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Figure 1.
A, Examples of 3 insulin infusion pumps; B and C, 2 subcutaneous catheter infusion sets that may be used for continuous subcutaneous insulin infusion.

A, Examples of 3 insulin infusion pumps; B and C, 2 subcutaneous catheter infusion sets that may be used for continuous subcutaneous insulin infusion.

Figure 2.
A typical profile of basal insulin infusion rates used in continuous subcutaneous insulin infusion. It is very common for people with diabetes to require a higher basal infusion of insulin in the predawn hours. Many people are more active in the late afternoon and more sedentary after dinner, requiring downward and upward adjustments, respectively.

A typical profile of basal insulin infusion rates used in continuous subcutaneous insulin infusion. It is very common for people with diabetes to require a higher basal infusion of insulin in the predawn hours. Many people are more active in the late afternoon and more sedentary after dinner, requiring downward and upward adjustments, respectively.

Characteristics to Consider When Evaluating a Potential CSII User*
Characteristics to Consider When Evaluating a Potential CSII User*
1.
DCCT Research Group, Diabetes Control and Complications Trial (DCCT): the effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin dependent diabetes mellitus. N Engl J Med. 1993;329977- 986Article
2.
UK Prospective Diabetes Study (UKPDS) Group, Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet. 1998;352837- 853Article
3.
Diabetes Control and Complications Trial Research Group, Implementation of treatment protocols in the Diabetes Control and Complications Trial. Diabetes Care. 1995;18361- 376Article
4.
Boaz-Christy  K Up and pumping: chart your way to better control. Diabetes Interview. March1999;30
5.
Brody  JE Small, convenient and flexible, insulin pumps catch on. New York Times. August10 1999;Personal Health section.
6.
Saudek  CD Novel forms of insulin delivery. Endocrinol Metab Clin North Am. 1997;26599- 610Article
7.
Strowig  SRaskin  P Intensive management of insulin-dependent diabetes mellitus. Porte  DSherwin  RSeds.Ellenberg's and Rifkin's Diabetes Mellitus. 5th ed. Stamford, Conn Appleton & Lange1997;709- 733
8.
Pickup  JCKeen  HParsons  JA  et al.  Continuous subcutaneous insulin infusion: an approach to achieving normoglycaemia. BMJ. 1978;1204- 207Article
9.
Tamborlane  WVSherwin  RSGenet  M  et al.  Normalization of plasma glucose in juvenile diabetics by subcutaneous administration of insulin with a portable infusion pump. N Engl J Med. 1979;300573- 578Article
10.
Unger  RH Meticulous control of diabetes: benefits, risks and precautions. Diabetes. 1979;31479- 483Article
11.
Teutsch  SMHerman  WHDwyer  DM  et al.  Mortality among diabetic patients using continuous subcutaneous insulin-infusion pumps. N Engl J Med. 1984;310361- 368Article
12.
Tamborlane  WVSherwin  RSGenel  M  et al.  Outpatient treatment of juvenile-onset diabetes with a preprogrammed portable subcutaneous insulin infusion system. Am J Med. 1980;68190- 196Article
13.
Pickup  JCWhite  MCKeen  H  et al.  Long-term continuous subcutaneous insulin infusion in diabetics at home. Lancet. 1979;2870- 873Article
14.
Kobayashi  TSawano  SItoh  T  et al.  The pharmacokinetics of insulin after continuous subcutaneous infusion or bolus subcutaneous injection in diabetic patients. Diabetes. 1983;32331- 336Article
15.
Rizza  RAO'Brien  PCService  FJ Use of beef ultralente for basal insulin delivery: plasma insulin concentrations after chronic ultralente administration in patients with IDDM. Diabetes Care. 1986;9120- 123Article
16.
Schiffrin  ABelmonte  MM Comparison between continuous subcutaneous insulin infusion and multiple injections of insulin: a one-year prospective study. Diabetes. 1982;31255- 264Article
17.
Leichter  SBSchreiner  MEReynolds  LR  et al.  Long-term follow-up of diabetic patients using insulin infusion pumps: considerations for future clinical application. Arch Intern Med. 1985;1451409- 1412Article
18.
Deeb  LCWilliams  PE Surveillance in Florida of continuous subcutaneous insulin infusion use in cohort. Diabetes Care. 1986;9591- 595Article
19.
Simonson  DCTamborlane  WVSherwin  RS  et al.  Improved insulin sensitivity in patients with type I diabetes mellitus after CSII. Diabetes. 1985;34Suppl 380- 86Article
20.
The Kroc Collaborative Study Group, Collaborative studies of the effects of continuous subcutaneous insulin infusion in insulin-dependent diabetes mellitus: conclusions. Diabetes. 1985;34(suppl 3)87- 89Article
21.
The Kroc Collaborative Study Group, Blood glucose control and the evolution of diabetic retinopathy and albuminuria: a preliminary multicenter trial. N Engl J Med. 1984;311365- 372Article
22.
Lauritzen  TFrost-Larsen  KLarsen  H-W  et al.  Two-year experience with continuous subcutaneous insulin infusion in relation to retinopathy and neuropathy. Diabetes. 1985;34(suppl 3)74- 79Article
23.
Haakens  KHanssen  KFDahl-Jorgensen  K  et al.  Continuous subcutaneous insulin infusion (CSII), multiple injections (MI), and conventional insulin therapy (CT) in self-selecting insulin-dependent diabetic patients: a comparison of metabolic control, acute complications and patient preferences. J Intern Med. 1990;228457- 464Article
24.
Dahl-Jorgensen  KBrinchmann-Hansen  OHanssen  KF  et al.  Effect of near normoglycaemia for two years on progression of early diabetic retinopathy, nephropathy, and neuropathy: the Oslo study. Br Med J (Clin Res Ed). 1986;2931195- 1199Article
25.
Schiffrin  AColle  EBelmonte  M Improved control in diabetes with continuous subcutaneous insulin infusion. Diabetes Care. 1980;3643- 649Article
26.
Helve  EKoivisto  VALehtonen  A  et al.  A cross-over comparison of continuous insulin infusion and conventional injection treatment of type 1 diabetes. Acta Med Scand. 1987;221385- 393Article
27.
Rizza  RA Treatment options for insulin-dependent diabetes mellitus: a comparison of the artificial endocrine pancreas, continuous subcutaneous insulin infusion, and multiple daily injections. Mayo Clin Proc. 1986;61796- 805Article
28.
Mecklenburg  RSBenson  EABenson Jr  JW  et al.  Long-term metabolic control with insulin pump therapy: report of experience with 127 patients. N Engl J Med. 1985;313465- 468Article
29.
Reeves  MLSeigler  DERyan  EA  et al.  Glycemic control in insulin-dependent diabetes mellitus: comparison of outpatient intensified conventional therapy with continuous subcutaneous insulin infusion. Am J Med. 1982;72673- 680Article
30.
Diabetes Control and Complications Trial Research Group, Implementation of treatment protocols in the Diabetes Control and Complications Trial. Diabetes Care. 1995;18361- 377Article
31.
Bischof  FMeterhoff  CPfeiffer  EF Quality control of intensified insulin therapy: HbA1 versus blood glucose. Horm Metab Res. 1994;26574- 578Article
32.
Lauritzen  TPramming  SDeckert  T  et al.  Pharmacokinetics of continuous subcutaneous insulin infusion. Diabetologia. 1983;24326- 329Article
33.
Koivisto  VAYki-Jarvinen  HKaronen  S-L  et al.  Pathogenesis and prevention of the dawn phenomenon in diabetic patients treated with CSII. Diabetes. 1986;3578- 82Article
34.
Haakens  KHanssen  KFDahl-Jorgensen  K  et al.  Early morning glycaemia and the metabolic consequences of delaying breakfast/morning insulin: a comparison of continuous subcutaneous insulin infusion and multiple injection therapy with human isophane or human ultralente insulin at bedtime in insulin-dependent diabetics. Scand J Clin Lab Invest. 1989;49653- 659Article
35.
Guerci  BMeyer  LDelbachian  I  et al.  Blood glucose control on Sunday in IDDM patients:intensified conventional insulin therapy versus continuous subcutaneous insulin infusion. Diabetes Res Clin Pract. 1998;40175- 180Article
36.
Mecklenburg  RSBenson  EABenson Jr  JW  et al.  Acute complications associated with insulin pump therapy: report of experience with 161 patients. JAMA. 1984;2523265- 3269Article
37.
Muhlhauser  IBerger  MSonnenberg  G  et al.  Incidence and management of severe hypoglycemia in 434 adults with insulin-dependent diabetes mellitus. Diabetes Care. 1985;8268- 273Article
38.
Arias  PKerner  WZier  H  et al.  Incidence of hypoglycemic episodes in diabetic patients under continuous subcutaneous insulin infusion and intensified conventional insulin treatment: assessment by means of semiambulatory 24-hour continuous blood glucose monitoring. Diabetes Care. 1985;8134- 140Article
39.
White  NHSkor  DACryer  PE  et al.  Identification of type I diabetic patients at increased risk for hypoglycemia during intensive therapy. N Engl J Med. 1983;308485- 491Article
