafter answered by 325 type 1 patients. The psychometric properties were investigated using exploratory factor analysis, Cronbach's alpha, content and convergent validity. RESULTS: The factor analysis showed that a three-factor solution was reasonable with the subscales Behaviour/Avoidance (10 items), Worry (6 items) and Aloneness (4 items). Cronbach's alpha coefficient for the total score was 0.85. The result also supports the instrument's content validity and convergent validity. CONCLUSION: The Swedish version of the HFS appears to be a reliable and valid instrument for measuring fear of hypoglycaemia (FoH) in type 1 patients. PRACTICE IMPLICATIONS: The results from this study suggest that the Swe-HFS, an instrument that is brief and easy to administer, may be valuable in clinically assessing FoH among patients with type 1 diabetes.
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| 11. |
- Guldstrand, Marie, et al.
(författare)
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Alteration of the counterregulatory responses to insulin-induced hypoglycemia and of cognitive function after massive weight reduction in severely obese subjects
- 2003
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Ingår i: Metabolism, Clinical and Experimental. - 1532-8600. ; 52:7, s. 900-907
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Tidskriftsartikel (refereegranskat)abstract
- The autonomic nervous system (ANS) and hypothalamic-pituitary-adrenal (HPA) axis are reported as activated in excess in the morbidly obese state and, therefore, changes after weight loss can be anticipated. The aim of this study was to investigate the impact of a massive (similar to30%) weight reduction on the activation of the HPA axis and the ANS following bariatric surgery. Eight (7 women, 1 man) severely obese (125 +/- 12 kg; body mass index [BMI], 45 +/- 4 kg/m(2)) nondiabetic subjects, underwent a 3-hour hyperinsulinemic (1,034 pmol/kg/h) glucose clamp study at hypoglycemia of arterial B-glucose concentration of 3.4 mmol/L. Cognitive function was evaluated by a visuospatial computerized problem-solving test, the Perceptual Maze Test (PMT). The mean weight loss was 40 +/- 9 kg approximately 12 months postsurgery when their weight was stabilized (85 6 kg; BMI, 31 +/- 3 kg/m(2)), and insulin sensitivity improved to an average increase of 376% +/- 250% (P < .01) of initial value. Before weight reduction, all patients demonstrated brisk peak responses in glucagon, epinephrine, pancreatic polypeptide (PP), norepinephrine, and cortisol, indicative of preserved or exaggerated activation of ANS and HPA axis. In the reduced-obese state, all these responses were attenuated and most markedly so for glucagon, which was totally abolished. In contrast, the growth hormone (GH) response was increased after weight reduction. The cognitive function was clearly modified by weight reduction both during normoglycemia and hypoglycemia and was changed preferentially to a speed-preferring strategy in the reduced-obese state compared with a more accuracy preferred problem-solving process of PMT test presurgery. These results demonstrate a reduction of the glucose counterregulatory hormonal responses, increased insulin sensitivity, and perturbed cognitive function after massive weight reduction. It may be speculated on if the increased insulin sensitivity and reduced counterregulation to hypoglycemia could predispose to low plasma glucose concentrations.
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| 12. |
- Johansson, Unn-Britt, et al.
(författare)
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A morning dose of insulin glargine prevents nocturnal ketosis after postprandial interruption of continuous subcutaneous insulin infusion with insulin lispro
- 2007
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Ingår i: Diabetes & Metabolism. - : Elsevier BV. - 1262-3636 .- 1878-1780. ; 33:6, s. 469-71
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Tidskriftsartikel (refereegranskat)abstract
- AIM: The aim of this crossover trial was to evaluate the potential of partial substitution of basal insulin with glargine, administered once daily in the morning, to protect against nocturnal ketosis after postprandial interruption of continuous subcutaneous insulin infusion (CSII). METHODS: Seven patients with type 1 diabetes received 4 weeks of treatment with insulin lispro, administered by CSII, and 4 weeks of treatment with CSII and a partial basal replacement dose of insulin glargine administered in the morning. On day 28 of each treatment phase, patients were admitted to the research unit where dinner was served and their usual dinner insulin bolus dose given, after which CSII was discontinued at 7 pm. Plasma (p) beta-hydroxybutyrate and p glucose were measured every hour for 12 h thereafter. RESULTS: Plasma beta-hydroxybutyrate at 7 pm was 0.16+/-0.05 and 0.13+/-0.07 mmol/l with and without glargine, respectively, and increased to 0.17+/-0.10 and 0.60+/-0.3 mmol/l within 6 h (P=0.02). Plasma glucose increased without glargine, from 8.6+/-2.9 to 21.1+/-3.0 mmol/l (P=0.003), but did not rise significantly following glargine (13.6+/-4.7 vs. 12.6+/-5.6 mmol/l; P=0.65). CONCLUSIONS: Partial replacement with a morning dose of insulin glargine protects against the development of ketosis for as much as 12 h after postprandial interruption of CSII. This treatment strategy could, therefore, be useful for patients who are prone to ketosis but, for other reasons, are deemed suitable for CSII.
