The evolution of diabetes information systems.

Diabetes information systems have already evolved rapidly in recent years along a developmental pathway initiated by the St Vincent Declaration, fuelled by the rapid pace of IT development in the 1990s and now endorsed by the emerging NHS information strategy. They will be central to the delivery of 'patient-centred' care and essential to supporting and monitoring the diabetes national service framework implementation. Widespread experience has identified three key principles. Firstly the need for a core data set that supports both service delivery and quality development. Secondly, because of the multiprofessional, multisector nature of diabetes care, there is a need to reconcile information from many diverse sources into unitary diabetes care records. Thirdly the crucial importance of making data collection a by-product of every day care delivery (i.e. no duplicate data entry). The work of many local innovators, allied to the increasing experience of the Diabetes UK sponsored UKDIABS project has generated substantial expertise. With the aid of new extraction/analysis tools such as QUIDS and a consistent approach to assessment, this work has hopefully laid secure foundations for monitoring the implementation of the national service framework. Furthermore, parallel developments under the aegis of the National electronic Library for Health (NeLH) should enable those involved with diabetes care to access relevant knowledge and information with ease. Increasingly user friendly ways by which patients can interact with their electronic records and linked knowledge sources will create many new opportunities. Diabetes information systems are likely to be at the forefront of diabetes care delivery in the future, providing patients and professionals with timely and accurate data for the organization and delivery of care.

A detailed examination of the clinical terms and concepts required for communication by electronic messages in diabetes care.

The wider electronic exchange of clinical information between heterogeneous information systems in the delivery of diabetes care demands a common structure in the form of a message standard. A European Standard electronic diabetes message is being developed in conjunction with CEN TC251. This paper describes the methodologies that the 1998 DO IT Workshop has used to identify potential areas of difficulty in the design and implementation of the preliminary message model. To facilitate implementation and to avoid ambiguity in electronic messaging it is particularly important that there is standardisation of the definitions of the clinical terms specifically used in diabetes care across systems. Comprehensive lists of such terms to describe all areas of diabetes care do not exist and there is a lack of harmonisation of definitions in many areas. Thus, to better understand the user requirements of diabetes messaging several approaches were adopted. A review of the clinical terms and concepts contained in pre-existing datasets was undertaken with detailed study of a number of specific areas of diabetes care, analysing the conceptual structure of all the clinical terms that they comprised. Consideration of several worst case clinical scenarios for messages to communicate was also made to identify deficiencies in the message structure. This activity confirmed the importance of creating a Standard for a superset or thesaurus of diabetes specific terms, with appropriate definitions, to harmonise data communication in different IT systems to facilitate messaging. A substantial number of new terms were identified in the workshop and these will form an important first step to accomplishing a first draft superset once fully analysed. It was also apparent that certain specific areas within diabetes care, but most particularly in nursing, dietetics and podiatry, need urgent work to further develop the concepts and terms. This needs to be facilitated for an appropriate group of such professionals. To achieve such a Standard, continued co-operation with CEN/ISSS was recognised to be very important.

Measurement of 8-Oxo-deoxyguanosine in Lymphocytes, Cultured Cells, and Tissue Samples by HPLC with Electrochemical Detection.

8-Oxoguanine is one of the most studied base oxidation products found in DNA. It has potential biological significance, because if present in DNA that is replicating, it can lead to incorporation of adenine rather than cytosine in the daughter strand. Thus it is considered as a premutagenic lesion. It occurs as a result of attack by reactive oxygen species released during the inflammatory response, and in small but significant amounts during normal respiration. The hydroxyl (OH) radical (arising from H(2)O(2) by the transition metal ion-catalyzed Fenton reaction within the nucleus) is most likely responsible for the formation of 8-oxoguanine. Analytical methods-gas chromatography with mass spectrometric detection (GC-MS) and high-performance liquid chromatography (HPLC) -were developed for quantitation of oxidized bases produced in experimental studies of radiation and chemical damage to DNA, and these methods were naturally also applied to the measurement of background levels of oxidized bases in cellular DNA (1). With GC-MS, very high levels of 8-oxoguanine have been reported, typically between 10 and 100 for every 10(5) normal guanines. It has recently been recognized that spurious oxidation of DNA readily occurs during isolation and hydrolysis of DNA, and derivatization of the bases for analysis. HPLC, normally applied to measurement of the nucleoside, 8-oxo-deoxyguanosine (8-oxo-dG), has generally given values below those obtained with GC-MS; but with HPLC, too, oxidation artefacts have been identified.

District diabetes registers: more trouble than they're worth?

