patients. They are portable and simplify the procedure of measuring the insulin dose.

The required dose can be dialled, and some pens feature audible and palpable dose graduations which are of value to those with impaired vision. Some versions of the pen are preloaded and disposable. Plastic insulin syringes with needle attached are still preferred by some patients, and they are still required by those who prefer to mix individual insulins in the syringe. They can be reused several times and between use can be stored in a refrigerator.

Insulin pumps
Sophisticated insulin pumps infuse insulin subcutaneously over 24 hours, with facilities for preprandial boosts. They are worn on a belt and attached to a subcutaneous cannula. They are expensive and not at present available on the NHS although they should be. They are of value for selected patients with Type 1 diabetes. For more detail regarding their use, see page 29.

Inhaled insulin
While nasal administration of insulin proved unsuccessful, the use of inhaled insulin looks promising. Absorption though inefficient is adequate to reduce hyperglycaemia, and this route of administration may prove to be of value, notably in Type 2 diabetic patients. The practicality of this technique is still under investigation.

Pancreas transplantation
For those needing a kidney transplantation, pancreas transplantation can be performed simultaneously, eliminating the need for insulin injections and rendering glucose tolerance normal or very nearly normal. Five years after transplantation, 60% of patients remain well without needing insulin injections (see page 70).

Islet cell transplantation

The feasibility of islet transplantation has been demonstrated, and with novel immunosuppression techniques islet survival has improved considerably, eliminating the need for injected insulin over increasing periods of time up to three years. Intensive research of this technique is in progress, and at present it is only available for those participating in carefully organised research trials now conducted in several centres including some in the United Kingdom.

Insulin injection sites

Insulin for routine treatment is given subcutaneously by intermittent injections or by continuous infusion. Insulin can be injected subcutaneously almost anywhere if there is enough flesh. The best site is the front of the thigh. The lower abdominal wall, buttocks, and upper arms may also be used. Patients who want to wear sleeveless clothes should normally avoid using the arms in case unsightly marks or fat hypertrophy should appear; some may then prefer to confine injections to the lower abdomen. It is important to vary the injection sites from day to day, using for example, each thigh alternately over as wide an area as possible. Absorption of insulin varies from one site to another, being most rapid from the abdominal site, and less rapid from the arms and least from the legs. If there are any difficulties with control it is advisable to use one area consistentlyfor example, the thigh. In diabetic emergencies soluble insulin is given intravenously, or occasionally intramuscularly (see chapter 9). Resources

BOOKS Consumer Reports Staff. Consumer Reports Complete Drug Reference. 2002 ed. Denver: Micromedex Thomson Healthcare, 2001. Ellsworth, Allan J., and others. Mosbys Medical DrugAbuse is a complex psychosocial problem that affects large numbers of adults as well as children throughout the world. It is listed in the Diagnostic and Statistic Manual of Mental Disorders (DSM-IV-TR) under the heading of Other Conditions That May Be a Focus of Clinical Attention. Although abuse was first defined with regard to children when it first received sustained attention in the 1950s, clinicians and researchers now recognize that adults can suffer abuse in a number of different circumstances. Abuse refers to harmful or injurious tlude not only the direct costs of immediate medical and psychiatric treatment of abused people but also the indirect costs of learning difficulties, interrupted education, workplace absenteeism, and long-term health problems of abuse survivors.Autoantibodies in type 1 diabetes Islet cell autoantibodies are present at diagnosis but will gradually decline and disappear in ensuing years. This means that if there is diagnostic uncertainty, islet cell antibodies can be checked early during presentation. Specific tests have been devised recently including anti-GAD (glutamate decarboxylase) antibodies and also

