Nurse-led cardiovascular risk factor intervention leads to improvements in cardiovascular risk targets and glycaemic control in people with Type 1 diabetes when compared with routine diabetes clinic attendance.

AIM: To compare the effects of a dedicated cardiovascular risk factor clinic run by a nurse consultant with routine diabetes clinic attendance in achieving glycaemic and cardiovascular risk targets in patients with Type 1 diabetes. METHODS: Eighty-one patients (45 male, mean age 34.6 years, mean duration of diabetes 15 years) with an HbA(1c) ≥ 8% (64 mmol/mol) and at least one other risk factor for the development of cardiovascular disease were randomized to receive either routine care or intensive nurse-led cardiovascular risk factor intervention. HbA(1c) , non-fasting lipid profile, blood pressure, weight, BMI and insulin dose were recorded at baseline, 6, 12 and 24 months. RESULTS: At baseline there were no differences between the groups. At 12 months, there were significant improvements in the nurse-led cardiovascular risk factor group: HbA(1c) [10.1% (87 mmol/mol) vs. 9.3% (78 mmol/mol), P < 0.001], total cholesterol (5.8 vs. 4.3 mmol/l, P < 0.001), systolic blood pressure (127 vs. 115 mmHg, P < 0.001) and diastolic blood pressure (71 vs. 65 mmHg, P < 0.05). Improvements were maintained in all variables at 24 months except diastolic blood pressure. In the routine group, only total cholesterol improved significantly (5.8 vs. 5.2 mmol/l, P < 0.01) after 12 months and this was maintained at 24 months. CONCLUSION: A nurse consultant cardiovascular risk factor clinic has a beneficial effect on cardiovascular risk targets in Type 1 diabetes, probably attributable to the increased use of lipid-lowering and anti-hypertensive agents and this was maintained at 24 months. Glycaemic control also improved.

Nurse-led clinics for strict hypertension control are effective long term: a 7 year follow-up study.

AIMS: The primary aim was to assess long-term blood pressure in 110 patients with Type 2 diabetes who had achieved optimal blood pressure control during attendance at a protocol-based nurse-led hypertension intensive intervention clinic 7 years previously. The secondary aim was to assess modifiable cardiovascular risk factor status. METHODS: One hundred and ten patients who attended the clinic during 2000-2002 were selected to reattend to have their blood pressure measured to the same standard as it was during the intensive intervention clinic, by the same specialist nurse. Treatment details were recorded. RESULTS: Of the 110 patients, 36 (33%) had died; 69 (63%) of the remaining 74 patients were eligible to be contacted by letter; and 35 (51%) agreed to reattend. Age was 70 +/- 9 years; 21 (60%) were male; and the duration of diabetes was 17 +/- 7 years. Compared with 7 years previously, there was no difference in blood pressure control (systolic 130 +/- 17 vs. 131 +/- 16 mmHg, P = 0.62; diastolic 68 +/- 9 vs. 65 +/- 9 mmHg, P = 0.11). The number of patients with blood pressure <130/80 mmHg remained the same: 17 (49%) vs. 17 (49%; P > 0.99). During the 7 year period, 14 (40%) vs. 20 (57%) had macrovascular disease (P = 0.23), and 14 (40%) vs. 19 (54%) microvascular disease (P = 0.33). Thirteen (37%) vs. 18 (51%) were taking three or more antihypertensive drugs (P = 0.33), and 26 (74%) vs. 28 (80%) angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (P = 0.77). CONCLUSIONS: Optimal blood pressure control was sustained with no significant changes to antihypertensive medication, demonstrating the effectiveness of a protocol-based nurse-led clinic in achieving strict BP control.

Blood pressure measurement.

Blood pressure measurement is an essential clinical skill for all nurses. However, if the procedure is not followed carefully there is potential for error that can adversely affect patient management. Nurses performing blood pressure measurement should be appropriately trained and updated on the procedure and the correct use of equipment. This article outlines the procedure for measuring blood pressure using a conventional mercury or aneroid sphygmomanometer and an electronic blood pressure monitor. It also identifies potential sources of error.