Many areas in the UK are developing district-based diabetic registers with the anticipation that this will facilitate the call and recall of patients for regular reviews and thereby improve their quality of care, as well as provide data for many other uses, such as local healthcare planning and epidemiological research. But there are a clutch of unanswered questions which need attention. The ethical issues surrounding the consent and confidentiality of data on individuals are not resolved. There are practical problems which impede the collection and maintenance of complex data sets, especially if they are to include biomedical fields, and as yet no cost-effectiveness research which informs this debate. The argument that district registers may be the best way to demonstrate comprehensive diabetes services must not override two important concerns: firstly, where should the responsibility lie for monitoring silently damaging chronic illnesses--with patients, practices or districts, or all three? Secondly, if district level registers do become the accepted tools, let us not ignore the missing data field--that the quality of diabetic care is dependent more on the patient-doctor relationship than we want to acknowledge, or measure, however efficient our system. We conclude by observing that rudimentary registers are arriving in many areas, but the question remains--will diabetes registers aid the delivery of a high quality service for diabetes across the primary/secondary care interface? Truthfully, it is just too early to tell, and perhaps too late to ask?

Implementation and evaluation of a decision support system for type II diabetes.

A decision support system for the management of oral hypoglycaemic therapy in type II diabetes was evaluated. The ruleset contained therein forms the basis of a prototype computer programme, but in order to assess the robustness of the individual rules, it was decided it was necessary to use a paper-based form of the ruleset. A nurse with no previous experience of managing type II diabetes was trained to use the system and then undertook the exclusive management of half of all new type II diabetics, from a district population of 300,000, over a 16-month period. General practices within this area were divided into two groups, study and control, matching for size, geographical area and standards of existing diabetes care. Patients (n = 102) from the study group practices were then assigned to her care. Those patients (n = 116) in the control group of practices were treated according to their normal procedures. The decision support system for oral hypoglycaemic therapy was based on the following criteria: the current type of treatment (six levels); current glycaemic control (HbA1 and FBS)-whether improving, steady or worsening; and weight-%IBW, whether rising, steady or falling. Each of these parameters was carefully defined on the basis of established practice and clinical experience. Patients after initial education were seen at their usual clinic by the nurse only, on a monthly basis, until satisfactory glycaemic control was established and thereafter reviewed 3 monthly. She was also responsible for ensuring the organisation of Diabetes Annual Review procedures. The medical records of the control group patients were examined at the end of the study and data on glycaemic control and Annual Reviews extracted. In the study group 98% patients achieved HbA1 levels within the normal range and all patients had full annual reviews performed. The control practices achieved much poorer degrees of metabolic control (P < 0.01) and completed fewer annual reviews. The study group did not demonstrate a significantly increased frequency of clinical hypoglycaemia consequent upon better blood sugar control. No exceptions to the ruleset, as initially defined, were detected. In conclusion, this decision support system was successful at achieving standards of diabetes control and care equal to or better than conventional structures of diabetes care. Implementation of such a system, on a simple computer platform, could greatly assist and possibly improve diabetes management in general practice.

Creation of a District Diabetes Register using the DIALOG system.

A District Diabetes Register has been created using the Family Health Services Computer Unit system, DIALOG, linked to the Family Health Services Authority (FHSA) population register. Initial informal discussions between the Diabetes Centre, Public Health, and the FHSA led to a formal proposal being accepted by the Local Diabetes Services Advisory Group to pilot the DIALOG software. Following installation of DIALOG on a separate computer, electronically linked to the main FHSA system, the register was compiled. This was approached in three ways. The existing Diabetes Centre Register was downloaded into DIALOG and patients matched with the FHSA register. A 'diabetes roadshow' was mounted, with Postgraduate Education Allowance approval, to individually visit every general practice in the district to explain the aims and objectives of creating a diabetes register and to enlist the support of these practices. Where practices already held their own diabetes register this was similarly transferred, if not, assistance was provided to identify their patients with diabetes. All patients were notified in writing that their names were being placed upon a diabetes register and that clinical data would be held against their entry. This notification included an opportunity to opt out. Additionally, a self registrations scheme was introduced whereby all retail pharmacists dispensing any diabetes related product and all optometrists seeing a person with diabetes, gave the patient a leaflet, describing the register and its purposes and inviting them to register themselves. A 'Data Ownership Committee' was established to control the use and interpretation of all clinical data held upon the register. The process of diabetes annual review is now being prompted across both primary and secondary care and clinical data is being returned to the register.

DIALOG: co-ordination of the annual review process through a District Diabetes Register linked to the FHSA database.