40.
Bode  BWSteed  DRDavidson  PC Reduction in severe hypoglycemia with long-term continuous subcutaneous insulin infusion in type 1 diabetes. Diabetes Care. 1996;19324- 327Article
41.
Haardt  MJBerne  CDorange  C  et al.  Efficacy and indications of CSII revisited: the Hotel Dieu cohort. Diabetic Med. 1997;14407- 408Article
42.
Del Rio  GBaldini  ACarani  C  et al.  Adrenomedullary hyperactivity in type 1 diabetic patients before and during continuous subcutaneous insulin treatment. J Clin Endocrinol Metab. 1989;68555- 559Article
43.
Kanc  KJanssen  MJKeulen  ETP  et al.  Substitution of night-time continuous subcutaneous insulin infusion therapy for bedtime NPH insulin in a multiple injection regimen improves counterregulatory hormonal responses and warning symptoms of hypoglycaemia in IDDM. Diabetologia. 1998;41322- 329Article
44.
Feldt-Rasmussen  BMathiesen  ERDeckert  T  et al.  Effect of 2 years of strict metabolic control on progression of incipient nephropathy in insulin-dependent diabetes. Lancet. 1986;21300- 1304Article
45.
Deckert  TLauritzen  TParving  H-H  et al.  Effect of two years of strict metabolic control on kidney function in long-term insulin-dependent diabetics. Diabet Nephropathy. 1984;36- 10
46.
Dahl-Jorgensen  KBjoro  TKierulf  P  et al.  Long-term glycemic control and kidney function in insulin-dependent diabetes mellitus. Kidney Int. 1992;41920- 923Article
47.
Boulton  AJMDrury  JClarke  B  et al.  Continuous subcutaneous insulin infusion in the management of painful diabetic neuropathy. Diabetes Care. 1982;5386- 390Article
48.
Jakobsen  JChristiansen  JSKristoffersen  I  et al.  Autonomic and somatosensory nerve function after 2 years of continuous subcutaneous insulin infusion in type 1 diabetes. Diabetes. 1988;37452- 455Article
49.
Kronert  KHulser  JLuft  D  et al.  Effects of continuous subcutaneous insulin infusion and intensified conventional therapy on peripheral and autonomic nerve function. J Clin Endocrinol Metab. 1987;641219- 1223Article
50.
Helve  ELaatikainene  LMerenmies  L  et al.  Continuous insulin infusion therapy and retinopathy in patients with type I diabetes. Acta Endocrinol (Copenh). 1987;115313- 319
51.
Bibergeil  HHuttl  IFelsing  W  et al.  36 Months continuous subcutaneous insulin infusion (CSII) in insulin dependent diabetes (IDDM)—influence on early stages of retinopathy, nephropathy and neuropathy: psychological analysis. Exp Clin Endocrinol. 1987;9051- 61Article
52.
White  NHWaltman  SRKrupin  T  et al.  Reversal of abnormalities in ocular fluorophotometry in insulin-dependent diabetes after five to nine months of improved metabolic control. Diabetes. 1982;3180- 85Article
53.
Selam  JLMillet  PSaluski  S  et al.  Beneficial effect of glycaemic improvement in non-ischaemic forms of diabetic retinopathy: a 3-year follow-up. Diabet Med. 1986;360- 64Article
54.
Shimizu  HShimomura  YTakahashi  M  et al.  Enteral hyperalimentation with continuous subcutaneous insulin infusion improved severe diarrhea in poorly controlled diabetic patient. JPEN J Parenter Enteral Nutr. 1991;15181- 183Article
55.
Falko  JMO'Dorisio  TMCataland  S Improvement of high-density lipoprotein-cholesterol levels: ambulatory type I diabetics treated with the subcutaneous insulin pump. JAMA. 1982;24737- 39Article
56.
Lawson  PTrayner  IRosenstock  J  et al.  The effect of continuous subcutaneous insulin infusion on serum lipids. Diabete Metab. 1984;10239- 244
57.
Schmitz  OSchwartz Sorensen  SAlberti  KGMM  et al.  Metabolic control in newly kidney transplanted insulin-dependent diabetics: improvement by insulin pump treatment (CSII). J Diabet Complications. 1987;181- 86Article
58.
American Association of Diabetes Educators, Position statement: education for continuous subcutaneous insulin infusion pump users. Diabetes Educ. 1986;1310
59.
Marcus  AO Patient selection for insulin pump therapy. Pract Diabetol. November1992;12- 18
60.
Selam  J-LCharles  MA Devices for insulin administration. Diabetes Care. 1990;13955- 979Article
61.
Not Available, Deaths among patients using continuous subcutaneous insulin infusion pumps. MMWR Morb Mortal Wkly Rep. 1982;3180- 82
62.
Home  PDMarshall  SM Problems and safety of continuous subcutaneous insulin infusion. Diabet Med. 1984;141- 44Article
63.
Mecklenburg  RSGuinn  TSSannar  CA  et al.  Malfunction of continuous subcutaneous insulin infusion systems: a one-year prospective study of 127 patients. Diabetes Care. 1986;9351- 355Article
64.
Peden  NRBraaten  JTMcKendry  JBR Diabetic ketoacidosis during long-term treatment with continuous subcutaneous insulin infusion. Diabetes Care. 1984;71- 5Article
65.
Castillo  MJScheen  AJLefebvre  PJ Treatment with insulin infusion pumps and ketoacidotic episodes: from physiology to troubleshooting. Diabetes Metab Rev. 1995;11161- 177Article
66.
Castillo  MJScheen  AJLefebvre  PJ The degree/rapidity of the metabolic deterioration following interruption of a subcutaneous insulin infusion is influenced by the prevailing blood glucose level. J Clin Endocrinol Metab. 1996;811975- 1978
67.
Midthjell  KKapelrud  HBjornerud  A  et al.  Severe or life-threatening hypoglycemia in insulin pump treatment. Diabetes Care. 1994;171235- 1236
68.
Pietri  ARaskin  P Cutaneous complications of chronic continuous subcutaneous insulin infusion therapy. Diabetes Care. 1981;4624- 626Article
69.
Guinn  TSBailey  GJMecklenburg  RS Factors related to discontinuation of subcutaneous insulin-infusion therapy. Diabetes Care. 1988;1146- 51Article
70.
Chantelau  ELange  GSonnenberg  GE  et al.  Acute cutaneous complications and catheter needle colonization during insulin-pump treatment. Diabetes Care. 1987;10478- 482Article
71.
Wickline  CLCornitius  TGButler  T Cellulitus caused by Rhizomucor pusillus in a diabetic patient receiving continuous insulin infusion pump therapy. South Med J. 1989;821432- 1434Article
72.
Van Faassen  Not AvailableRazenberg  PPASimoons-Smit  AM  et al.  Carriage of Staphylococcus aureus and inflamed infusion sites with insulin-pump therapy. Diabetes Care. 1989;12153- 155Article
73.
Van Den Hove  JJacobs  M-CTennstedt  D  et al.  Allergic contact dermatitis from acrylates in insulin pump infusion sets. Contact Dermatitis. 1996;35108Article
74.
Corazza  MMaranini  CAlleotti  A  et al.  Nickel contact dermatitis due to the needle of an insulin pump, confirmed by microanalysis. Contact Dermatitis. 1998;39144Article
75.
Mecklenburg  RSGuinn  TS Complications of insulin pump therapy: the effect of insulin preparation. Diabetes Care. 1985;8367- 370Article
76.
Schmaub  SKonig  ALandgraf  R Human insulin analogue [LYS(B28),PRO(B29)]: the ideal pump insulin? Diabet Med. 1998;15247- 249Article
77.
Zinman  BTildesley  HChiasson  J-L  et al.  Insulin lispro in CSII: results of a double-blind crossover study. Diabetes. 1997;46440- 443Article
78.
Melki  VRenard  ELassman-Vague  V  et al.  Improvement of HbA1c and blood glucose stability in IDDM patients treated with lispro insulin analog in external pumps. Diabetes Care. 1998;21977- 982Article
79.
Attia  NJones  TWHolcombe  J  et al.  Comparison of human regular and lispro insulins after interruption of continuous subcutaneous insulin infusion and in the treatment of acutely decompensated IDDM. Diabetes Care. 1998;21817- 821Article
80.
Reichel  ARietzsch  HKohler  HJ  et al.  Cessation of insulin infusion at night-time during CSII-therapy: comparison of regular human insulin and insulin lispro. Exp Clin Endocrinol Diabetes. 1998;106168- 172Article
81.
Rudolf  MCAhern  JGenel  M  et al.  Optimal insulin delivery in adolescents with diabetes: impact of intensive treatment or psychosocial adjustment. Diabetes Care. 1982;5(suppl 1)53- 57
82.
Schiffrin  ADDesrosiers  MAleyossine  H  et al.  Intensified insulin therapy in the type 1 diabetic adolescent: a controlled trial. Diabetes Care. 1984;7107- 113Article
83.
Tamborlane  WVBatas  SERudolf  MC  et al.  Comparison of continuous subcutaneous insulin infusion versus multiple daily injections in adolescents with insulin-dependent diabetes. Adv Diabetologia. 1989;2(suppl 1)24- 27
84.
De Beaufort  CEBruning  GJ Continuous subcutaneous insulin infusion in children. Diabet Med. 1987;4103- 108Article
85.
Oesterle  ABoland  EYu  C  et al.  CSII: a new way to achieve strict metabolic control and lower the risk of severe hypoglycemia in adolescents [abstract]. Diabetes. 1998;21(suppl 1)1320A
86.
Boland  EAhern  JGrey  M A primer on the use of insulin pumps in adolescents. Diabetes Educ. 1998;2478- 86Article
87.
Knight  GBoulton  AJMWard  JD Experience of subcutaneous insulin infusion in the outpatient management of diabetic teenagers. Diabet Med. 1986;382- 84Article
88.
