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Don't Point the Finger Too Quickly
As a type 1 female who was diabetic throughout my teenage years (diagnosed at age 10), I don't feel that this article ("The Difference Between Boys and Girls: Study Finds More Adolescent Girls Hospitalized Than Boys," April 1998) accurately portrayed my teenage experience.
I had a terrible time keeping my blood sugars in control as a teenager and lived with blood glucose averaging in the 300s for five to six years. I missed one or two injections inadvertently in a year or two period, but I never intentionally skipped injections.
During this time, I found that physicians were all too ready to accuse me of skipping shots to lose weight. One that I only visited once told my mother and I that I was lying when I said that I didn't skip injections and that if I stopped skipping injections my blood glucose would be in better control. Another told me that I was really terribly unhappy with my life and I was just skipping shots as a slow and easy form of suicide.
None of the physicians that I saw were interested in hearing my side of the story, they were all highly accusing.
Finally, I found a physician who listened to my story and worked with me. He placed me on insulin pump therapy which was the first time that my blood glucose remained stable. I'm now 24 and in excellent control. I am also very lucky that no signs of complications have materialized yet.
I just wanted to share another side of the story. Not all physicians are reticent about talking to their patients about eating disorders or injection schedules. In fact, many are all too ready to lay inappropriate blame on their patients instead of helping them solve their problems.
Department of Molecular Biology and Oncology
University of Texas Southwestern Medical Center
Three Steps to Better Calibration
I want to add some important details to the answer given to a question in the April 1998 Q & A section by Wythe Whiting about differences between plasma vs. whole blood glucose monitoring.
Susan Barlow, RD, LD, CDE, responded to the question and then added a recommendation to periodically check your monitor with the lab. This is an excellent point and not utilized enough by the diabetes community, but there are important things to consider in addition to the steps recommended.
Regarding Step 1 (Take your monitor with you to your doctor's office or laboratory.), when comparing to a lab glucose reading, make sure your meter is in good working order and that it has been cleaned and properly coded to the strips you will be using. Even though monitors are now more user friendly, all are technique dependent and may provide inaccurate results if used improperly. It is a good idea for all people using monitors to review their glucose testing technique with a diabetes educator periodically to ensure proper use.
Step 2 (Perform a test within five to ten minutes of when the lab draws blood from your arm.) is an important point, but what a lab does after the sample collection can alter the results. Do they centrifuge it immediately or let it sit for a couple of hours? Glucose concentrations can decrease over time due to the glycotic enzyme activity of red blood cells.
The best scenario is if the sample is centrifuged immediately and the assay run on the plasma within a couple of hours. Most lab personnel know that they should not use fluoride or iodoacetic acid as a preservative for the blood specimen, as this can render the result inaccurate.
Also, use only capillary (finger stick) blood unless the strip package insert indicates differently. The oxygen concentration is different in venous and capillary samples and, depending on the strips, could affect the accuracy of the result.
Step 3 (Write down the result you get from your monitor and compare it with your lab result to find the percent difference.) should recommend fasting at least four to six hours before the blood sampling. The glucose in capillary blood is higher than in venous blood after eating and can result in a reading that is higher by as much as 70 mg/dl in a non-fasting individual.
Your meter is considered accurate by ADA standards if it is within 15 percent of the lab result.
Even though this sounds complicated, it is an excellent way to verify the monitor's results and give users the confidence to make adjustments in their diabetes care based on their blood glucose readings.
Linda Parks, RN, CDE
Diabetes Specialty Representative
San Rafael, Calif.
Diabetes Health has received a number of letters in support of Sandra Silvestri, author of April's Personal Perspective column, "The Wrong Dose." The article chronicled Ms. Silvestri's accidentally giving her son Joey the wrong insulin dose. Here is a sample of what readers had to say:
Thank you for this beautiful and moving article.
I just wonder whether using a Novo Pen with pre-filled insulin (e.g. the Mixtard series) that we use as the standard in Europe wouldn't prevent this sort of mistake, or at least make it harder to happen.
Wishing Sandra and Joey all the best. Keep it up; he will need you for a long time to come.
I am a mother of a diabetic child, and I have come very close to doing that very same thing. Don't feel guilty, and yes, I think you would have been most justified in reading the riot act at the hospital no matter who it would have offended. The nurse deserved it for mouthing off, and the doctors deserved it for not getting to your son sooner.
