Which are the insulin treatment regimens used in France? The "Schema survey".

OBJECTIVE: To examine how insulin therapy is used in France under real life conditions for type 1 and insulin-treated type 2 patients. MATERIAL AND METHODS: The "Schema survey" was a cross-sectional survey carried out for all the insulin-treated patients seen by participating physicians on a given day. All registered diabetologists in France were invited to participate, 934 initially agreed, 450 returned at least one questionnaire. These 450 physicians appeared to be representative of the whole. The reasons for which 484 physicians who had initially agreed to participate did not were collected by telephone and do not seem to introduce a bias. 1,263 patients were included in the analysis, type 1: 57.6%, type 2: 36.8%. RESULTS: Over 54% of type 1 patients were treated with 3 or more insulin injections per day. Among type 1 patients treated with 2 injections per day, 30% were younger than 18. Over 82% type 2 patients were treated with 1 or 2 insulin injections per day. A regimen combining oral agents and bed time NPH was used in 18% of type 2 patients. Premixed insulins were used by 45.5% of type 2 and 39.5% of type 1 patients. For patients under 3 or more injections per day, over 30 different regimens were identified. About 40% of patients, either type 1 or 2, were poorly controlled (HbA1c > 8.5%). The frequency of blood glucose monitoring appears to comply with recommendations. CONCLUSIONS: Under real life conditions, a majority of French type 1 patients are treated with intensified multiple injections but a lot are not, despite inadequate metabolic control. Only few type 2 patients are treated with intensified therapy.

Effects of clinical audit on the quality of care in patients with type 2 diabetes: results of the DIABEST pilot study.

OBJECTIVE: To improve the quality of diabetes care in general practice by the use of audit. MATERIAL AND METHODS: A prospective multicenter pilot study. Thirty-five groups of ten general practitioners (GPs) have been set up throughout France on a voluntary basis. These groups were led by a steering committee that includes a diabetologist and a GP. Each group established a consensus on healthcare standards and carried out 2 data collections over a 12-month period, with adoption of corrective measures between these 2 collections. RESULTS: 309 (90.4%) of the 342 practitioners completed the first data collection, assessing the management of 3,125 patients over a year. Less than half the groups have reached the 80% reference threshold for quality of care with regard to foot examination, microalbuminuria, ECG, fundoscopy and assessment of diet. The audit also found no intervention within one year in case of poor glucose control for 47% of patients, unsatisfactory quality of HbA(1c) measurement and insufficient resources for diet and education. 226 (66.1%) practitioners completed the second data collection assessing the management of 2,248 patients. Comparison between the two phases of the audit showed significant improvements for all the indicators of the process of care (p<0.001). Quality of HbA(1c) measurement and diet assessment by GPs progressed (p<0.01). Outcomes of care also improved with respect to the proportion of patients with HbA(1c)<=8% (p=0.007), fasting glycaemia<1.40 g/l (p=0.05) and SBP<140 mmHg (p=0.02). CONCLUSIONS: This pilot study confirms the feasibility of using clinical audit at the national level. It seems to be an effective measure to improve the management of patients with type 2 diabetes in primary care. It is intended that the large-scale DIABEST study will address this issue.

[Physical activity and management of obese patients]. / Activité physique et prise en charge des patients obèses.

Physical activity is recognized as an integral part of obesity treatment, in association with other therapeutic means. A major benefit of physical activity is the association with better long-term maintenance of weight loss. Physical activity has also positive psychological effects and increases quality of life. An evaluation of the usual level of physical activity and inactivity is needed for each patient. Physical activity counselling should be individualized and graded, in a perspective of individual progression. In subjects with massive obesity, remobilization based on physiotherapy techniques is the first step. All patients should be given simple advice to decrease sedentary behavior: use the stairs instead of the escalators, limit the time spent seated, etc. In general, current physical activity recommendations for the general population fit well with a majority of obese patients, i.e. a minimum of 30 minutes/day of moderate intensity physical activity (brisk walking or equivalent) on most, and preferably all, days of the week. Physical activities of higher intensities (endurance training programme) can be proposed on an individual basis. The type of physical activity required for long-term weight maintenance, and the question of adherence to physical activity recommendations in obese patients should be further investigated.

Intrathecal morphine and clonidine for coronary artery bypass grafting.

BACKGROUND: After cardiac surgery adequate postoperative analgesia is necessary. We assessed analgesia using intrathecal morphine and clonidine. METHODS: In a double-blind randomized study, 45 patients having coronary artery bypass graft surgery were allocated randomly to receive i.v. patient-controlled analgesia (PCA) morphine (bolus, 1 mg; lock-out interval, 7 min) (control group), either alone or combined with intrathecal morphine 4 microg kg(-1) or with both intrathecal morphine 4 microg kg(-1) and clonidine 1 microg kg(-1). Intrathecal injections were performed before the induction of general anaesthesia. Pain was measured after surgery using a visual analogue scale (VAS). We recorded i.v. PCA morphine consumption during the 24 h after operation. RESULTS: Morphine dosage [median (25th-75th percentiles)] was less in the first 24 h in the patients who were given intrathecal morphine + clonidine [7 (0-37) mg] than in other patients [40.5 (15-61.5) mg in the intrathecal morphine group and 37 (30.5-51) mg in the i.v. morphine group]. VAS scores were lower after intrathecal morphine + clonidine compared with the control group. Time to extubation was less after intrathecal morphine + clonidine compared with the i.v. morphine group [225 (195-330) vs 330 (300-360) min, P<0.05]. CONCLUSION: Intrathecal morphine and clonidine provide effective analgesia after coronary artery bypass graft surgery and allow earlier extubation.

Residual beta cell function in insulin-dependent diabetes: evaluation by circadian determination of C-peptide immunoreactivity.

Residual beta cell function was evaluated through circadian determination of C-peptide immunoreactivity (CPR) in eighty insulin-dependent diabetics. Evaluation of beta cell activity through circadian CPR determination was in good agreement with the results obtained by glucagon test which is considered a potent stimulus of C-peptide release. The prevalence of residual beta cell function in our population was 35%. Residual beta cell function was associated with a shorter duration of diabetes, a lower dose of insulin therapy and less chronic complications. On the other hand, serum growth hormone circadian variations were more spread in diabetics without beta cell function. That is consistent with diabetes instability which has been reported more commonly insulin-dependent diabetics without beta cell function.