Becker  DKernesky  KTransue  D  et al.  Continuous subcutaneous insulin infusion (CSII) in adolescents with IDDM [abstract]. Int Study Group Diabetes Child Adolesc Bull. 1984;1110
89.
Steindel  BSRoe  TRCostin  G  et al.  Continuous subcutaneous insulin infusion (CSII) in children and adolescents with poorly controlled type 1 diabetes. Diabetes Res Clin Pract. 1995;27199- 204Article
90.
Boland  EAGrey  MOesterle  A  et al.  Continuous subcutaneous insulin infusion: a new way to lower risk of severe hypoglycemia, improve metabolic control, and enhance coping in adolescents with type 1 diabetes. Diabetes Care. 1999;221779- 1784Article
91.
Bougneres  PFLandier  FLammel  C  et al.  Insulin pump therapy in young children with type 1 diabetes. J Pediatr. 1984;105212- 217Article
92.
Tubiana-Rufi  Nde Lonlay  PBloch  J  et al.  Dispartition des accidents hypoglycemiques severes chez le tres jeune enfant diabetique traite par pompe sours-cutanee. Arch Pediatr. 1996;3969- 976Article
93.
de Beaufort  CEBruining  GJAarsan  RSR  et al.  Does subcutaneous insulin infusion (CSII) prolong the remission phase of insulin-dependent diabetic children? Neth J Med. 1985;2853- 54
94.
Beaufort  CE Continuous Subcutaneous Insulin Infusion in Newly Diagnosed Diabetic Children.  Rotterdam, the Netherlands Mo Thesis1986;
95.
Bougneres  PFLandier  FLammel  C  et al.  Insulin pump therapy in young children with type 1 diabetes. J Pediatr. 1984;105212- 217Article
96.
Kitzmiller  JLCloherty  JPYounger  MD  et al.  Diabetic pregnancy and perinatal morbidity. Am J Obstet Gynecol. 1978;131560- 580
97.
Kitzmiller  JLGavin  LAGin  GD  et al.  Preconception care of diabetes: glycemic control prevents congenital anomalies. JAMA. 1991;265731- 736Article
98.
Diamond  MPReece  EACaprio  S  et al.  Impairment of counterregulatory hormone response to hypoglycemia in pregnant women with insulin-dependent diabetes mellitus. Am J Obstet Gynecol. 1992;16670- 77Article
99.
Kimmerle  RHeinemann  LDelecki  A  et al.  Severe hypoglycemia incidence and predisposing factors in 85 pregnancies of type 1 diabetic women. Diabetes Care. 1992;151034- 1037Article
100.
Leveno  KJFotunato  SJRaskin  P  et al.  Continuous subcutaneous insulin infusion during pregnancy. Diabetes Res Clin Pract. 1988;4257- 268Article
101.
Jensen  BMKuhl  CMolsted-Pedersen  L  et al.  Preconceptional treatment with insulin infusion pumps in insulin-dependent diabetic women with particular reference to prevention of congenital malformations. Acta Endocrinol Suppl (Copenh). 1986;27781- 85
102.
Potter  JMReckless  PDCullen  DR The effect of continuous subcutaneous insulin infusion and conventional insulin regimes on 24-hour variations of blood glucose and intermediary metabolites in the third trimester of diabetic pregnancy. Diabetologia. 1981;21534- 539
103.
Burkart  WHanker  JPSchneider  HPG Complications and fetal outcome in diabetic pregnancy. Gynecol Obstet Invest. 1988;26104- 112Article
104.
Carta  QMeriggi  ETrossarelli  GF  et al.  Continuous subcutaneous insulin infusion versus intensive conventional insulin therapy in type I and type II diabetic pregnancy. Diabete Metab. 1986;12121- 129
105.
Jornsay  DL Continuous subcutaneous insulin infusion (CSII) therapy during pregnancy. Diabetes Spectrum. 1998;1126- 32
106.
Caruso  ALanzone  ABianchi  V  et al.  Continuous subcutaneous insulin infusion (CSII) in pregnant diabetic patients. Prenat Diagn. 1987;741- 50Article
107.
Patten  BCLenhard  MJ Type 2 diabetes and pumps: out on a limb? Diabetes Forecast. 1999;5248- 52
108.
Della Casa  LDel Rio  GGlaser  B  et al.  Effect of 6-month gliclazide treatment on insulin release and sensitivity to endogenous insulin in NIDDM: role of initial continuous subcutaneous insulin infusion-induced normoglycemia. Am J Med. 1991;90(suppl 6A)37S- 45SArticle
109.
Ilkova  HGlaser  BTunckale  A  et al.  Induction of long-term glycemic control in newly diagnosed type 2 diabetic patients by transient intensive insulin treatment. Diabetes Care. 1997;201353- 1356Article
110.
Glaser  BLeibovich  GNesher  R  et al.  Improved beta-cell function after intensive insulin treatment in severe non-insulin-dependent diabetes. Acta Endocrinol (Copenh). 1988;118365- 373
111.
Moura  PVLe Magoarou  MParies  J  et al.  Short-term effects of continuous subcutaneous insulin infusion treatment on insulin secretion in non–insulin-dependent overweight patients with poor glycaemic control despite maximal oral anti-diabetic treatment. Diabete Metab. 1997;2351- 57
112.
Kaplan  RMWilson  DKHartwell  SL  et al.  Prospective evaluation of HDL cholesterol changes after diet and physical conditioning programs for patients with type II diabetes mellitus. Diabetes Care. 1985;8343- 348Article
113.
Lormeau  BAurousseau  MHValensi  P  et al.  Hyperinsulinemia and hypofibrinolysis: effects of short-term optimized glycemic control with continuous insulin infusion in type II diabetic patients. Metabolism. 1997;461074- 1079Article
114.
Jennings  AMLewis  KSMurdoch  S  et al.  Randomized trial comparing continous subcutaneous insulin infusion and conventional insulin therapy in type II diabetic patients poorly controlled with sulfonylureas. Diabetes Care. 1991;14738- 744Article
115.
Saudek  CDDuckworth  WCGiobbie-Hurder  A  et al.  Implantable insulin pump vs multiple-dose insulin for non–insulin-dependent diabetes mellitus. JAMA. 1996;2761322- 1327Article
116.
Schmulling  R-MJakober  BPfohl  M  et al.  Exercise and insulin requirements. Horm Metab Res. 1990;2483- 87
117.
Mitchell  THAbraham  GSchiffren  A  et al.  Hyperglycemia after intense exercise in IDDM subjects during continuous subcutaneous insulin infusion. Diabetes Care. 1988;11311- 317Article
118.
Yki-Jarvinen  HDeFronzo  RAKoivisto  VA Normalization of insulin sensitivity in type I diabetic subjects by physical training during insulin pump therapy. Diabetes Care. 1984;7520- 527Article
119.
Thuesen  LChristiansen  JSSorensen  KE  et al.  Exercise capacity and cardiac function in type 1 diabetic patients treated with continuous subcutaneous insulin infusion: a controlled study. Scand J Clin Lab Invest. 1986;46779- 784Article
120.
Sachse  GNeuzner  JMaser  E  et al.  Continuous subcutaneous insulin infusion therapy (CSII) influences cardiovascular responses to graded exercise in patients with autonomic diabetic neuropathy of the cardiovascular system (ADNCS). Life Support Syst. 1985;3(suppl 1)530- 534
121.
Chantelau  EWirth  R Habitual physical activity in adult IDDM patients. Diabetes Care. 1992;15(suppl 4)1727- 1731Article
122.
Jornsay  DLDuckles  AEHankinson  JP Psychological considerations for patient selection and adjustment to insulin pump therapy. 1988;14291- 296
123.
Holmes  DM The person and diabetes in psychosocial context. Diabetes Care. 1986;9194- 205Article
124.
Stein  C Psychological reactions to insulin infusion pumps. Med Clin North Am. 1982;661285- 1292
125.
Shapiro  JWigg  DCharles  MA  et al.  Personality and family profiles of chronic insulin-dependent diabetic patients using portable insulin infusion pump therapy: a preliminary investigation. Diabetes Care. 1984;7137- 142Article
126.
Wolf  FMJacober  SJWolf  LL  et al.  Quality of life activities associated with adherence to insulin infusion pump therapy in the treatment of insulin-dependent diabetes mellitus. J Clin Epidemiol. 1989;421129- 1136Article
127.
Grimm  JJHaardt  MJThibult  N  et al.  Lifestyle, metabolic control and social implications of pump therapy in 54 routine type 1 diabetic patients. Diabete Metab. 1987;133- 11
128.
Rudolf  MCAhern  JAGenel  M  et al.  Optimal insulin delivery in adolescents with diabetes: impact of intensive treatment on psychological adjustment. Diabetes Care. 1982;5(suppl 1)53- 57
129.
Goldson  DStewart  JObrosky  DS  et al.  Psychological functioning of children with insulin-dependent diabetes mellitus: a longitudinal study. J Pediatr Psychol. 1990;15619- 632Article
130.
Walsh  JRoberts  R Pumping Insulin.  San Diego, Calif Torrey Pines Press1994;
131.
Strowig  SM Initiation and management of insulin pump therapy. Diabetes Educ. 1993;1950- 59
132.
Norby  D Intensive Insulin Therapy Using an Insulin Infusion Pump: A Guide to Developing a Protocol to Implement Insulin Pump Therapy.  Minneapolis, Minn Disetronic Medical Systems Inc1995;
133.
Fredrickson  I The Insulin Pump Therapy Book: Insights From the Experts.  Sylmar, Calif MiniMed Technologies1995;
134.
Boland  E Teens Pumping It! Insulin Pump Therapy Guide for Adolescents.  Sylmar, Calif MiniMed Technologies1995;
135.
Brink  SJStewart  C Insulin pump treatment in children, adolescents, and young adults. JAMA. 1986;255617- 621Article
Review Article
October 22, 2001