Capillary blood glucose monitoring.

This article, the first in a series of articles relating to clinical skills in nursing, outlines the procedure of capillary blood glucose monitoring. This is a convenient way of monitoring blood glucose patterns and can be a useful aid in guiding treatment changes in patients with type 1 and type 2 diabetes, especially during periods of illness or frequent hypoglycaemia.

Abnormal heart rate variability in adults with growth hormone deficiency.

GH-deficient (GHD) patients have increased risk of cardiovascular death and may have cardiac structural abnormalities. In non-GHD patients these are associated with cardiac autonomic dysfunction, and it is possible that autonomic dysfunction is also present in GHD patients. Power spectral analysis (PSA) of heart rate variability (HRV) indirectly measures cardiac autonomic tone and generates peaks at 3 frequency bands, very low frequency (VLF), low frequency (LF) and high frequency (HF). The area under the LF curve is considered to reflect predominantly cardiac sympathetic activity, whereas HF indicates parasympathetic activity. PSA of HRV was performed in 14 normotensive GHD patients (5 men and 9 women; mean age, 35.2 yr) and 19 healthy controls (9 men and 10 women; mean age, 38.3 yr). GHD patients had 26% lower normalized LF power (P < 0.004), 39% higher normalized HF power (P < 0.001), 28% lower normalized VLF power (P < 0.046), and 51% lower LF/HF ratio (an index of sympathovagal balance; P < 0.001) compared to controls. These data indicate that heart rate variability is abnormal in patients with GHD. The decreased sympathetic tone could be a consequence of reduced central sympathetic tone or altered cardiac responsiveness to autonomic control and may contribute to the increased cardiovascular risk in GHD patients.

Apo E phenotype and changes in serum lipids in adult patients during growth hormone replacement.

OBJECTIVE: To determine whether apo E phenotype influences changes in lipid profiles induced by growth hormone replacement in growth hormone (GH)-deficient adults. DESIGNS: Patients were treated for 6 months with recombinant human GH (hGH), given in a dose of 0.125 U/kg per week for 4 weeks followed by 0.25 U/kg per week thereafter. The effects on serum lipids and the influence of apo E phenotype were examined. METHODS: Thirty patients (aged 35.1+/-11.8 years: mean +/- S.D.) with adult growth hormone deficiency with included in the study. Fasting serum samples were analysed for apo E phenotype total cholesterol, high-density lipoprotein (HDL)-cholesterol, triglycerides, lipoprotein (a) (Lp(a)) and IGF-I. Low-density lipoprotein (LDL)-cholesterol was calculated using the Friedwald formula. RESULTS: Six months of replacement treatment with hGH resulted in a reduction in HDL-cholesterol from 0.90+/-0.10 to 0.68+/-0.08 mmol/l (P<0.01), and a small, non-significant reduction in total cholesterol from 6.14+/-0.40 to 5.99+/-0.35 mmol/l (P = 0.06). There was no significant change in the other lipid parameters. The decrease in HDL-cholesterol concentration was greater in patients carrying the apo E2 allele (0.40+/-0.07 mmol/l, P<0.05) than in patients homozygous for the apo E3 allele (0.23+/-0.04 mmol/l) and patients carrying the apo E4 allele (0.15+/-0.36 mmol/l). Patients with the apo E4 allele had lower baseline cholesterol concentrations than patients lacking the apo E4 allele, and this persisted after treatment with hGH (P<0.05). CONCLUSIONS: Apo E phenotype may be a determining factor in the response of HDL-cholesterol to hGH in GH-deficient adults.

Glycaemic control in a type 1 diabetes clinic for younger adults.

