Thursday, June 29, 2006

Soccer and pumping - additional conclusions

Since starting the experiment on pumping I have had some issues when playing soccer (BG's that piss me off, and Soccer and pumping). My nurse has been convinced that the high BG's that I see after a game, where I have been disconnected for 1-2.5 hours, were mainly due to release of "fight"-hormone (adrenaline) during the game, and not the period of time being disconnected. I was not too sure about that conclusion, though I certainly agree that the adrenaline probably does take part in the high-party. I have found that adding Lantus and Actrapid to my insulin regimen on game days have almost eliminated the problem, which makes me even more convinced that the post-game hyperglycemia issues that I have been experiencing running solely on NovoRapid from my pump and being disconnected 2-3 times longer than recommended in the manual, are not a mere result of excessive adrenaline release. Today at work we had "Activity Day" in our department. This arrangement was arranged by the department's social committee with the purpose of making all the staff and students get together and enjoy a summer afternoon with games and chatting around the barbeque. Thus, we only had to work until noon, and then we all meet outside on the grass for dart, croquet, petanque, vikingespil, soccer, volleyball and foot-tennis. Of course I was up for a soccer game together with quite a few other people from my group. We set up a field on the rough (this part of the lawn is seemingly not mowed as often as those parts were fields were set up for vikingespil, petanque, croquet and dart!) and played two halfs - we needed a break and a drink (the department hosted the barbeque along with plenty of beer and some soft drinks to enjoy before, during and afterwards) :-) I guess that we played something like 30 and 45 minutes, but I really don't know because I didn't check the clock while playing, so it may actually have been longer than that. As always, when playing soccer, I disconnect. I reconnected during our break though. During the second game I didn't feel that fit, suspecting a hypo comming along, so, because I hate stopping in the middle of something, I just consumed half a packet of glucose tabs not leaving the game. When we stopped, I tested just before the barbeque was ready: 3.8 (68). Well, the hypo during the game seemed to be true and I was still on the low side, so I ate some raisins while waiting for the sausages and bread on the two grills to be eatable. About 14.30 PM food was ready. I was not really that hungry as I had an early lunch before the beginning of the activities, but I wouldn't miss the sausages. I only had one though, along with one bread, and figured that a bolus of 1 unit should cover that. A couple of hours later, when getting ready to go home, I tested 9.0 (162). Why??? I didn't really give more thought to it, I was a bit hungry so I bolused 2.3 units (wizard's recommendation) for a bun, ate it and hit the road on my bike. The 2.3 units for the bun is usually more than enough to cover it, especially when going on a 9 km bike ride afterwards, but when I tested before dinner 1.5 h later I was 216!!! By this time I realized that maybe, because I didn't take any Lantus in the morning to cover the periods of time being disconnected during the games, I was probably experiencing the post-game hyperglycemia effect that I have become familiar with since starting the pump. As far as I can tell, I didn't go as high as I have sometimes been following games, which may give adrenaline the honor of throwing the readings through the roof after all, because as the intensity of the games today was not as high as in our games of the tournament, the adrenaline release was probably lighter. Still, I dare to say that this also proves that adrenaline is not the only culprit in this post-game hyperglycemia game, it just does take part.

For the record, by 19.30 PM I was back in range at 4.5 (81) again, so eventhough it required a larger bolus for my dinner this post-game hyperglycemia attack was not as stubborn as previously seen :-)
Now it is time for the final reading before going to bed, I hope this one is just as good as the previous one!

Wednesday, June 28, 2006

My week....

Another busy week has past by. Thursday I had an endo-appointment, which didn't provide any new ideas as to the issues I feel I have been having with pumping insulin. My doctor (MK) did not appear to be that familiar with pump therapy - just amazed of how the pump and infusion site look like nowadays, compared to years ago - and we agreed that I should continue working with the nurse. At the end of my appointment MK asks me if I feel we are getting too close (MK was my co-supervisor during my Master's project, and we have kept contact afterwards because he felt that some of the results I obtained should be published), if I felt I could not talk openly to him because he knew me more than just as a patient and would be more comfortable changing to a new doctor. I was a bit amazed about these questions, although we have discussed it previously, but I told him, as is the truth, that it was not a problem for me as long as we could keep things apart at my endo appointments, i.e. that the time is primarily used to solve diabetes related issues, not experimental or paper issues. That has unfortunately been the case at some appointments, especially if it had been a long time since we have meet scientifically, but this time it was not, and MK agreed to focus on separating the two fields of discussions.