Continuous Subcutaneous Insulin InfusionA Comprehensive Review of Insulin Pump Therapy

Author Affiliations

From the Diabetes and Metabolic Diseases Center, Section of Endocrinology, Christiana Care Health Services (Dr Lenhard), and the Division of Pediatric Endocrinology, DuPont Hospital for Children (Dr Reeves), Wilmington, Del; and Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pa (Drs Lenhard and Reeves).

Arch Intern Med. 2001;161(19):2293-2300. doi:10.1001/archinte.161.19.2293
Abstract

A tremendous amount of data suggest that near-normal glycemic control prevents or delays complications of diabetes, which has led to a dramatic increase in continuous subcutaneous insulin infusion (CSII) or insulin pump use. In this article, the data supporting CSII in type 1 diabetes is reviewed, and the advantages and disadvantages of CSII are analyzed. In addition, CSII use in specific situations is examined, including during childhood and pregnancy and while exercising. The published articles suggest that CSII provides better glycemic control than does conventional therapy and comparable to or slightly better control than multiple daily injections. The use of CSII may be especially indicated during pregnancy or for preconception care and for diabetes presenting in childhood or adolescence.

The Diabetes Control and Complications Trial (DCCT) demonstrated a dramatic reduction in the frequency and severity of complications of diabetes mellitus type 1 in adolescents and young adults by achieving and maintaining glucose control in the near-normal range.1 Comparable but less dramatic results were demonstrated in the UK Prospective Diabetes Study for people with type 2 diabetes.2 These studies established intensive management of diabetes as the standard of care, which has rekindled an interest in external insulin infusion pumps, referred to as continuous subcutaneous insulin infusion (CSII). The patients treated with CSII in the DCCT demonstrated slightly better glycemic control than those treated with multiple daily injections, and CSII therapy was well tolerated.3

Consequently, the popularity of CSII has increased dramatically. Approximately 50 000 to 70 000 adults in the United States are thought to be using CSII, representing about 8% of the adult population with type 1 diabetes.4,5 In addition, the number of insulin pump users is estimated to have doubled over the last 5 years.4 Despite this surge in popularity, a comprehensive review of CSII has not appeared in the literature for many years, although brief reviews have been published in textbooks.6,7 Continuous subcutaneous insulin infusion seems to be the most physiologic method of delivering insulin subcutaneously to achieve near-normal glycemic control. With patients and their families demanding to use CSII, this review is an attempt to describe the best uses, special considerations, and problems associated with CSII therapy.

DATA SOURCES

All articles found in MEDLINE from 1979 to 2000 that contained the words "CSII" or "insulin pump" were read. There were 991 articles listed, although some articles appeared on both lists. Review articles were included and differences among conclusions explored. Both reviewers abstracted data independently.

PRINCIPLES AND BACKGROUND

Insulin pumps were introduced in the late 1970s. There was initial excitement over this new technology,8,9 but within a few years their popularity waned because their size, safety, and efficacy became troublesome issues.10,11 Insulin pumps had a resurgence in popularity in late 1993 after the DCCT results were published. The new pumps are smaller, more efficacious, and easier to use. There are presently 3 manufacturers of insulin pumps in the United States: Disetronic Medical Systems Inc (St Paul, Minn); MiniMed Technologies (Sylmar, Calif); and Animas (Frasier, Pa). The new pumps are small, weighing around 400 g, and they all operate similarly. The insulin pump contains an insulin-filled cartridge or a syringe connected to a catheter that is inserted into the subcutaneous tissue (Figure 1). The pump continuously delivers predetermined basal rates to meet nonprandial insulin requirements. The devices allow programming of many different basal infusion rates, although the average patient requires only 4 to 6 different rates (Figure 2). It also infuses a bolus to cover mealtime or snack time insulin requirements.

MISCONCEPTIONS

Therapy using CSII is not well understood by the public, patients with diabetes, or even some health care providers. There is no surgery involved. The subcutaneous catheter is manually inserted, typically in less than 5 minutes. The pump is not an artificial pancreas. While patients who use CSII may sleep later in the morning because their levels are better controlled for longer duration, appropriate adjustments in the insulin infusion rates must be made. They cannot ignore their calorie- and carbohydrate-restricted diets. The patient needs to self-monitor blood glucose levels as much as if not more than patients who rely on multiple daily injections (MDI). While there is good evidence that CSII will provide better glycemic and metabolic control than MDI, with fewer dangerous glycemic excursions, there is often a misconception that it will completely eliminate episodes of severe hypoglycemia or hyperglycemia.

ADVANTAGES OF CSII
Glycemic Control

Intensive diabetes management with CSII provides better glycemic control than does conventional management, which is usually defined as 2 or fewer injections per day and 2 self-monitored blood glucose checks.12,13 It also provides as good and often better glycemic control than intensive diabetes management with MDI.1430 In addition to lowering the levels of glycosylated hemoglobin, CSII has been shown to decrease glycemic variability31,32 and lower fasting glucose values.16,29,3335

Hypoglycemia

Hypoglycemia is a serious risk associated with intensive therapy and occurs with both CSII and MDI. Early studies suggested that the risk of hypoglycemia with CSII was greater or similar to that of conventional diabetes management 36,37 and MDI.38,39 More recently, however, reports have suggested that severe hypoglycemia may be reduced by CSII as much as 4-fold compared with MDI treatment40,41 with no reduction in glycemic control. This decrease in hypoglycemic events has been accompanied by an increase in self-reported warning symptoms of hypoglycemia, as well as by an increase in counterregulatory hormonal responses to hypoglycemia.42,43 Severe hypoglycemia has now become an accepted indication for initiation of CSII therapy.

Other Metabolic Factors and Diabetes Complications

Intensive diabetes management with CSII improves glycemic control. The improved control is associated with fewer diabetic and metabolic complications. Treatment with CSII also improves or slows the progression of diabetic nephropathy,4446 peripheral and autonomic neuropathy,4749 retinopathy,5054 hypertriglyceridemia and hypoalphalipoproteinemia,55,56 and diabetic changes in transplanted kidneys.57

Lifestyle Flexibility

The improvement in lifestyle may be the most important reason to the patient who chooses CSII. The ability to increase flexibility in moment-to-moment living is the reason most frequently cited by individuals who have chosen CSII.58 It allows the patient to modify insulin availability hour by hour, which makes possible the performance of activities that would otherwise be risky: skipping or delaying meals, sleeping late on weekends, or engaging in vigorous exercise.59 This increased flexibility may be fueling the upsurge in patient demand for CSII more than any other factor.

DISADVANTAGES OF CSII

As recently as 1990, some authorities asserted that "the use of CSII is discouraged in routine clinical practice," suggesting instead that it be limited to specific subsets of patients with type 1 diabetes.60 While earlier reports of increased and unexplained mortality among CSII users61 have largely been explained,11 there are several risks associated with CSII.

Diabetic Ketoacidosis

There is no subcutaneous depot of long-acting insulin with CSII. If the flow of the regular, short-acting insulin is interrupted, ketonemia and diabetic ketoacidosis can develop more rapidly and more frequently with CSII than with other treatments.21,36,62 The interruption of insulin may be intentional, to allow patients to participate in certain activities, or unintentional, caused by catheter occlusion, catheter disinsertion, battery failure, depleted insulin supply, and other causes.6365 Many times, the interruption of insulin is a result of patient error and inadequate training, particularly when patients do not take the emergency steps necessary in the event of unexplained hyperglycemia.6 In experimental settings where insulin delivery was intentionally interrupted, plasma-free insulin values fell to very low levels (4-8 mU/L) within a 6-hour period, accompanied by large increases in blood glucose, plasma 3-β-hydroxybutyrate, and free fatty acid values.66

Hypoglycemia

While hypoglycemia generally occurs less frequently with CSII than with MDI, concern has been expressed about hypoglycemia resulting from unintentional insulin delivery, or "pump runaway." While this event has occurred,67 it is exceedingly rare and, to our knowledge, has not been found in the United States in the last 10 years. Technological advances in the microprocessor components and insulin delivery alarms of the currently marketed insulin pumps now make the occurrence of such an event extremely unlikely.

Catheter Site Infection and Contact Dermatitis

The most common complication associated with CSII is infection at the infusion site36,67,68; this is one of the most common causes listed for discontinuation of CSII.69 Most cases of infection have been bacterial, usually Staphylococcus or Streptococcus species,70 although Rhizomucor cellulitis has been found.71 Presumably, almost any pathogen could be a cause. There are conflicting reports as to whether CSII users are chronic carriers of Staphylococcus.70,72 Occasionally, the infection may lead to cellulitis or abscess formation requiring surgical debridement. The annual rate of catheter site infection has been estimated at 7.3 to 11.3 events per 100 years of patient follow-up.3 Additionally, occasional cases of contact dermatitis attributed to the components of the infusion sets and tape have been described.73,74 On very rare occasions, the contact dermatitis persists despite changing the type of tape and/or catheter, and is so severe that CSII must be discontinued.

Weight Gain

The most common metabolic adverse effect of improved glycemic control is weight gain, largely attributable to reducing glycosuria. Participants in the DCCT who used intensive management gained about 10 pounds (4.5 kg) more than the conventional treatment group,1 although there was no difference in the weight gained between patients using CSII and those using MDI.3

Cost

The insulin pump and the supplies needed to begin therapy average about $5000. The infusion set and catheters must be purchased regularly for as long as CSII is used, at a yearly cost of approximately $1500. Most insurance companies, including Medicare and Medicaid, cover the cost of CSII treatment after medical approval. We are not aware of any detailed studies of the cost-benefit analysis of CSII.