A working party was established by the Population Screening Project Board (UK), in conjunction with the Family Health Services Computer Unit, in order to develop a system for diabetes care (DIALOG) that would create a District Diabetes Register and prompt the process of diabetes annual review across both primary and secondary care. To simplify the creation and maintenance of the Diabetes Register, DIALOG has been designed to interface with the Family Health Services Authority population register to enable realtime download of demographic data. The system will also accumulate clinical information for the continuing audit diabetes services according to the data items specified in the standard UK diabetes dataset and can deliver detailed statistical analyses. Data input can be manual or electronic. DIALOG has been created to complement and integrate with existing diabetes information systems in primary and secondary care; it is not intended to be a clinic management system. It has the potential to become a National Diabetes Register.

Strict nocturnal diabetic control diminishes subsequent glycemic escape during acute insulin withdrawal.

Five Type 1 (insulin dependent) diabetic patients with no endogenous insulin secretion and very low antiinsulin antibody levels (IBC less than 4%) were studied twice. Nocturnal plasma glucose was maintained by intravenous insulin just beyond each extreme of the normal range, either "hypoglycemic," at 2.71 +/- 0.03 mmol/L, or "hyperglycemic," 8.59 +/- 0.13 mmol/L. Glucose turnover measurements were performed before and after insulin was discontinued the following morning. The steady state plasma glucose concentration achieved during subsequent glycemic escape was significantly lower following nocturnal hypoglycemia, (16.1 +/- 0.3 v 20.2 +/- 0.03 mmol/L; P less than 0.01). The initial rate of rise of plasma glucose was identical in both groups. Free insulin levels, although significantly higher in the hypoglycemic study, before withdrawal, 24.3 +/- 6.0 v 13.3 +/- 0.8 mU/L, (P less than 0.01), fell to similarly low levels 1 hour after insulin withdrawal. Free fatty acid and total ketone concentrations were normalized during hypoglycemia, but remained elevated in the hyperglycemic group. Lactate concentrations were not different in the two studies. During glycemic escape glucose appearance rate (Ra) rose faster following hypoglycemia, but similar final rates were achieved in each group. When related to plasma glucose concentration glucose uptake (Rd) was normal following hypoglycemia and remained persistently greater than the hyperglycemic group throughout the 5 hours following insulin withdrawal. Plasma cortisol, pancreatic glucagon, and growth hormone levels were not significantly different in the two groups following withdrawal. It is suggested that the persistent normal glucose uptake, following glycemic control that has been sufficient to normalize plasma metabolites, will limit glycemic excursions caused by acute reductions in plasma-free insulin concentration.(ABSTRACT TRUNCATED AT 250 WORDS)

Pituitary Cushing's disease arising from a previously non-functional corticotrophic chromophobe adenoma.

Severe pituitary Cushing's disease of sudden onset after 18 years of unsuccessful treatment for a previously non-functioning chromophobe adenoma is described in a middle-aged woman. Initial presentation with symptoms of optic nerve compression had been preceded by two years of amenorrhoea. Transfrontal resection of a chromophobe adenoma followed by radiotherapy, performed both at this time and again after a recurrence eight years later, failed to eradicate the tumour. Ten more years elapsed before she rapidly developed florid features of Cushing's syndrome. Plasma ACTH levels were markedly elevated and were only partially reduced by further transfrontal surgery, complete removal of the tumour proving impossible. Subsequent bilateral adrenalectomy was performed to control her hypercortisolism and a course of cytotoxic chemotherapy was administered in an attempt to treat the tumour recurrence. Immunocytochemical staining of tumour obtained at surgery demonstrated ACTH immunoreactivity both before and after the development of Cushing's disease. Although silent corticotrophic adenomas of the human pituitary, including chromophobic tumours, have been previously described, this is the first report of such a tumour becoming functional, sufficient to cause clinically evident Cushing's disease.

The effect of selective and non-selective beta-adrenoceptor blockade, and of naloxone infusion, on the hormonal mechanisms of recovery from insulin-induced hypoglycaemia in man.

The rise in plasma adenosine-3',5'-monophosphate occurring in response to insulin induced hypoglycaemia in normal human subjects, was abolished by non-selective beta-adrenoceptor blockade but unaffected by selective beta 1-adrenoceptor blockade. This implies that the rise is secondary to beta 2-adrenoceptor stimulation. The abolition of this rise by non-selective beta-adrenoceptor blockade had no pronounced effect on the recovery from hypoglycaemia. Endogenous opiate receptor blockade with naloxone had no significant effect on the recovery from insulin induced hypoglycaemia, or the hormonal mechanisms involved.