After the endo appointment, I had a 2 H meeting with a clinical professor and his associate professor along with a couple of people from my lab. Our quest was to promote mass spectrometry in general, and particularly our knowledge of this area, to these professors as they had announced at least one opening for a Ph.D. position at the end of this year, something that we would like get into. The meeting went very well, so we are all hopeful that it will result in them hiring at least one of us for projects in the future.

Friday was the traditional Danish Midsummer Eve, where people usually join at bonfires to "send witches towards Bloksbjerg". Jimmi and I had talked about going to the large meadow in Odense where the largest bonfire of the city was set, but we ended up just staying at home for several reasons. Jimmi has just been sent on sick leave from work due to a work-related back injury he got back in December and he wasn't really up to taking the 8 km trip to the meadow just to look at a bonfire when there was World Cup soccer in the television. We also needed to go shopping for something to eat for breakfast the next day. Going to the supermarket for this, we were also determined that at least we would celebrate the evening by buying some fresh Danish strawberries (strawberries and midsummer is closely related in Denmark). So we had our first Danish strawberries of the year along with ice cream - uhmm!!! But first I had to treat a stubborn low that made me get off my bike on the way back from the supermarket, because my arms and legs were not cooperative. Grrr!!!

Saturday was just a quiet day used for house work and a trip to the Rosengaardscenter, a large shopping mall in the south eastern part of Odense. I went there because I didn't manage to go to the pharmacy in the morning, and on Saturdays most of the pharmacies closes at noon, but the one in the mall is open until 2 PM which gave me time to fill a prescription on insulin. They did not have the 3 bottles that my presciption entitles me to get each time, I could only get 1, but that was actually ok because I realized that I had just started all over on the annual medical grant arrangement, meaning that I have to pay full price for the medicine up to 480 kr. (approximately 80 dollars) before I start getting the tiered grant again :-(

Sunday was a very hot and sunny day. We had the last soccer game of the spring season at 10.45 AM, playing on a field properly shielded for the wind by close-grained trees and bushes. That was tough because there wasn't any shadow what so ever on the field during the game, so we felt like it was almost impossible to replenish the water lost by sweating without camel packs on our backs (just imagine how that would look if 22 players were running around with a straw in their mouth from camel packs on their backs ;-)). Unfortunately we lost the game, but overall we can be very happy with our spring season as we stayed in the league that we were promoted to last fall, ending 5 th. of 10 teams.

Whether it was the heat, all the soccer (requiring the use of Lantus to be able to stay off the pump for a suitable amount of time) and bicycling being performed on Sunday or whatever, the night between Sunday and Monday I experienced another severe low. Jimmi woke up at about 1 AM because I was taking up an awful lot of space in the bed. When he wanted to make me move, he noticed I was all limb and sweaty, figuring that I must be low. He started feeding me glucose tabs patiently awaiting my awakening, but it didn't come. After almost an hour and a whole pack of glucose tabs, I still seemed unresponsive so he did a a BG-test that showed 2.3 mmol/l (41). Sure too low, and being worried that all the glucose he had stuffed me with did have any effect, he decided to call 112 (911 in the US). I think that I remember them arriving though, despite I was very sleepy and thus hoping that it was just a dream. Anyway, besides the two paramedics this time there was also a doctor and a nurse along - our bedroom was suddenly quite crowded! I don't know why the latter two had been called, but I guess that I should just be happy about that because it meant that instead of getting a glucagon shot, which tend to make me very sick afterwards, I got IV-glucose in stead, lifting the BG from 2.6 (47) at their arrival to 7.1 (128) at their departure - and I didn't have to go to the hospital. The episode did destroy my night's sleep though, because I could not go back to sleep after they left. I tossed and turned for at least 1 H, feeling like the BG was about to go through the roof - and it was on its way up there being 16.5 (297) when testing, so I did a correction of 4 units and finally fell asleep, only to wake up with difficulty about 1.5 H later with symptoms of being low again. I didn't test, just ate a couple of glucose tabs, lowered the pump basal and immediately got back to sleep - for 1 H then the alarm clock announced that it was time to get up and go to work :-( BG 5.4 (97), though, so that was at least a small victory. These are the time when I really, really HATE this f...... disease - and the inability of me to control the BG just as well as the non-diabetic body can!