Prevention of Disadvantages

To minimize the risk of ketoacidosis, patients must check their blood glucose levels at least 4 times a day to prevent the development of severe diabetic ketoacidosis. Frequent self-monitoring of blood glucose levels will also allow for early recognition of hypoglycemia. A change of catheter site every 2 to 3 days will minimize the risk for developing skin infections. The application of a local antibiotic ointment to mild skin infections will usually cure them, and creams with aloe, vitamin E, or corticosteroids may be helpful for contact dermatitis. Weight gain does not have to occur with CSII. Exercise and close attention to caloric intake can result in weight maintenance and, if necessary, weight reduction.

SPECIAL CONSIDERATIONS WITH CSII THERAPY
Choice of Insulin for CSII

Phosphate-buffered insulin demonstrates a decreased incidence of catheter obstruction, and therefore is the preferred insulin for CSII.75 There are currently 2 insulin preparations available that contain a phosphate buffer. Velosulin (Novo Nordisk, Princeton, NJ) is buffered regular insulin, and lispro insulin (Lilly, Indianapolis, Ind) is an insulin analogue modified to provide very fast action. While only Velosulin has a Food and Drug Administration indication for CSII, lispro insulin has some clear advantages: lispro CSII has resulted in less severe and fewer cases of hypoglycemia and better glycemic control than Velosulin CSII.7578 However, since lispro is more rapidly absorbed, there is a concern that the interruption of lispro insulin infusion may lead to more rapid metabolic deterioration than an interrupted infusion with buffered regular insulin. Consensus is lacking. One study showed no temporal difference.79 Another study showed that with lispro metabolic deterioration occurred 1.5 to 2 hours earlier and was associated with a larger decrease in blood pH.80 Thus, CSII with lispro insulin seems to provide better glycemic control and fewer and less severe instances of hypoglycemia than CSII with buffered regular insulin, although diabetic ketoacidosis may develop more rapidly.

CSII Use in Children and Adolescents

In contrast to the adult population with type 1 diabetes, there is scarce data on the use of CSII in the adolescent and childhood populations (especially childhood). The literature includes few studies, all very limited in scope; none are randomized, and most involve adolescents. Most of the studies are small, usually 25 or fewer subjects, and short in duration, usually 12 months or less.8190 In addition to nonrandomization, a limited number of subjects, and a relatively short duration, the 3 CSII studies in the childhood diabetic population have other major limitations. Two involve only toddlers,91,92 and the others involve only children with newly diagnosed diabetes.93,94

The results of the few studies in the adolescent and childhood diabetes population are contradictory. Most of the studies, especially the more recent ones, demonstrate that insulin pump therapy provides as good or better metabolic and glycemic control than MDI and that it is as well or better tolerated.3,8186 Earlier studies, however, demonstrated that it did not provide better control and was not well tolerated.87,88 Recent studies demonstrate that CSII is associated with lower or comparable rates of complications such as hypoglycemia, ketoacidosis, and weight gain than are MDI,85,89,90,95 while earlier studies demonstrated more complications.87,88 Notwithstanding the scarcity of information and some variance in the findings on the safety and efficacy of CSII in the pediatric diabetes population, children and adolescents with diabetes and their parents are demanding to use the pump because they perceive it to be the safest, easiest, and the most physiologic method of delivering insulin subcutaneously to achieve near-normal glycemic control.

CSII Use During Pregnancy

The association between excessive maternal hyperglycemia in women with type 1 diabetes and the risk of fetal anomalies is well accepted.96,97 In addition to striving for preconception euglycemia, euglycemic or near euglycemic control should be the goal throughout pregnancy. Hypoglycemia increases during the first trimester of pregnancy. This may be due in part to attempts at improved metabolic control, the passive diffusion of glucose across the placenta, and alterations in the counterregulatory responses of epinephrine, growth hormone, and glucagon.98 Kimmerle et al99 reported rates of severe hypoglycemia, defined as coma, seizure, or incapacitation requiring the help of others, to be as high as 41% in pregnant women with diabetes. With the advantages of CSII in decreasing hypoglycemia and improving glycemic variability, it is logical to assume that CSII would be beneficial for pregnant women with diabetes. As with early studies of CSII efficacy for glycemic control in nonpregnant patients, some of the earlier studies of CSII during pregnancy demonstrated no significant improvement in glycemic control, perinatal morbidity, or length of hospitalization.100 Subsequent studies, however, suggest that CSII is superior to conventional therapy97,101 and at least comparable to MDI102104 in achieving metabolic goals in pregnancy. Several aspects of CSII suggest that even if glycemic control is only comparable to MDI, pregnant women may prefer CSII because of its several advantages. These include increased ease of treating morning sickness and hyperemesis gravidarum, reductions in glycemic excursions and hypoglycemia, ease of treating the dawn phenomenon that increases during pregnancy, and improved management in the postpartum period when insulin requirements may fluctuate.105 Three studies have found comparable results for pregnant women with type 2 or gestational diabetes,104106 although this area has not been well studied.

CSII Use for Type 2 Diabetes

The data on CSII therapy in type 2 diabetes is rather scarce compared with data for treating type 1 diabetes, although the enthusiasm for implementing CSII with type 2 diabetes has increased.107 Several short-term trials have demonstrated improvement in glycemic control at 6 months,108,109 improved β-cell function and first-phase insulin secretion,110,111 and improvement in the altered metabolic milieu associated with type 2 diabetes.112,113 There is only 1 randomized trial comparing CSII with conventional insulin therapy.114 In this 4-month trial involving 20 subjects, CSII achieved superior glycemic control, with comparable insulin doses and similar amounts of weight gain. Ultimately, CSII may prove to be of significant benefit to patients with type 2 diabetes, but the paucity of data makes it impossible to draw any conclusions at present. The many publications detailing the successful use of the experimental implantable insulin pump in type 2 diabetes gives hope that these results can be extended to CSII.115

CSII and Exercise

Habitual physical activity has significant benefit to the patient with diabetes, and CSII may make it easier for the patient to maintain glycemic parameters acutely during exercise because of its ability to readily alter the rate of insulin delivery.116 Although CSII has not always led to significant improvement in postexercise hyperglycemia,117 insulin sensitivity and aerobic exercise capacity have been shown to improve with CSII.118,119 Several studies have suggested that CSII may be superior to conventional insulin therapy in improving cardiac function in subjects with cardiac autonomic neuropathy.119,120 And while regular exercise is certainly to be encouraged, adequate training of the CSII user is essential to allow safe changes in the basal infusion rate and to avoid disrupting the catheter site during brisk physical activity.121

Psychological and Social Implications of CSII

The use of CSII may evoke psychological issues to a greater degree than conventional diabetes therapy.122 An emotional and psychosocial assessment is necessary prior to initiating CSII to prevent discontinuation and ensure proper use of the pump.

Several aspects of CSII are unique, and therefore may present barriers to successful glycemic control. Since the pump is visible to others, some patients express difficulty with body image and their self-perceived attractiveness.123 Other people feel inconvenienced explaining CSII to others and consider it an invasion of their privacy.124 Although CSII may help provide exceptional metabolic control, this mechanical dependency may invoke feelings of vulnerability and fear of device failure.122 Patient and family education prior to initiation of CSII helps to minimize this.122 Patient selection is vital to patient tolerance of CSII. It is not always possible to predict whether CSII will be successful.95 While some studies have shown CSII to be associated with significantly less anxiety and depression and improved family social dynamics,125 other studies have suggested that these benefits are most notable in patients who asked to remain on CSII after completion of the study.126,127 In effect, these studies self-selected those patients who were likely to express the greatest satisfaction and least psychological discomfort with CSII. There are few data on the psychological effect of CSII in children and adolescents, with studies showing both an improved sense of control over their life for some patients128 and an increase in anxiety for others.129

Patient Selection and Implementation of CSII

Several excellent texts and articles on the strategies and procedures of initiating CSII have been published and provide a detailed "how to" guide for the health care practitioner.7,130135 Beginning CSII involves more than merely changing the method of insulin delivery. Patients should participate in a formal educational program. A dietitian should instruct the patient in proper meal planning and carbohydrate counting, whereby the patient calculates the quantity of insulin to take at each meal based on the amount of carbohydrates to be consumed. A diabetes educator should instruct the patient in insulin pump management. And a psychologist and/or social worker should assess motivation, cognitive and problem-solving skills, maturity level, financial stability, and social support systems. It may be difficult to successfully implement CSII without the assistance of ancillary health care providers and a team approach. The successful implementation of CSII may be as dependent on a motivated, flexible, and skilled health care team as it is on the patient.

There are no universally applicable criteria for determining which patients will do well on CSII. Table 1 lists some characteristics that may help determine which patients will be successful. The current model is that the motivated, relatively stable patient is the best candidate for CSII. A different school of thought, however, holds that the patient with poorly controlled diabetes who may, in addition, not possess the highest level of motivation, cognitive skills, or social support may benefit to an even greater degree than the more enfranchised patient. There is currently no data to support this opinion, but relevant research is being conducted.

SUMMARY

Continuous subcutaneous insulin infusion has proven to be extremely effective in treating type 1 diabetes. It provides glycemic control superior to that of conventional therapy and comparable or slightly superior to MDI. It also decreases the frequency and/or severity of hypoglycemic reactions and increases lifestyle flexibility. With good compliance and proper attention to details, the disadvantages and risks of CSII can be minimized.

