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Cunningham CR, Mehrsheikh AL, Aswani Y, Shetty AS, Itani M, Ballard DH, Khot R, Moshiri M, Picard MM, Northrup BE. Off the wall: incidental paraspinal and pelvic muscle pathology on abdominopelvic imaging. Abdom Radiol (NY) 2024:10.1007/s00261-024-04365-x. [PMID: 38831073 DOI: 10.1007/s00261-024-04365-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 04/27/2024] [Accepted: 04/28/2024] [Indexed: 06/05/2024]
Abstract
As the use of cross-sectional abdominal and pelvic imaging has increased exponentially in the past several decades, incidental musculoskeletal findings have become commonplace. These are often unrelated to the indication for the examination and are frequently referred to as the "radiologist's blind spot" on these studies. The differential diagnosis for abnormalities of the paraspinal and pelvic musculature is, in many cases, quite different from the anterior abdominal wall muscles. Furthermore, due to their relatively deep location, pathology involving the former muscle groups is more likely to be clinically occult, often presenting only incidentally when the patient undergoes cross-sectional imaging. Effective treatment of diseases of these muscles is dependent on adherence to a diverse set of diagnostic and treatment algorithms. The purpose of this review article is to familiarize the radiologist with the unique pathology of these often-overlooked muscles of the abdomen and pelvis.
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Affiliation(s)
- Christopher R Cunningham
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd., Campus Box 8131, St. Louis, MO, 63110, USA
| | - Amanda L Mehrsheikh
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd., Campus Box 8131, St. Louis, MO, 63110, USA
| | - Yashant Aswani
- Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Anup S Shetty
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd., Campus Box 8131, St. Louis, MO, 63110, USA
| | - Malak Itani
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd., Campus Box 8131, St. Louis, MO, 63110, USA
| | - David H Ballard
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd., Campus Box 8131, St. Louis, MO, 63110, USA
| | - Rachita Khot
- Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, VA, USA
| | - Mariam Moshiri
- Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA
| | - Melissa M Picard
- Department of Radiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Benjamin E Northrup
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd., Campus Box 8131, St. Louis, MO, 63110, USA.
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Gupta S, Ramteke H, Gupta S, Gupta S, Gupta KS. Are People With Type 1 Diabetes Mellitus Appropriately Following Insulin Injection Technique Practices: A Review of Literature. Cureus 2024; 16:e51494. [PMID: 38304656 PMCID: PMC10831209 DOI: 10.7759/cureus.51494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 01/01/2024] [Indexed: 02/03/2024] Open
Abstract
People with type 1 diabetes mellitus (T1DM) need to take multiple doses of insulin injections daily throughout their lives. However, a notable portion of people with diabetes mellitus (DM) show suboptimal insulin injection technique practices. They are supposed to follow the recommended insulin injection technique guidelines. Our explorative literature search, including studies from the past 30 years, is expected to identify the deficiencies of self-injection insulin techniques and the associated complications in people with T1DM, where we have summarised the overall incidence of complications that have occurred due to nonadherence of the prescribed guidelines, along with their associated risk factors. We have attempted to include multiple systematic reviews, meta-analyses, literature reviews, case reports, and original articles from the search engines and databases like PubMed, Scopus, ScienceDirect, Cochrane Library, Google Scholar, and BioMed Central, and studies with only human participants were included in this search. The knowledge sharing from this research may be utilised for enhancing the structured education diabetes programme and implementing the population-based corrective measures, including the thrust areas in future multi-centre longitudinal research studies and recommendations, which can prevent unnecessary complications and enhance their quality of life. Correct insulin administration technique, abstaining from administration of injection at the areas with lipohypertrophy, rotation of injection sites, and ultrasound scanning can be used as a complimentary method to detect the lipohypertrophy at an early stage. Liposuction is beneficial in reducing the extensive lipohypertrophic tissues but helps achieve only cosmetically satisfactory outcome; thus, empowering people to follow insulin injection technique guidelines is one of the best strategies to reduce the high prevalence of lipohypertrophy. To conclude, education among the people with DM, especially T1DM who have to take insulin regularly, needs to be carried out consistently in the clinical settings, to prevent the severe complications caused due to inappropriate insulin injection techniques.