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| 13. |
- Johansson, Unn-Britt, et al.
(författare)
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A paracetamol-pasta test for assessing gastric emptying in healthy and diabetic subjects
- 2003
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Ingår i: Scandinavian Journal of Clinical and Laboratory Investigation. - : Informa UK Limited. - 0036-5513 .- 1502-7686. ; 63:2, s. 159-66
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Tidskriftsartikel (refereegranskat)abstract
- Previous studies have shown that the relationship between gastrointestinal symptoms and gastric emptying is weak. Therefore the quantitative assessment of gastric emptying with a relatively simple, non-invasive test would be of considerable clinical value in insulin-treated diabetic patients to identify those with disturbed gastric emptying. The aim of this investigation was to evaluate the inter- and intra-subject variability of a paracetamol-pasta test in healthy subjects and in IDDM patients. Eighteen healthy subjects (8 women) with a mean age of 37 years (range 19-68) and 19 IDDM patients (10 women) with a mean age of 48 years (range 25-62) and mean duration of diabetes of 28 years (range 6-52) were studied on two occasions with an interval of 1 to 4 weeks. After an overnight fast the subjects ingested a standardized pasta meal mixed with 2 g paracetamol in a period of 15 min. Blood samples were drawn at regular intervals after meal intake and analysed for paracetamol (P) and blood glucose. The serum levels of P were significantly lower at 15 min in diabetic patients. The intra-subject coefficients of variation (CV%) of the areas under the serum paracetamol concentration-time curve (AUC) were almost identical in healthy and diabetic subjects, while the intra-subject CV of the P-Tmax was considerably lower in diabetic patients as well as markedly lower than the corresponding inter-subject CV. The inter-subject CVs of all parameters calculated were generally higher in diabetic patients. This study indicates that the assessment of paracetamol absorption kinetics during a paracetamol-pasta test is reproducible in healthy as well as in diabetic subjects. Diabetic patients with non-optimal glucose control and without a case history indicating gastroduodenal motor function disturbances achieve lower serum concentration of P at 15 min and generally display a higher inter-individual variability indicative of subclinical disturbances of gastric emptying in this group of patients.
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| 14. |
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| 15. |
- Johansson, Unn-Britt, et al.
(författare)
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Patient management of long-term continuous subcutaneous insulin infusion
- 2005
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Ingår i: Journal of Advanced Nursing. - : Wiley. - 0309-2402 .- 1365-2648. ; 51:2, s. 112-8
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Tidskriftsartikel (refereegranskat)abstract
- AIM: This paper reports a study of patients' current practice with continuous subcutaneous insulin infusions, particularly with respect to the management of the pump. BACKGROUND: Successful implementation of continuous subcutaneous insulin infusion requires a motivated patient with a range of technical skills and self-management capabilities. The therapy should be prescribed, implemented and monitored by a skilled professional team familiar with it and capable of supporting the patient. METHODS: A questionnaire was mailed to 102 continuous subcutaneous insulin infusion treated patients at a Swedish university hospital with experience of pump treatment for at least 6 months. RESULTS: The questionnaire was answered by 88% of the patients, 53 women and 37 men, aged 22-71 years with a duration of continuous subcutaneous insulin infusion use of between 7 months and 19 years. The changing interval for soft infusion set ranged from 2.0 to 10.0 days (mean 4.8) and for metal needles from 1.5 to 7.5 days (mean 3.8), P = 0.001. Catheter occlusions were significantly more often reported in patients with presence of bleeding at the infusion site (P = 0.011) and among those using insulin lispro (P = 0.032). CONCLUSIONS: Patients having long-term continuous subcutaneous insulin infusion should be carefully audited with respect to the management of the insulin pump and its accessories. In patients who frequently experience problems, shorter intervals between changes of infusion sets are strongly advocated and type of insulin preparation may be of importance in some cases.
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