Some specific patient situations may be especially attractive for the use of CSII, including pregnancy or preconception care and diabetes presenting in childhood or adolescence. For the successful use of CSII, a skilled and motivated health care delivery team is required, and a thorough evaluation and training of the CSII candidate is necessary prior to implementation. There is also a need for ongoing close contact between the pump user and the health care team.

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Article Information

Accepted for publication March 29, 2001.

We thank Zoe Meyers of Disetronic Medical Systems Inc (St Paul, Minn), and the librarians at the Christiana Care Medical Library, Wilmington, Del, especially Joan Smith, for assistance with the literature search.

The photographs were expertly taken at the Medical Photography section at Christiana Hospital.

Corresponding author and reprints: M. James Lenhard, MD, Diabetes and Metabolic Diseases Center, Section of Endocrinology, Christiana Care Health Services, 700 Lea Blvd, Suite 300, Wilmington, DE 19802 (e-mail: JLenhard@ChristianaCare.org).

References
1.
DCCT Research Group, Diabetes Control and Complications Trial (DCCT): the effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin dependent diabetes mellitus. N Engl J Med. 1993;329977- 986Article
2.
UK Prospective Diabetes Study (UKPDS) Group, Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet. 1998;352837- 853Article
3.
Diabetes Control and Complications Trial Research Group, Implementation of treatment protocols in the Diabetes Control and Complications Trial. Diabetes Care. 1995;18361- 376Article
4.
Boaz-Christy  K Up and pumping: chart your way to better control. Diabetes Interview. March1999;30
5.
Brody  JE Small, convenient and flexible, insulin pumps catch on. New York Times. August10 1999;Personal Health section.
6.
Saudek  CD Novel forms of insulin delivery. Endocrinol Metab Clin North Am. 1997;26599- 610Article
7.
Strowig  SRaskin  P Intensive management of insulin-dependent diabetes mellitus. Porte  DSherwin  RSeds.Ellenberg's and Rifkin's Diabetes Mellitus. 5th ed. Stamford, Conn Appleton & Lange1997;709- 733
8.
Pickup  JCKeen  HParsons  JA  et al.  Continuous subcutaneous insulin infusion: an approach to achieving normoglycaemia. BMJ. 1978;1204- 207Article
9.
Tamborlane  WVSherwin  RSGenet  M  et al.  Normalization of plasma glucose in juvenile diabetics by subcutaneous administration of insulin with a portable infusion pump. N Engl J Med. 1979;300573- 578Article
10.
Unger  RH Meticulous control of diabetes: benefits, risks and precautions. Diabetes. 1979;31479- 483Article
11.
Teutsch  SMHerman  WHDwyer  DM  et al.  Mortality among diabetic patients using continuous subcutaneous insulin-infusion pumps. N Engl J Med. 1984;310361- 368Article
12.
Tamborlane  WVSherwin  RSGenel  M  et al.  Outpatient treatment of juvenile-onset diabetes with a preprogrammed portable subcutaneous insulin infusion system. Am J Med. 1980;68190- 196Article
13.
Pickup  JCWhite  MCKeen  H  et al.  Long-term continuous subcutaneous insulin infusion in diabetics at home. Lancet. 1979;2870- 873Article
14.
Kobayashi  TSawano  SItoh  T  et al.  The pharmacokinetics of insulin after continuous subcutaneous infusion or bolus subcutaneous injection in diabetic patients. Diabetes. 1983;32331- 336Article
15.
Rizza  RAO'Brien  PCService  FJ Use of beef ultralente for basal insulin delivery: plasma insulin concentrations after chronic ultralente administration in patients with IDDM. Diabetes Care. 1986;9120- 123Article
16.
Schiffrin  ABelmonte  MM Comparison between continuous subcutaneous insulin infusion and multiple injections of insulin: a one-year prospective study. Diabetes. 1982;31255- 264Article
17.
Leichter  SBSchreiner  MEReynolds  LR  et al.  Long-term follow-up of diabetic patients using insulin infusion pumps: considerations for future clinical application. Arch Intern Med. 1985;1451409- 1412Article
18.
Deeb  LCWilliams  PE Surveillance in Florida of continuous subcutaneous insulin infusion use in cohort. Diabetes Care. 1986;9591- 595Article
19.
Simonson  DCTamborlane  WVSherwin  RS  et al.  Improved insulin sensitivity in patients with type I diabetes mellitus after CSII. Diabetes. 1985;34Suppl 380- 86Article
20.
The Kroc Collaborative Study Group, Collaborative studies of the effects of continuous subcutaneous insulin infusion in insulin-dependent diabetes mellitus: conclusions. Diabetes. 1985;34(suppl 3)87- 89Article
21.
The Kroc Collaborative Study Group, Blood glucose control and the evolution of diabetic retinopathy and albuminuria: a preliminary multicenter trial. N Engl J Med. 1984;311365- 372Article
22.
Lauritzen  TFrost-Larsen  KLarsen  H-W  et al.  Two-year experience with continuous subcutaneous insulin infusion in relation to retinopathy and neuropathy. Diabetes. 1985;34(suppl 3)74- 79Article
23.
Haakens  KHanssen  KFDahl-Jorgensen  K  et al.  Continuous subcutaneous insulin infusion (CSII), multiple injections (MI), and conventional insulin therapy (CT) in self-selecting insulin-dependent diabetic patients: a comparison of metabolic control, acute complications and patient preferences. J Intern Med. 1990;228457- 464Article
24.
Dahl-Jorgensen  KBrinchmann-Hansen  OHanssen  KF  et al.  Effect of near normoglycaemia for two years on progression of early diabetic retinopathy, nephropathy, and neuropathy: the Oslo study. Br Med J (Clin Res Ed). 1986;2931195- 1199Article
25.
Schiffrin  AColle  EBelmonte  M Improved control in diabetes with continuous subcutaneous insulin infusion. Diabetes Care. 1980;3643- 649Article
26.
Helve  EKoivisto  VALehtonen  A  et al.  A cross-over comparison of continuous insulin infusion and conventional injection treatment of type 1 diabetes. Acta Med Scand. 1987;221385- 393Article
27.
Rizza  RA Treatment options for insulin-dependent diabetes mellitus: a comparison of the artificial endocrine pancreas, continuous subcutaneous insulin infusion, and multiple daily injections. Mayo Clin Proc. 1986;61796- 805Article
28.
Mecklenburg  RSBenson  EABenson Jr  JW  et al.  Long-term metabolic control with insulin pump therapy: report of experience with 127 patients. N Engl J Med. 1985;313465- 468Article
29.
Reeves  MLSeigler  DERyan  EA  et al.  Glycemic control in insulin-dependent diabetes mellitus: comparison of outpatient intensified conventional therapy with continuous subcutaneous insulin infusion. Am J Med. 1982;72673- 680Article
30.
Diabetes Control and Complications Trial Research Group, Implementation of treatment protocols in the Diabetes Control and Complications Trial. Diabetes Care. 1995;18361- 377Article
31.
Bischof  FMeterhoff  CPfeiffer  EF Quality control of intensified insulin therapy: HbA1 versus blood glucose. Horm Metab Res. 1994;26574- 578Article
32.
Lauritzen  TPramming  SDeckert  T  et al.  Pharmacokinetics of continuous subcutaneous insulin infusion. Diabetologia. 1983;24326- 329Article
33.
Koivisto  VAYki-Jarvinen  HKaronen  S-L  et al.  Pathogenesis and prevention of the dawn phenomenon in diabetic patients treated with CSII. Diabetes. 1986;3578- 82Article
34.
Haakens  KHanssen  KFDahl-Jorgensen  K  et al.  Early morning glycaemia and the metabolic consequences of delaying breakfast/morning insulin: a comparison of continuous subcutaneous insulin infusion and multiple injection therapy with human isophane or human ultralente insulin at bedtime in insulin-dependent diabetics. Scand J Clin Lab Invest. 1989;49653- 659Article
35.
Guerci  BMeyer  LDelbachian  I  et al.  Blood glucose control on Sunday in IDDM patients:intensified conventional insulin therapy versus continuous subcutaneous insulin infusion. Diabetes Res Clin Pract. 1998;40175- 180Article
36.
Mecklenburg  RSBenson  EABenson Jr  JW  et al.  Acute complications associated with insulin pump therapy: report of experience with 161 patients. JAMA. 1984;2523265- 3269Article
37.
Muhlhauser  IBerger  MSonnenberg  G  et al.  Incidence and management of severe hypoglycemia in 434 adults with insulin-dependent diabetes mellitus. Diabetes Care. 1985;8268- 273Article
38.
Arias  PKerner  WZier  H  et al.  Incidence of hypoglycemic episodes in diabetic patients under continuous subcutaneous insulin infusion and intensified conventional insulin treatment: assessment by means of semiambulatory 24-hour continuous blood glucose monitoring. Diabetes Care. 1985;8134- 140Article
39.
White  NHSkor  DACryer  PE  et al.  Identification of type I diabetic patients at increased risk for hypoglycemia during intensive therapy. N Engl J Med. 1983;308485- 491Article
40.