BACKGROUND: In the Diabetes Control and Complications Trial (DCCT, 1993) tight diabetes control (HbA1c <7%) was associated with significantly less microvascular complications compared to 'conventionally' treated type 1 patients. AIM: To assess the effectiveness of a dedicated young-adult type 1 diabetes clinic in achieving HbA1c levels <7% between 1991 and 2001. DESIGN: Retrospective review of case-notes. METHODS: All patients who attended the clinic in the first six years (1991 to 1996) were studied. All were offered at least two appointments per year. Case-notes were reviewed up to December 2001. RESULTS: We treated 386 type 1 patients (59.8% male, mean age 28.7 years, mean duration diabetes 9.5 years). After a mean follow-up of 7.7 years, 261 (67.6%) had attended in the past 2 years, 22 (5.8%) were known to have died, 11 (2.8%) had transferred to another clinic and 92 (23.8%) had repeatedly failed to attend appointments for 2 years. Over 11 years, the total mean (SD) HbA1c was 9.19% (1.3). Only 3.4% of patients achieved an average HbA1c of <7% during the study period, and 80% of patients had average HbA1c levels of >8%. DISCUSSION: Despite regular specialist physician, specialist diabetes nurse and dietician input, encouragement of multiple daily insulin injections and repeatedly following-up failed appointments (including home visits), fewer than 1:20 patients achieved the DCCT target of mean HbA1c <7%. Tight diabetes control is rare in a routine clinic setting.

Diabetic peripheral neuropathy and quality of life.

The quality of life (QOL) of 79 people with type 1 and type 2 diabetes and 37 non-diabetic controls was assessed using the Nottingham Health Profile (NHP). The NHP consists of six domains assessing energy, sleep, pain, physical mobility, emotional reactions and social isolation. Symptomatic diabetic neuropathy was present in 41 of the patients. The neuropathy patients had significantly higher scores (impaired QOL) in 5/6 NHP domains than either the other diabetic patients (p < 0.01) or the non-diabetic (p < 0.001) controls. These were: emotional reaction, energy, pain, physical mobility and sleep. The diabetic patients without neuropathy also had significantly impaired QOL for 4/6 NHP domains compared with the non-diabetic control group (p < 0.05) (energy, pain, physical mobility and sleep). This quantification of the detrimental effect on QOL of diabetes, and in particular of chronic symptomatic peripheral diabetic neuropathy, emphasizes the need for further research into effective management of these patients.

Intensified treatment of type 2 diabetes--positive effects on blood pressure, but not glycaemic control.

BACKGROUND: Since publication of the UK Prospective Diabetes Study (UKPDS) in 1998, there has been a clear evidence base for tight glycaemic (HBA(1c) < 7.0%) and blood pressure (BP < 140/85 mmHg) control. AIM: To determine the effect of UKPDS-based intensified glycaemic and BP targets on the care of type 2 diabetic patients attending a routine diabetes clinic. DESIGN: Two surveys, each of 500 consecutively attending type 2 diabetic patients. METHODS: The first survey was in a 3-month period in 1999, shortly after publication of the UKPDS study. The second was identical, but 2 years later. Glycaemic control (by DCCT-aligned HBA(1c)), BP and treatment details were recorded in both. RESULTS: BP control was significantly improved in the second survey (mean +/- SD systolic BP from 151 +/- 25 to 146 +/- 26 mmHg, p = 0.001; diastolic from 77 +/- 13 to 72 +/- 12 mmHg, p < 0.0001) and the proportion of patients on anti-hypertensive treatment increased from 33% to 60% (p < 0.0001). Mean HbA(1c) however remained unchanged (8.7 +/- 1.8% in 1999 vs. 8.5 +/- 1.8% in 2001), although there was evidence of more intensive treatment patterns, with declining numbers on diet alone and more on oral agents and/or insulin. DISCUSSION: Intensified BP control may be achievable within the confines of routine diabetes care, but achievement of optimal glycaemic targets remains problematic.

How accurate is the smoking history in newly diagnosed diabetic patients?