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Affiliation(s)
- Swar Gupta
- Medicine and Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Harshal Ramteke
- Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Shlok Gupta
- Internal Medicine, Sunil's Diabetes Care n' Research Centre, Nagpur, IND
| | - Sunil Gupta
- Diabetology, Sunil's Diabetes Care n' Research Centre, Nagpur, IND
| | - Kavita S Gupta
- Nutrition, Sunil's Diabetes Care n' Research Centre, Nagpur, IND
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3
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Kirac CO, Sirikci V, Findikli HA. The impact of insulin induced lipohypertrophy on carotid intima-media thickness in patients with type 2 diabetes mellitus. Medicine (Baltimore) 2023; 102:e34696. [PMID: 37773793 PMCID: PMC10545240 DOI: 10.1097/md.0000000000034696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 07/20/2023] [Indexed: 10/01/2023] Open
Abstract
Lipohypertrophy (LH) is a major localized complication of insulin therapy. We aimed to investigate the association between insulin-induced LH and carotid intima-media thickness (CIMT) in patients with type 2 diabetes mellitus (DM). A total of 75 patients with DM treated with insulin were included in this study. The insulin injection sites of the patients were evaluated by inspection and palpation and then radiologically with ultrasound. The CIMT of the patients was evaluated using ultrasonography. According to the guideline recommendation, the CIMT cutoff value was taken as 0.9 mm, and the patients were categorized into 2 groups according to the CIMT value and evaluated statistically. The presence of LH (CI: 1.379-30.000; OR = 6.432; P < .05), age (CI: 1.036-1.149; OR = 1091; P < .05), BMI (CI: 1.003-1.262; OR = 1.125; P < .05) and duration of DM (CI: 1.001-1.300; OR = 1.141; P < .05) were independent risk factors for high-CIMT in patients with DM. The most interesting result of this study was that the presence of LH was an independent risk factor for increased CIMT. According to this result, we think that LH may increase the risk of cardiovascular disease as well as being a complication that disrupts the blood glucose regulation of patients with DM and increases the cost of treatment.
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Affiliation(s)
- Cem Onur Kirac
- Necip Fazil City Hospital, Department of Internal Medicine, Division of Endocrinology and Metabolism, Kahramanmaras, Turkey
| | - Vehbi Sirikci
- Necip Fazil City Hospital, Department of Internal Medicine, Kahramanmaras, Turkey
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Sørensen FMW, Svensson J, Kinnander C, Berg AK. Ultrasound Detected Subcutaneous Changes in a Pediatric Cohort After Initiation of a New Insulin Pump or Glucose Sensor. Diabetes Technol Ther 2023; 25:622-630. [PMID: 37279034 DOI: 10.1089/dia.2023.0137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Objective: This study examined subcutaneous tissue changes at sites used by continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring (CGM), and tested whether these changes, if any, were associated with glycated hemoglobin (HbA1c). Research Design and Methods: This prospective study investigated recently used CSII or CGM sites in 161 children and adolescents during the first year after initiation of a new diabetes device. Subcutaneous changes such as echogenicity, vascularization, and the distance from the skin surface to the muscle at CSII and CGM sites were assessed by ultrasound. Results: The distance from skin surface to muscle fascia at both the upper arm and abdomen was influenced by age, body mass index z-score, and sex. Especially in boys and the youngest, the depth of many devices outreached the mean distance. The mean distance for boys at the abdomen and upper arm ranged from 4.5-6.5 mm and 5-6.9 mm for all ages, respectively. Hyperechogenicity at CGM sites was 4.3% after 12 months. The frequency of subcutaneous hyperechogenicity and vascularization at CSII sites increased significantly over time (41.2% to 69.3% and 2% to 16% respectively, P < 0.001 and P = 0.009). Hyperechogenicity in the subcutis was not a predictor of elevated HbA1c (P = 0.11). Conclusion: There is large variation in the distance from the skin surface to the muscle fascia and many diabetes devices reach even deeper. Hyperechogenicity and vascularization increased significantly over time at CSII sites, but not CGM sites. The importance of hyperechogenicity for insulin absorption is unclear and further investigations are needed. Clinical Trial Registration number: NCT04258904.