Bode  BWSteed  DRDavidson  PC Reduction in severe hypoglycemia with long-term continuous subcutaneous insulin infusion in type 1 diabetes. Diabetes Care. 1996;19324- 327Article
41.
Haardt  MJBerne  CDorange  C  et al.  Efficacy and indications of CSII revisited: the Hotel Dieu cohort. Diabetic Med. 1997;14407- 408Article
42.
Del Rio  GBaldini  ACarani  C  et al.  Adrenomedullary hyperactivity in type 1 diabetic patients before and during continuous subcutaneous insulin treatment. J Clin Endocrinol Metab. 1989;68555- 559Article
43.
Kanc  KJanssen  MJKeulen  ETP  et al.  Substitution of night-time continuous subcutaneous insulin infusion therapy for bedtime NPH insulin in a multiple injection regimen improves counterregulatory hormonal responses and warning symptoms of hypoglycaemia in IDDM. Diabetologia. 1998;41322- 329Article
44.
Feldt-Rasmussen  BMathiesen  ERDeckert  T  et al.  Effect of 2 years of strict metabolic control on progression of incipient nephropathy in insulin-dependent diabetes. Lancet. 1986;21300- 1304Article
45.
Deckert  TLauritzen  TParving  H-H  et al.  Effect of two years of strict metabolic control on kidney function in long-term insulin-dependent diabetics. Diabet Nephropathy. 1984;36- 10
46.
Dahl-Jorgensen  KBjoro  TKierulf  P  et al.  Long-term glycemic control and kidney function in insulin-dependent diabetes mellitus. Kidney Int. 1992;41920- 923Article
47.
Boulton  AJMDrury  JClarke  B  et al.  Continuous subcutaneous insulin infusion in the management of painful diabetic neuropathy. Diabetes Care. 1982;5386- 390Article
48.
Jakobsen  JChristiansen  JSKristoffersen  I  et al.  Autonomic and somatosensory nerve function after 2 years of continuous subcutaneous insulin infusion in type 1 diabetes. Diabetes. 1988;37452- 455Article
49.
Kronert  KHulser  JLuft  D  et al.  Effects of continuous subcutaneous insulin infusion and intensified conventional therapy on peripheral and autonomic nerve function. J Clin Endocrinol Metab. 1987;641219- 1223Article
50.
Helve  ELaatikainene  LMerenmies  L  et al.  Continuous insulin infusion therapy and retinopathy in patients with type I diabetes. Acta Endocrinol (Copenh). 1987;115313- 319
51.
Bibergeil  HHuttl  IFelsing  W  et al.  36 Months continuous subcutaneous insulin infusion (CSII) in insulin dependent diabetes (IDDM)—influence on early stages of retinopathy, nephropathy and neuropathy: psychological analysis. Exp Clin Endocrinol. 1987;9051- 61Article
52.
White  NHWaltman  SRKrupin  T  et al.  Reversal of abnormalities in ocular fluorophotometry in insulin-dependent diabetes after five to nine months of improved metabolic control. Diabetes. 1982;3180- 85Article
53.
Selam  JLMillet  PSaluski  S  et al.  Beneficial effect of glycaemic improvement in non-ischaemic forms of diabetic retinopathy: a 3-year follow-up. Diabet Med. 1986;360- 64Article
54.
Shimizu  HShimomura  YTakahashi  M  et al.  Enteral hyperalimentation with continuous subcutaneous insulin infusion improved severe diarrhea in poorly controlled diabetic patient. JPEN J Parenter Enteral Nutr. 1991;15181- 183Article
55.
Falko  JMO'Dorisio  TMCataland  S Improvement of high-density lipoprotein-cholesterol levels: ambulatory type I diabetics treated with the subcutaneous insulin pump. JAMA. 1982;24737- 39Article
56.
Lawson  PTrayner  IRosenstock  J  et al.  The effect of continuous subcutaneous insulin infusion on serum lipids. Diabete Metab. 1984;10239- 244
57.
Schmitz  OSchwartz Sorensen  SAlberti  KGMM  et al.  Metabolic control in newly kidney transplanted insulin-dependent diabetics: improvement by insulin pump treatment (CSII). J Diabet Complications. 1987;181- 86Article
58.
American Association of Diabetes Educators, Position statement: education for continuous subcutaneous insulin infusion pump users. Diabetes Educ. 1986;1310
59.
Marcus  AO Patient selection for insulin pump therapy. Pract Diabetol. November1992;12- 18
60.
Selam  J-LCharles  MA Devices for insulin administration. Diabetes Care. 1990;13955- 979Article
61.
Not Available, Deaths among patients using continuous subcutaneous insulin infusion pumps. MMWR Morb Mortal Wkly Rep. 1982;3180- 82
62.
Home  PDMarshall  SM Problems and safety of continuous subcutaneous insulin infusion. Diabet Med. 1984;141- 44Article
63.
Mecklenburg  RSGuinn  TSSannar  CA  et al.  Malfunction of continuous subcutaneous insulin infusion systems: a one-year prospective study of 127 patients. Diabetes Care. 1986;9351- 355Article
64.
Peden  NRBraaten  JTMcKendry  JBR Diabetic ketoacidosis during long-term treatment with continuous subcutaneous insulin infusion. Diabetes Care. 1984;71- 5Article
65.
Castillo  MJScheen  AJLefebvre  PJ Treatment with insulin infusion pumps and ketoacidotic episodes: from physiology to troubleshooting. Diabetes Metab Rev. 1995;11161- 177Article
66.
Castillo  MJScheen  AJLefebvre  PJ The degree/rapidity of the metabolic deterioration following interruption of a subcutaneous insulin infusion is influenced by the prevailing blood glucose level. J Clin Endocrinol Metab. 1996;811975- 1978
67.
Midthjell  KKapelrud  HBjornerud  A  et al.  Severe or life-threatening hypoglycemia in insulin pump treatment. Diabetes Care. 1994;171235- 1236
68.
Pietri  ARaskin  P Cutaneous complications of chronic continuous subcutaneous insulin infusion therapy. Diabetes Care. 1981;4624- 626Article
69.
Guinn  TSBailey  GJMecklenburg  RS Factors related to discontinuation of subcutaneous insulin-infusion therapy. Diabetes Care. 1988;1146- 51Article
70.
Chantelau  ELange  GSonnenberg  GE  et al.  Acute cutaneous complications and catheter needle colonization during insulin-pump treatment. Diabetes Care. 1987;10478- 482Article
71.
Wickline  CLCornitius  TGButler  T Cellulitus caused by Rhizomucor pusillus in a diabetic patient receiving continuous insulin infusion pump therapy. South Med J. 1989;821432- 1434Article
72.
Van Faassen  Not AvailableRazenberg  PPASimoons-Smit  AM  et al.  Carriage of Staphylococcus aureus and inflamed infusion sites with insulin-pump therapy. Diabetes Care. 1989;12153- 155Article
73.
Van Den Hove  JJacobs  M-CTennstedt  D  et al.  Allergic contact dermatitis from acrylates in insulin pump infusion sets. Contact Dermatitis. 1996;35108Article
74.
Corazza  MMaranini  CAlleotti  A  et al.  Nickel contact dermatitis due to the needle of an insulin pump, confirmed by microanalysis. Contact Dermatitis. 1998;39144Article
75.
Mecklenburg  RSGuinn  TS Complications of insulin pump therapy: the effect of insulin preparation. Diabetes Care. 1985;8367- 370Article
76.
Schmaub  SKonig  ALandgraf  R Human insulin analogue [LYS(B28),PRO(B29)]: the ideal pump insulin? Diabet Med. 1998;15247- 249Article
77.
Zinman  BTildesley  HChiasson  J-L  et al.  Insulin lispro in CSII: results of a double-blind crossover study. Diabetes. 1997;46440- 443Article
78.
Melki  VRenard  ELassman-Vague  V  et al.  Improvement of HbA1c and blood glucose stability in IDDM patients treated with lispro insulin analog in external pumps. Diabetes Care. 1998;21977- 982Article
79.
Attia  NJones  TWHolcombe  J  et al.  Comparison of human regular and lispro insulins after interruption of continuous subcutaneous insulin infusion and in the treatment of acutely decompensated IDDM. Diabetes Care. 1998;21817- 821Article
80.
Reichel  ARietzsch  HKohler  HJ  et al.  Cessation of insulin infusion at night-time during CSII-therapy: comparison of regular human insulin and insulin lispro. Exp Clin Endocrinol Diabetes. 1998;106168- 172Article
81.
Rudolf  MCAhern  JGenel  M  et al.  Optimal insulin delivery in adolescents with diabetes: impact of intensive treatment or psychosocial adjustment. Diabetes Care. 1982;5(suppl 1)53- 57
82.
Schiffrin  ADDesrosiers  MAleyossine  H  et al.  Intensified insulin therapy in the type 1 diabetic adolescent: a controlled trial. Diabetes Care. 1984;7107- 113Article
83.
Tamborlane  WVBatas  SERudolf  MC  et al.  Comparison of continuous subcutaneous insulin infusion versus multiple daily injections in adolescents with insulin-dependent diabetes. Adv Diabetologia. 1989;2(suppl 1)24- 27
84.
De Beaufort  CEBruning  GJ Continuous subcutaneous insulin infusion in children. Diabet Med. 1987;4103- 108Article
85.
Oesterle  ABoland  EYu  C  et al.  CSII: a new way to achieve strict metabolic control and lower the risk of severe hypoglycemia in adolescents [abstract]. Diabetes. 1998;21(suppl 1)1320A
86.
Boland  EAhern  JGrey  M A primer on the use of insulin pumps in adolescents. Diabetes Educ. 1998;2478- 86Article
87.
Knight  GBoulton  AJMWard  JD Experience of subcutaneous insulin infusion in the outpatient management of diabetic teenagers. Diabet Med. 1986;382- 84Article
88.