A smoking history was obtained from 94 consecutive newly diagnosed diabetic patients referred to an adult diabetic clinic. The smoking load was measured using urinary cotinine/creatinine ratios (COT/Cr). Fifty-six patients (60%) claimed to be non-smokers, but COT/Cr suggested active smoking in five of these. The patients who admitted to smoking were given standardised anti-smoking advice. At 3 months, 32 smoking patients were reviewed and 21 (66%) claimed to have reduced or stopped smoking. However, the median COT/Cr in the 32 patients showed no significant reduction (11.15 vs. 9.30 micrograms/mg). Urinary COT/Cr indicated that 6 patients had stopped smoking (median COT/Cr 6.98 fell to 0.97 micrograms/mg), but several patients had a marked rise in COT/Cr, demonstrating that their smoking habit had increased considerably. Therefore the smoking history obtained from new diabetic patients can be very misleading. An objective measure of smoking habits in the initial assessment and follow-up of diabetes may be worthwhile. Anti-smoking counselling at diagnosis of diabetes may persuade some smokers to stop.

Growth hormone deficiency in adults.

This article describes growth hormone deficiency in adults. The causes and clinical features are explained and the article looks at treatment approaches, their effects and the role of the nurse.

The outcome of brittle type 1 diabetes--a 20 year study.

AIMS: To determine the long-term (20 years from presentation) outcome of brittle type 1 diabetes characterized by recurrent episodes of ketoacidosis (DKA). METHODS: The cohort studied was a group of brittle diabetic patients from various parts of UK originally identified between 1979 and 1985. Patients were traced, where possible, via their diabetic clinics and/or general practitioners. Data on survival or otherwise were obtained from hospital case notes and information from diabetes care team members. For survivors, clinical and demographic information obtained included complication status and whether they still had brittle characteristics. They were also compared with a matched case-control group of type 1 patients with no history of brittle behaviour. RESULTS: The original cohort comprised 33 patients- all female and mean ± SD, aged 18 ± 5 years and diabetes duration 8 ± 4 years. Thirteen were not traceable and 10 of the remaining 20 (50%) had died during the mean 22 years of follow-up. Deaths occurred evenly throughout the period, and causes were chronic renal failure (3), DKA (3), hypoglycaemia (2), subarachnoid haemorrhage (1) and uncertain (1). Age at death ranged from 27 to 45 years. Of the 10 survivors, none remained brittle, but they had a substantial burden of complications. Compared with the non-brittle control group, there was a significant excess of nephropathy and autonomic neuropathy. CONCLUSION: We conclude that brittle diabetes characterized by recurrent DKA has high long-term outcome mortality. These deaths were premature and almost all diabetes related. Those who survived had resolution of brittleness, but suffered a significant complication burden.

Aerobic fitness and hand grip strength in Type 1 diabetes: relationship to glycaemic control and body composition.

AIM: To clarify the relationship of aerobic fitness and handgrip strength with glycaemic control (HbA1c), body composition and lipid profile in Type 1 diabetes. METHODS: Aerobic capacity (Chester Step Test), handgrip strength and body composition (bioelectrical impedance) were measured in 141 patients with Type 1 diabetes. RESULTS: Aerobic capacity correlated positively with HbA1c and lean body mass and negatively with body mass index and fat mass. Handgrip strength correlated positively with aerobic capacity and negatively with HbA1c and fat mass. In addition, there was a positive correlation between HbA1c and total cholesterol. CONCLUSION: Patients with Type 1 diabetes who have good aerobic capacity have poorer glycaemic control. However, this was an observational study and the results must be interpreted with caution. Further investigation into how these patients manage blood glucose during exercise is required.

Successful cardiovascular risk reduction in Type 2 diabetes by nurse-led care using an open clinical algorithm.

AIM: To implement a protocol-driven, nurse-led cardiovascular risk reduction clinic using an open clinical algorithm. The primary aim of the clinic was to optimize blood pressure (BP) control; secondary aims were to reduce modifiable cardiovascular risk factors. METHODS: We studied 110 people with Type 2 diabetes attending a diabetes out-patient centre at University Hospital Aintree, Liverpool. Patients taking one or more antihypertensive drugs were selected for referral to the nurse-led clinic if BP was > 140/85 mmHg; there was no age threshold. An open clinical algorithm was designed to direct the nurse on the use of antihypertensive, statin and aspirin therapy plus lifestyle advice and concordance. RESULTS: Thirty-one percent of patients attending for a first visit to the nurse-led clinic had BP within target when measured to British Hypertension Society standards out of the consultant clinic. Mean BP was 150/76 mmHg compared with 178/88 mmHg (P < 0.001). Subsequently, BP was reduced to 130/68 mmHg (P < 0.001), this reduction being sustained at review 9 months later (mean BP 133/67 mmHg), with 87 (79%) achieving BP

Improved glycaemic control--an unintended benefit of a nurse-led cardiovascular risk reduction clinic.