Because of the lack of sleep, I was happy that my Monday was not that challenging. I had an ongoing mail correspondence with MK about the paper that I am trying to write - he is reading my draft these days, hopefully providing me with some ideas and critics to go on with - and other wise just did some data analysis before going to a Master's defense at MK's lab in the afternoon. I did not want to go back to work when the defense was over - it is a 30 min bike ride for maybe 1 H more at the computer - so I was back home at astonishing 4 PM! Because of this, we decided to have an early dinner and then head for the movies to see the last movie of the season with our Cinema Club tickets. It was a Danish movie about a guy, Jorgen, being responsible for the lottery club at work. Every time he bought coupons for the lottery club, he would also buy one for his wife, dog-earing it to make sure he could tell them apart. The lottery club usually never win anything, but one day when Jorgen checks the coupons he realizes that they have a full lottery win of 3.5 mill. kr (583,000 dollars). They are 6 guys in the club, so they will each get plenty of money out of this win, yet Jorgen starts to think that he and his wife deserve all the money themselves. This causes them to enter a cycle of lies and excuses about their actions. It wears them down, Jorgen in particular, and he end up telling the other guys of the lottery club the truth. They tell him that he is an idiot, any of them would have kept all the money themselves, and thus it is sort of a happy ending with a clear moral that cheating and lying just doesn't pay. Quite a good movie, also because you could relate to the lives and struggles of the main characters, including the thought about what you would do if you suddenly became a millionaire in the lottery (if you play the lottery, that is ;-)).

Yesterday was plane desk work with a lot of not too encouraging data analysis, which I have continued doing today. However, the biweekly group meeting, which we had today, sort of cut the day in half because it starts at 10 AM and usually takes a couple of hours. This means that you get away from what you have been doing, and for me this made the data analysis I needed to return to even more boring, which is why I am not taking the time to white this long post eventhough I ought to be searching spectra :-) Well, maybe I should just get back to work now!

Tuesday, June 20, 2006

Another meme

I haven't been too good at posting on a regular basis. I simply haven't taken the time to do it. Work takes a lot of time - even though I sometimes take a break and spent it on the Internet, as just now ;-) - and in the evenings I hardly turn on the computer because I either have soccer practice/games to attend, want to enjoy the decent summer weather we have at the moment, and/or follow the World Cup games on TV (yes, I am a soccer freak, and I do enjoy watching soccer almost as much as playing it myself, although it is sad that Denmark is not among the participants in the current World Cup). Still, I do manage to spent a few minutes now and then catching up on some of the diabetes related blog that I like to read. One of them ( inspired me to make this post on the "Highs and lows of pumping".

I am approaching the end of the initial 3-month pump-try-out that I reluctantly agreed upon in March. I was set up on April 6 and my now have 2.5 months of experience and learning with pump therapy. As MDI therapy is still fresh in my memory, I cannot help to compare the two regimes.