anti-IAP (inhibitor of apoptosis protein) antibodies. The presence of both together is associated with a significantly higher risk of developing type 1 diabetes. The use of these tests in clinical practice is restricted to situations where there is doubt about the diagnosis of the type of diabetes and to distinguish from type 2 diabetes. Clinically, the implication is that if the tests are negative the patient might then not require insulin. Attempts to prevent type 1 diabetes in these susceptible individuals has thus far not proved successful. Type 2 diabetes Type 2 diabetes is a complex heterogeneous condition and recent genetic studies have revealed numerous sub-types. Children presenting with mild hyperglycaemia present diagnostic problems as they may have latent slowly progressing type 1 diabetes. These children may then progress to requiring insulin. On the other hand, with increasing prevalence of obesity more children are now presenting with type 2 diabetes, particularly from ethnic minorities. In the USA, in some areas, up to 50% of children with diabetes are now presenting with the type 2 form. Latent autoimmune diabetes in adults (LADA) is thought to comprise about 5% of all patients with type 2 diabetes. These people have autoantibodies usually seen in type 1 diabetes, but their clinical presentation is like someone with type 2 diabetes. This is a group that may present an excellent opportunity for subsequent prevention of diabetes if an effective intervention can be developed

to prevent further beta cell destruction. Monogenic diabetes (previously referred to as maturity onset diabetes in the young, MODY) Monogenic diabetes is the term used for a collection of conditions that cause diabetes now shown to result from single gene defects. One feature of these conditions is that they show autosomal dominant inheritance patterns where the disease appears to be vertically transmitted (e.g. through several generations). It is also diagnosed before the age of 25 years, but, unlike type 1 diabetes patients, monogenic diabetes patients do not often require insulin for at least 5 years after diagnosis. Genetic testing in these cases can confirm the particular sub-type of diabetes. This can have significant clinical implications. Patients with HNF1a (hepatocyte nuclear factor 1a) mutations, for example, exhibit exquisite sensitivity to sulphonylureas and can be successfully treated with tablets. Knowledge of the mutation, therefore, can help in the management of this disorder, even in children who would otherwise have been put onto insulin. This is also one form of type 2 diabetes where we would use a sulphonylurea in preference to metformin when initiating therapy. Patients with HNF1 have renal cysts. Patients with glucokinase mutations are less common but the diagnosis is significant for the individual and their families. Such patients are much less likely to develop complications of diabetes because they mainly have mild fasting hyperglycaemia without significant post

meal hyperglycaemia. Maternally inherited diabetes with deafness (MIDD) This is a form of diabetes due to mutations in mitochondria, most commonly related to 3243A > G mitochondrial DNA mutation. Mitochondria in an individual are inherited from the mother rather than from the father, therefore one clue would be evidence of strong maternal transmission of diabetes, particularly when this is associated with a sensorineural deafness. Some patients may also have peripheral vision problems, particularly night blindness. These patientsAbuse is a complex psychosocial problem that affects large numbers of adults as well as children throughout the world. It is listed in the Diagnostic and Statistic Manual of Mental Disorders (DSM-IV-TR) under the heading of Other Conditions That May Be a Focus of Clinical Attention. Although abuse was first defined with regard to children when it first received sustained attention in the 1950s, clinicians and researchers now recognize that adults can suffer abuse in a number of different circumstances. Abuse refers to harmful or injurious tlude not only the direct costs of immediate medical and psychiatric treatment of abused people but also the indirect costs of learning difficulties, interrupted education, workplace absenteeism, and long-term health problems

of abuse survivors. Types of abuse Physical often require insulin. Infusion strategy
Initially reduce total daily insulin dose by 30%. Give half the daily insulin dose as the constant basal pump
rate (usually around 1 unit/hour). Give half the daily insulin dose divided between the three main meals, giving the insulin boost immediately before the meal. The patient is taught to count carbohydrate portions (see page 12) and thereafter will give the bolus doses in direct relation to the amount of carbohydrate consumed (for example, 1 unit for every 10 g of carbohydrate). During the first few days adjustments need to be made as follows: basal rate determined by assessment of fasting and 3 am blood glucose readings preprandial boosts are adjusted by assessment of postprandial blood glucose readings. Note: Specific instructions are given for exercise, and basal rates should be reduced during and after exercise.