Becker  DKernesky  KTransue  D  et al.  Continuous subcutaneous insulin infusion (CSII) in adolescents with IDDM [abstract]. Int Study Group Diabetes Child Adolesc Bull. 1984;1110
89.
Steindel  BSRoe  TRCostin  G  et al.  Continuous subcutaneous insulin infusion (CSII) in children and adolescents with poorly controlled type 1 diabetes. Diabetes Res Clin Pract. 1995;27199- 204Article
90.
Boland  EAGrey  MOesterle  A  et al.  Continuous subcutaneous insulin infusion: a new way to lower risk of severe hypoglycemia, improve metabolic control, and enhance coping in adolescents with type 1 diabetes. Diabetes Care. 1999;221779- 1784Article
91.
Bougneres  PFLandier  FLammel  C  et al.  Insulin pump therapy in young children with type 1 diabetes. J Pediatr. 1984;105212- 217Article
92.
Tubiana-Rufi  Nde Lonlay  PBloch  J  et al.  Dispartition des accidents hypoglycemiques severes chez le tres jeune enfant diabetique traite par pompe sours-cutanee. Arch Pediatr. 1996;3969- 976Article
93.
de Beaufort  CEBruining  GJAarsan  RSR  et al.  Does subcutaneous insulin infusion (CSII) prolong the remission phase of insulin-dependent diabetic children? Neth J Med. 1985;2853- 54
94.
Beaufort  CE Continuous Subcutaneous Insulin Infusion in Newly Diagnosed Diabetic Children.  Rotterdam, the Netherlands Mo Thesis1986;
95.
Bougneres  PFLandier  FLammel  C  et al.  Insulin pump therapy in young children with type 1 diabetes. J Pediatr. 1984;105212- 217Article
96.
Kitzmiller  JLCloherty  JPYounger  MD  et al.  Diabetic pregnancy and perinatal morbidity. Am J Obstet Gynecol. 1978;131560- 580
97.
Kitzmiller  JLGavin  LAGin  GD  et al.  Preconception care of diabetes: glycemic control prevents congenital anomalies. JAMA. 1991;265731- 736Article
98.
Diamond  MPReece  EACaprio  S  et al.  Impairment of counterregulatory hormone response to hypoglycemia in pregnant women with insulin-dependent diabetes mellitus. Am J Obstet Gynecol. 1992;16670- 77Article
99.
Kimmerle  RHeinemann  LDelecki  A  et al.  Severe hypoglycemia incidence and predisposing factors in 85 pregnancies of type 1 diabetic women. Diabetes Care. 1992;151034- 1037Article
100.
Leveno  KJFotunato  SJRaskin  P  et al.  Continuous subcutaneous insulin infusion during pregnancy. Diabetes Res Clin Pract. 1988;4257- 268Article
101.
Jensen  BMKuhl  CMolsted-Pedersen  L  et al.  Preconceptional treatment with insulin infusion pumps in insulin-dependent diabetic women with particular reference to prevention of congenital malformations. Acta Endocrinol Suppl (Copenh). 1986;27781- 85
102.
Potter  JMReckless  PDCullen  DR The effect of continuous subcutaneous insulin infusion and conventional insulin regimes on 24-hour variations of blood glucose and intermediary metabolites in the third trimester of diabetic pregnancy. Diabetologia. 1981;21534- 539
103.
Burkart  WHanker  JPSchneider  HPG Complications and fetal outcome in diabetic pregnancy. Gynecol Obstet Invest. 1988;26104- 112Article
104.
Carta  QMeriggi  ETrossarelli  GF  et al.  Continuous subcutaneous insulin infusion versus intensive conventional insulin therapy in type I and type II diabetic pregnancy. Diabete Metab. 1986;12121- 129
105.
Jornsay  DL Continuous subcutaneous insulin infusion (CSII) therapy during pregnancy. Diabetes Spectrum. 1998;1126- 32
106.
Caruso  ALanzone  ABianchi  V  et al.  Continuous subcutaneous insulin infusion (CSII) in pregnant diabetic patients. Prenat Diagn. 1987;741- 50Article
107.
Patten  BCLenhard  MJ Type 2 diabetes and pumps: out on a limb? Diabetes Forecast. 1999;5248- 52
108.
Della Casa  LDel Rio  GGlaser  B  et al.  Effect of 6-month gliclazide treatment on insulin release and sensitivity to endogenous insulin in NIDDM: role of initial continuous subcutaneous insulin infusion-induced normoglycemia. Am J Med. 1991;90(suppl 6A)37S- 45SArticle
109.
Ilkova  HGlaser  BTunckale  A  et al.  Induction of long-term glycemic control in newly diagnosed type 2 diabetic patients by transient intensive insulin treatment. Diabetes Care. 1997;201353- 1356Article
110.
Glaser  BLeibovich  GNesher  R  et al.  Improved beta-cell function after intensive insulin treatment in severe non-insulin-dependent diabetes. Acta Endocrinol (Copenh). 1988;118365- 373
111.
Moura  PVLe Magoarou  MParies  J  et al.  Short-term effects of continuous subcutaneous insulin infusion treatment on insulin secretion in non–insulin-dependent overweight patients with poor glycaemic control despite maximal oral anti-diabetic treatment. Diabete Metab. 1997;2351- 57
112.
Kaplan  RMWilson  DKHartwell  SL  et al.  Prospective evaluation of HDL cholesterol changes after diet and physical conditioning programs for patients with type II diabetes mellitus. Diabetes Care. 1985;8343- 348Article
113.
Lormeau  BAurousseau  MHValensi  P  et al.  Hyperinsulinemia and hypofibrinolysis: effects of short-term optimized glycemic control with continuous insulin infusion in type II diabetic patients. Metabolism. 1997;461074- 1079Article
114.
Jennings  AMLewis  KSMurdoch  S  et al.  Randomized trial comparing continous subcutaneous insulin infusion and conventional insulin therapy in type II diabetic patients poorly controlled with sulfonylureas. Diabetes Care. 1991;14738- 744Article
115.
Saudek  CDDuckworth  WCGiobbie-Hurder  A  et al.  Implantable insulin pump vs multiple-dose insulin for non–insulin-dependent diabetes mellitus. JAMA. 1996;2761322- 1327Article
116.
Schmulling  R-MJakober  BPfohl  M  et al.  Exercise and insulin requirements. Horm Metab Res. 1990;2483- 87
117.
Mitchell  THAbraham  GSchiffren  A  et al.  Hyperglycemia after intense exercise in IDDM subjects during continuous subcutaneous insulin infusion. Diabetes Care. 1988;11311- 317Article
118.
Yki-Jarvinen  HDeFronzo  RAKoivisto  VA Normalization of insulin sensitivity in type I diabetic subjects by physical training during insulin pump therapy. Diabetes Care. 1984;7520- 527Article
119.
Thuesen  LChristiansen  JSSorensen  KE  et al.  Exercise capacity and cardiac function in type 1 diabetic patients treated with continuous subcutaneous insulin infusion: a controlled study. Scand J Clin Lab Invest. 1986;46779- 784Article
120.
Sachse  GNeuzner  JMaser  E  et al.  Continuous subcutaneous insulin infusion therapy (CSII) influences cardiovascular responses to graded exercise in patients with autonomic diabetic neuropathy of the cardiovascular system (ADNCS). Life Support Syst. 1985;3(suppl 1)530- 534
121.
Chantelau  EWirth  R Habitual physical activity in adult IDDM patients. Diabetes Care. 1992;15(suppl 4)1727- 1731Article
122.
Jornsay  DLDuckles  AEHankinson  JP Psychological considerations for patient selection and adjustment to insulin pump therapy. 1988;14291- 296
123.
Holmes  DM The person and diabetes in psychosocial context. Diabetes Care. 1986;9194- 205Article
124.
Stein  C Psychological reactions to insulin infusion pumps. Med Clin North Am. 1982;661285- 1292
125.
Shapiro  JWigg  DCharles  MA  et al.  Personality and family profiles of chronic insulin-dependent diabetic patients using portable insulin infusion pump therapy: a preliminary investigation. Diabetes Care. 1984;7137- 142Article
126.
Wolf  FMJacober  SJWolf  LL  et al.  Quality of life activities associated with adherence to insulin infusion pump therapy in the treatment of insulin-dependent diabetes mellitus. J Clin Epidemiol. 1989;421129- 1136Article
127.
Grimm  JJHaardt  MJThibult  N  et al.  Lifestyle, metabolic control and social implications of pump therapy in 54 routine type 1 diabetic patients. Diabete Metab. 1987;133- 11
128.
Rudolf  MCAhern  JAGenel  M  et al.  Optimal insulin delivery in adolescents with diabetes: impact of intensive treatment on psychological adjustment. Diabetes Care. 1982;5(suppl 1)53- 57
129.
Goldson  DStewart  JObrosky  DS  et al.  Psychological functioning of children with insulin-dependent diabetes mellitus: a longitudinal study. J Pediatr Psychol. 1990;15619- 632Article
130.
Walsh  JRoberts  R Pumping Insulin.  San Diego, Calif Torrey Pines Press1994;
131.
Strowig  SM Initiation and management of insulin pump therapy. Diabetes Educ. 1993;1950- 59
132.
Norby  D Intensive Insulin Therapy Using an Insulin Infusion Pump: A Guide to Developing a Protocol to Implement Insulin Pump Therapy.  Minneapolis, Minn Disetronic Medical Systems Inc1995;
133.
Fredrickson  I The Insulin Pump Therapy Book: Insights From the Experts.  Sylmar, Calif MiniMed Technologies1995;
134.
Boland  E Teens Pumping It! Insulin Pump Therapy Guide for Adolescents.  Sylmar, Calif MiniMed Technologies1995;
135.
Brink  SJStewart  C Insulin pump treatment in children, adolescents, and young adults. JAMA. 1986;255617- 621Article
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