Highs of pumping:
  1. A great advantage when I was in Prague for a conference in the beginning of May. Not knowing was to expect from lunch would have been a bit tricky with injections, as I preferred to use Actrapid (Regular) for meals, thus usually would do the injection 15-30 min. before starting to eat. With the pump it was just take a look on that lunch pack you were handed, estimate the amount of insulin needed to cover it and then GO!
  2. Even more flexibility than I had with injections as far as to when and what I eat.
  3. Unexpected temptations (food-wise) can be handled - though when on injections, I would usually carry at least a fast-acting insulin pen with me, there have been time where I did not expect to be out during meal time and therefore did not bring any along, thus needing to moderate my intake of food significantly, or simply say no, because I could not bolus for it.
Lows of pumping:
  1. Adjusting the basals, parameter for the wizard function ect. is a living nightmare! When I started the pump, I did expect it to take some time before these things were settled, but I did not expect it to take as long as it did - it is actually not settled completely yet, though it is far more acceptable now than just a month ago. I know I ought to go through these fasts in order to check how the basals match my need, and I have completed the night-to-lunch fasts, but it has been hard and actually I ought to repeat them as I have changed the basals in order to get closer to my target range than the initial basal would get me. My problem with these fasts are that I am very active every day so I get hungry if I do not eat regularly. If I am fasting while hungry, I can't focus on what I should be doing (work ect.), which is not very effective. My nurse, Alice, understands this, fortunately, but her colleague, who started me up because Alice was on vacation, did not. She actually suggested that I just lay off some of the activity until the basals were set, but I argued against this for several reasons. First, and most importantly, I can't see how you can use resultsobtainedd on a "lazy day" to regulate the basals needed for usual week days where I bike 20-40 km and/or play soccer practicee or game)! Second, I do not have the patience to commute by city busses to get to work. I have had enough of commuting by train and busses the first years of my study, and as we don't have a car, I would rather spent 25-30 min. on my bike in the mornings and afternoons than twice the amount of time in different city busses to get from my home to work and back again.
  2. Pumping is so incompatible with my soccer games! I virtually never had any great troubles with game days when using MDI, but with the pump, I have experienced nothing but trouble controlling BG's. I am usually able to start out pretty good, and a few time I have even managed to be in range just after the game as well, but whether or not I am in range just after the match, I can be sure that the BG will sky rocket afterwards. An example: 6.1 mmol/l (110) just after a game, 17.8 mmol/l (320) with beginning ketones and generally feeling lousy just 2 hours later! I am not comfortable with wearing the pump during games, so I disconnect. I also do that atpracticee, which is 1.5 H, approximately the same as a game without the warm-up, and I have no problems with that. I am not sure if the game issue is related to the amount of time being disconnected, fight hormones, or a combination of factors, but I have never had these problems when on injections. The last couple of games I have therefore defied threcommendationsns from the hospital about not involving any other types of insulin when pumping, and taken a shot of Lantus (dose approximatelequalingng 75 % of my pump basal) in the morning and then a shot of actrapid for the last meal I have before the game. I then run my pump basal very low (10-15 %) until the actrapid is out of my system again, then depending on the blood sugar I will raise the pump basal to 25-50 % of normal waiting for Lantus to also leave. So far this has worked nicely for me, having avoided both hypoglycemia before and during the game as well as hyperglycemia afterwards.
  3. The pump should in theory even out the swing of your BG, but I havdefinitelyly seen a lot more out of range BG's the last 2.5 months. I know some of them are of cause due to the issues mentioned in item 1 in this Lows-of-pumping-paragraph, but still I am certainly not comfortable with the number of BG's below 2.0 mmol/l (36) that I have obtained in this period of time. I even managed to test as low as my meter just saying "LO", meaning a BG below 1.1 mmol/l (20) - I was certainly not feeling well at that time, and fortunately my boyfriend was there to make sure that I got something to treat that nasty low with.
  4. Temptations of delicious and carb-loaded foods can be hard to resist, because bolusing is so easy, not requiring an injection.
This is not a complete list of pro's and con's of pumping for me, but the most important ones for me at the moment. I hope that at least some of the lows will disappear or get less significant by time. I'll let you know what I learn.

Tuesday, June 13, 2006

Hot, hot, hot

After a week at the Greek island Kos with temperatures above 30 C every day, and difficulties to get temperatures below 28 C in our hotel room at night, we returned to Denmark where temperatures could hardly exceed 18 C during the day. Though we were literally freezing at first, we quickly adapted. However, during last week summer has returned to Denmark, and the last four days this has been with temperatures of 25-30 C. I like summer and sunshine, but I must admit that I prefer temperature not above 25 C, because the air humidity is usually high enough to make the air feel rather heavy.
The hot weather is also - as usual - a challenge for BG-control. I tend to cruise on the low side, but usually I am able to avoid extreme lows by having small meals/snacks every 3-4 H. Sunday Jimmi and I was to take part in a family-get-together-to help-Verner-and-Lotte-shining-up-their-garden. Verner is Jimmi's grandfather, who just had a new hip this winter and therefore is not able to do much gardening yet, so his wife's children had arranged for all the children and grandchildren with their spouses to show up and help with that. We were about 20 people to rearrange the flower beds, paint the garden shed, ect. We started at 10 AM, and as I had just changed site in the morning, I tested before starting the work: 3.4 (61). Hmm, a little too low, maybe due to the 11 km bike ride? I ate a handful of raisins, figuring that to do the trick, and then joined the painting team. We had a short break to eat ice cream later in the morning. I didn't test at that time (I know I should have), just did a small bolus (0.5 U) after consuming the ice. Around 12.30 my boyfriend encourage me to come with him and do a test. I am reluctant to do so, so he almost drag me inside. My memory of it is actually a bit blurred, however I do remember doing the test and seeing the result "LO" on the meter, meaning a BG below 1.1 (20) and thinking "that can't be, I must have used too little blood or something". I can't remember how many glucose tabs I had, but they were followed by a piece of black bread with liver paste. Getting better, I couldn't help being a bit scared by the fact that I actually managed to function, although not that well I admit, and test myself with a BG that low.

Well, I should go back to work. I am analyzing mass spectra at my computer in a very small office that I share with 2 other girls. There is no ventilation in the office and with 3 people and the same number of running computers the temperature is about 35 C, making you sweat even when you are just moving your fingers around the computer keyboard or the mouse.