AIMS: One hundred and ten patients with Type 2 diabetes were referred into a nurse-led cardiovascular risk reduction clinic. The primary aim of the clinic was to optimize blood pressure (BP) control and address cardiovascular risk factors. METHODS: Those attending outpatient clinics were referred into a nurse-led cardiovascular risk reduction clinic if BP was above 140/85 mmHg. There was no intervention strategy designed in the nurse clinic protocol to improve glycaemic control. RESULTS: Following attendance at the clinic, there was a significant improvement in HbA1c noted when patients were reviewed 9 months later. HbA1c improved from 8.7 +/- 1.6 to 8.1% +/- 1.6% (P < 0.001) in the whole cohort. Further analysis showed that, after excluding those who had received intervention to improve glycaemic control from another source, during the same period there remained a significant improvement in the non-intervention group of patients. CONCLUSION: Frequent regular contact and health education in a nurse-led clinic to reduce cardiovascular risk may improve HbA1c in the absence of any specific intervention to improve glycaemic control.

Hospital in-patients with diabetes: increasing prevalence and management problems.

AIMS: To re-assess the prevalence, management problems, clinical outcomes and discharge summaries of hospital in-patients with diabetes. METHODS: Case records of all patients occupying in-patient beds were audited on a single weekday in 2003 in a large urban hospital and repeated after 3 months. Data was compared with an identical audit 12 years previously. RESULTS: Over 12 years the number of beds available for admission (1191) had reduced by 25% with a bed occupancy of 97%. Diabetes prevalence had increased from 7.0% to 11.1% (P < 0.01) (97% Type 2). Diabetes management was considered inappropriate in 29%, more than in 1991 (20%). After 3 months, discharge summaries had been completed on 75% of patients but diabetes was mentioned in only 53%. CONCLUSION: The prevalence of in-patient diabetes (11.1%) was over 50% greater and diabetes management was suboptimal in more patients than in 1991. In many length of stay was prolonged and almost half of the discharge summaries did not mention diabetes. These findings have major implications for service delivery and resource planning.

The quality of life of adults with growth hormone deficiency: comparison with diabetic patients and control subjects.

OBJECTIVE: Adults with GH deficiency (GHD) frequently report a poor quality of life (QOL). Whether this poor QOL is specifically due to hormone deficiency or a non specific effect of a chronic condition is not known. We therefore assessed QOL in adults with hypopituitarism and GHD and compared scores with a group of patients with diabetes mellitus, another life-long condition with potentially serious complications and a group of healthy controls. PATIENTS: We studied 57 patients with hypopituitarism and GHD (peak stimulated GH response < 9 mU/l) (23 male, mean age 36.4 years, mean stimulated GH response 2.3 mU/l), secondary to a variety of hypothalamic-pituitary disorders. Fifty had been treated surgically (39 cranial surgery, 11 transsphenoidal) and 37 had received external cranial irradiation involving the hypothalamic region. Fifty-seven age and sex matched patients with diabetes mellitus (31 insulin treated, 18 on oral hypoglycaemic agents, 8 on diet alone) and 57 matched healthy controls were also studied. DESIGN AND MEASUREMENTS: We assessed and compared health related QOL in the 3 groups using 4 self rating questionnaires: Hospital Anxiety and Depression Scale, Self Esteem Scale, Mental Fatigue Questionnaire and Life Fulfilment Scale. In addition the GHD and diabetic groups also completed the Disease Impact Scale. RESULTS: The GHD group reported significantly more depression (P < 0.05) and mental fatigue (P < 0.05) and significantly less self esteem (P < 0.05) and life fulfilment (P < 0. 05) than either the group with diabetes or the controls. Patients with GHD reported significantly higher anxiety scores (P < 0.05) than the controls. Within the GHD group there were no differences in QOL scores between patients with pituitary tumours (n = 24), craniopharyngiomas/hypothalamic tumours (n = 18) or other brain tumours. In addition there were no significant differences according to surgical treatment modality or radiotherapy. However subgroup analysis revealed that the patients who had undergone transsphenoidal surgery (n = 11) differed significantly from the control group in life fulfillment and depression (P < 0.01) only and did not differ from the DM group in any of the questionnaires used. There were no significant differences between the group with diabetes and the control group in any of the measures except depression (P < 0.05). CONCLUSIONS: This study revealed a significant impairment of QOL in adults with GHD, particularly those who had undergone cranial surgery, when compared to matched patients with diabetes and healthy controls.