No one but those who have to live with diabetes can understand how tough it is. Congratulations on handling it so well and for letting us know what happened. I will have some idea what to expect if I should ever do the same.
I am ashamed to say that I have done something like this more than once to myself. One of the tricks I came up with is using a different delivery system for each type of insulin (Humalog in cartridge, UltraLente in vial, and NPH in prefilled). Of course this means additional sticks, but after 25 years and a few mistakes, it's a small price to pay.
I empathize with the mother of a young child. When I did something like that I just enjoyed myself. I got to eat all of those things I wasn't supposed to, and lots of them! I can definitely understand the fear when it happens to someone else for whom you are responsible and love, however.
Learn to be demanding and don't be afraid of hospital personnel. Most of them are not as well educated about diabetes as you are.
Twice I found myself crying in reading and rereading "The Wrong Dose."
Emergency rooms, particularly the logging in, can be one big pain in the ass. Recently, my wife was rushed to the E.R. by paramedics for a possible stroke (found out it was not). I said that I wanted to go give my wife a pat and let her know I would be in the E.R. room with her as soon as I finished the paper work in the lobby.
The staff said no, paper work first. "This is not Nazi Germany!" I thought and began pounding on the locked E.R. door. I wanted my wife reassured by me before her doctor arrived. Finally, I was let in.
The paramedics who brought my wife to the hospital were great. I have never met a paramedic or fireman that I did not like or respect. I cannot say the same for physicians, nurses, police or E.R. lobby staff.
Joey feels your love and concerns, Sandra, probably always has. He is blessed, not with having diabetes, but with having a mom with your goodness.
Off the Mark on Islet Transplants?
I thought your May 1998 editorial "Can Dr. Soon-Shiong Perform Miracles" was a bit off the mark. The problem starts at the top, with the headline. If indeed this research proves out, will it really be a "miracle?"
No. It will be the end result of lots and lots of very fundamental research in biology, immunology, endocrinology, human genetics and many allied fields. "Miracle" somehow connotes an extra-human, divine guidance sort of engine that produces an unforeseen result. In fact, this research has been going on for years, if not decades. It will certainly be great, but hardly miraculous, if islet cell transplants finally come to be.
Which brings me to the second thing that seemed off. The tone and tenor of the piece was that this research was IT in terms of what's happening with islet cell transplants. Soon-Shiong's research is one of several approaches to making islet cell transplants feasible. Lots of encapsulation techniques are being tested, as well as other options for getting islet cells past the immune system. I think you could have put it in better perspective by reminding people of that.
In describing Soon-Shiong's cool reception when describing getting human islets to "proliferate 32 times" (by which I assume you meant reproduce 32 times; you usually speak of something proliferating, but not a specific number of times) before an audience of his peers, you say that "If he is right, than everybody else's work in the field is finished and their careers are over."
I think you really got two things mixed together. Getting islet cells to reproduce themselves successfully would be great, but hardly career-ending for all the other researchers. Yes, they need to develop techniques to harvest and reproduce islet cells outside the body, but the real challenge and what's really keeping researchers going is getting them into the body and past the immune system. Soon-Shiong's success at reproducing the cells would have no implications for the researchers' efforts at slipping one past the immune system.
I also thought it a bit of a non sequitur to say that it is theoretically possible to catch something from a pig, and then "For example, some believe the AIDS virus may have come from a monkey."
Huh? What does the monkey have to do with the price of fish in Kenya, or the chances of getting a virus from a pig? Your point would have been much better made, I think, had you pointed out that pigs are used so often in the final pre-human phase of drug and medical device testing because they are so close to humans in so many ways; close enough to make it a very realistic possibility that what's a viable virus in one could be a viable virus in the other. Maybe that paragraph, being near the end, suffered a cut. It just seemed like an awkward logical jump from pig to monkey, without stating more explicitly that your point was that interspecies transmission of viruses can and does happen (witness the recent fowl flu, which would have probably been an even more vivid example).
Lest you think me a total ingrate, I rush to assure you I find Diabetes Health an A+ operation. You're doing a super job of both covering and explaining the news of importance to diabetics, and I commend you for your every effort.
0 comments - Jun 1, 1998
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