Dose adjustment for normal eating (DAFNE)

A more liberal dietary pattern for Type 1 diabetic patients has become possible by using the DAFNE approach, ideal for some people who thus regain considerable freedom while at the same time maintaining good control. It is based on: a 5-day structured, group education programme delivered by quality assured diabetes educators the educational approach is based on adult educational principles to facilitate new learning two injections of medium acting insulin each day (see page 21) injections of short acting insulin every time meals are taken testing blood glucose before each injection. This programme enables people to eat more or less what they like when they like, and not to eat if they do not wish to do so. It depends on a quantitative understanding of the carbohydrate values of individual foods, and calculating by trial and error the correct amount of soluble insulin needed for a specified quantity of carbohydrate, developing an insulin/carbohydrate ratio for each individual patient. DAFNE has been used in continental Europe for many years: the- tongue covered with fur. Bell, (white and clammy,

which can be pulled off in strings), Phos. (black crusts). - tongue c. with mucus. Bell, (brown), Carbo. veg. (yellow-brown), Kali bi. (ropy), Merc, sol., Nitr.- ac. (tough, ropy, with ulcers), Phos. ac. (clammy, tough). Puls, (tenacious), Psorin,(whitish-yellow), Rhus. tox. (brown), Sil.(brownish). - tongue c. with ulcers. Caps, (flat, sensitive, spreading), Kali bi. (small, painful), Natr. mur. (also vesicles).

- tongue c. with vesicles, Ars. (painful, burning), Apis* (stinging), Canth. (at base). Hell., Natr. mur. (smarting and burning when touched by food), Spong., Zinc. Cracked. Ailanth., Apis, Arum., Bapt., Bar., Bell., Benz. ac, Bry., Calc. fl., Cham., China, Cic, Cur., Hyos., Kali bi, I^yc, Magn. mur., Nux-vom., Phos., Phos. ac, Plb., Podo., Puls., Ran.sc, Rhus tox., Sacch., Spig., Sulph., Ver. alb. - edges, Nux vom. (rest black or red). - middle, across the, Cobalt. - tip, Lach. - tongue dry, parched and cracked, Ailanth. - tongue dry, parched and cracked in typhus, Bapt. - chronic inflammation of tongue; c, swollen and bleeding, Podo. - tongue swollen, dry, c, sore, ulcerated, covered with vesicles. Apis - tongue, painful and burning. Arum. - tongue yellow along center, first white with reddish papillae; followed by yellow-brown coating in center, edges dark red and shining; dry brown down center (Plb.); c, sore, ulcerated, Bapt., (Apis, Ars., Rhus tox). - smarting, burning pain in tip of tongue, sore and c. Bar. carb. - tongue rough, c, and often of a dark- brown color, Bry. - tongue dry, smooth, red, c. (in dysentery). Kali bi. - tongue dry, red, brown, c, and tremulous, Hyos. - tongue dry, red, c, black stiff, Lach., Rhus tox. - tongue coated yellow, burning with blisters, c, Spig. - tongue smooth, red and c, dry and red, coated - thick whitish-yellow, ulcerated. Kali bi. - mouth very sore, parched and dry, mucous membrane c. and bleeding, tongue swollen and covered - with blisters on each side, Lach. - dry, black or c. tongue, Lj^c. (Ars., Lach., Phos., Rhus tox. ) - tongue cold, dry, blackish, c, red and swollen, Ver. alb. - brown, parched, c. tongue, Sulph. - tongue c. or coated yellow, with red tip and edges, Ver. alb. - and burning, Arum tr.. Bell., Bry., Ran. sc., Sulph., Ver. alb. - black and dry, stiff as a board, Ars. - on edges, black or dark red, Nux. vom. - and dry (tip). Kali bi., Lach., Rhus tox., Sulph. Crack deep,