Clinical presentation of thyroid dysfunction and Addison's disease in young adults with type 1 diabetes.

In a clinic population of 509 type 1 diabetic patients aged 16-45 years, 5.5% had received treatment for thyroid disorders (20 hypothyroid, three males; eight thyrotoxicosis, four males), and Addison's disease was present in four patients (0.8%, one male). In all patients, type 1 diabetes preceded the diagnosis of the other autoimmune disorder. The clinical presentation of hypothyroidism was usually insidious with few symptoms, although an increased frequency of hypoglycaemic symptoms and/or raised serum cholesterol levels often prompted thyroid function testing. In contrast, the patients with thyrotoxicosis had florid symptoms, weight loss (mean 8.12 kg), palpable goitres, increasing insulin requirements, and low cholesterol levels. Six patients did not achieve remission or had recurrent thyrotoxicosis after oral antithyroid treatment and required 131I or thyroid surgery. A family history of autoimmune disease was present in 25% of patients with thyroid disorders (seven thyrotoxic and one hypothyroid) and in three of the four patients with Addison's disease. In this population of young adult type 1 diabetic patients, appropriate tests for thyroid dysfunction and Addison's disease should be carried out if there is clinical suspicion and/or unexplained changes in diabetic metabolic control or serum cholesterol. Careful follow-up of patients with a family history of these conditions is recommended.

Trends in the smoking habits of young adults with diabetes.

OBJECTIVES: To examine changes in the prevalence of smoking in young adult diabetic patients between 1990 and 1999. SETTING: Walton Diabetes Centre, University Hospital Aintree, Liverpool, UK. DESIGN: Direct questioning as well as the urinary cotinine:creatinine ratio were used to assess the smoking habits of 99 young type 1 diabetic patients in 1991 (mean age 21.5 years, duration of diabetes 7.3 years), and in 112 similar patients in 1999 (mean age 23.4 years, duration of diabetes 9.6 years). RESULTS: The admitted smoking rate was 31/99 (31%) in 1990 compared with 31/112 (28%) in 1999 (not significant). However, in 1990 there were an additional 17 "covert" smokers (patients who denied smoking, but had an unequivocally raised urinary cotinine:creatinine ratio), but only three in 1999 (p<0.05). This gave a corrected validated smoking rate of 48/99 (48%) in 1990 and 34/112 (30%) in 1999, representing a significant fall (p<0.02). CONCLUSION: Smoking rates in young type 1 diabetic patients appear to have fallen during the last decade, and reporting of smoking behaviour is now more honest.

Nodules of fibrocollagenous scar tissue induced by subcutaneous insulin injections: a cause of poor diabetic control.

A 46 year old man with longstanding type 1 diabetes developed major weight loss and marked deterioration in diabetic control. He had been persistently injecting insulin into areas of abdominal lipohypertrophy within which hard collagenised fibrous tissue nodules had developed. Injecting insulin at different sites dramatically improved blood glucose control. Fibrocollagenous nodules induced by insulin injections have not been previously described. Examination of a further 73 type 1 patients revealed lipohypertrophy in 44% and hard subcutaneous nodules on two.