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Affiliation(s)
- Fiona M W Sørensen
- Diabetes Technology, Clinical Research, Copenhagen University Hospital-Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Pediatrics, Herlev and Gentofte Hospital, Herlev, Denmark
| | - Jannet Svensson
- Diabetes Technology, Clinical Research, Copenhagen University Hospital-Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Pediatrics, Herlev and Gentofte Hospital, Herlev, Denmark
| | | | - Anna K Berg
- Diabetes Technology, Clinical Research, Copenhagen University Hospital-Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Pediatrics, Herlev and Gentofte Hospital, Herlev, Denmark
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Yu J, Wang H, Zhou M, Zhu M, Hang J, Shen M, Jin X, Shi Y, Xu J, Yang T. A Hypothesis on the Progression of Insulin-Induced Lipohypertrophy: An Integrated Result of High-Frequency Ultrasound Imaging and Blood Glucose Control of Patients. Diagnostics (Basel) 2023; 13:diagnostics13091515. [PMID: 37174907 PMCID: PMC10177501 DOI: 10.3390/diagnostics13091515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 03/26/2023] [Accepted: 03/29/2023] [Indexed: 05/15/2023] Open
Abstract
AIMS To put forward a scientific hypothesis about the progression of insulin-injection-induced lipohypertrophy (LH) according to the high-frequency ultrasonic imaging of insulin injection sites and the blood glucose control of patients. METHODS A total of 344 patients were screened for LH by means of high-frequency ultrasound scanning. The results of their ultrasound examination were described in detail and categorized into several subtypes. Seventeen patients with different subtypes of LH were followed up to predict the progression of LH. To further verify our hypothesis, the effects of different types of LH on glycemic control of patients were observed by comparing glycated hemoglobin A1c (HbA1C) and other glycemic-related indicators. RESULTS LH was found in 255 (74.1%) patients. According to the high-frequency ultrasonic imaging characteristics, LH can be categorized into three subtypes in general. Among all the LHs, the most common type observed was nodular hyperechoic LH (n = 167, 65.5%), followed by diffuse hyperechoic LH (n = 70, 27.5%), then hypoechoic LH (n = 18, 7.0%). At the follow-up after six months, all 10 patients with nodular hyperechoic LH had LH faded away. Of the five patients with diffuse hyperechoic LH, two had inapparent LH, and three had diffuse hyperechoic parts which had shrunk under ultrasound. No obvious changes were observed in the two cases of hypoechoic LH. Compared with the LH-free group, the mean HbA1C of the nodular hyperechoic LH group increased by 0.8% (9 mmol/mol) (95% CI:-1.394~-0.168, p = 0.005), that of the diffuse hyperechoic LH group increased by 2.0% (21 mmol/mol) (95% CI: -2.696~-1.20, p < 0.001), and that of the hypoechoic LH group increased by 1.5% (16 mmol/mol) (95% CI: -2.689~-0.275, p = 0.007). CONCLUSIONS It was hypothesized that the earlier stage of LH is nodular hyperechoic LH. If nodular LH is not found in time and the patient continues to inject insulin at the LH site and/or reuse needles, LH will develop into a diffuse type or, even worse, a hypoechoic one. Different subtypes of LH may represent differences in severity when blood glucose control is considered as an important resolution indicator. Further studies are needed to confirm our hypothesis on the progression and reversion of insulin-induced lipohypertrophy.
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Affiliation(s)
- Jian Yu
- Department of Endocrinology, The First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), Nanjing 210029, China
| | - Hong Wang
- Department of Endocrinology, The First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), Nanjing 210029, China
| | - Meijing Zhou
- Department of Endocrinology, The First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), Nanjing 210029, China
| | - Min Zhu
- Department of Endocrinology, The First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), Nanjing 210029, China
| | - Jing Hang
- Department of Ultrasound, The First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), Nanjing 210029, China
| | - Min Shen
- Department of Endocrinology, The First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), Nanjing 210029, China
| | - Xin Jin
- Department of Hospital Pharmacy, The Affiliated Suqian First People's Hospital of Nanjing Medical University, Suqian 223800, China
| | - Yun Shi
- Department of Endocrinology, The First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), Nanjing 210029, China
| | - Jingjing Xu
- Department of Endocrinology, The First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), Nanjing 210029, China
- Department of Nursing, The First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), Nanjing 210029, China
| | - Tao Yang
- Department of Endocrinology, The First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), Nanjing 210029, China
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Huang J, Yeung AM, Kerr D, Gentile S, Heinemann L, Al-Sofiani ME, Joseph JI, Seley JJ, Klonoff DC. Lipohypertrophy and Insulin. An Old Dog that Needs New Tricks. Endocr Pract 2023:S1530-891X(23)00386-5. [PMID: 37098370 DOI: 10.1016/j.eprac.2023.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/12/2023] [Accepted: 04/17/2023] [Indexed: 04/27/2023]
Abstract
OBJECTIVE To review the current status of practical knowledge related to insulin-associated lipohypertrophy (LH) - an accumulation of fatty subcutaneous nodules commonly caused by repeated injections and/or infusions of insulin into the same site. METHODS Review of published literature with additional contributions from leading multidisciplinary experts with the emphasis on clinical aspects including pathophysiology, clinical and economic consequences, diagnosis, prevention and treatment. RESULTS LH is the most common dermatologic complication of insulin therapy. Risk factors for the development of lipohypertrophy include repeated delivery of large amounts of insulin into the same location over time, repeated injection trauma to the skin and subcutaneous tissue, and multiple injections using the same needle. Subcutaneous insulin injection in skin areas with lipohypertrophy is associated with reduced pain; however, this problem can interfere with insulin absorption, thereby increasing the likelihood of glucose variability, hypo- and hyperglycemia when a site is changed. Modern visualization technology of the subcutaneous space with ultrasound can demonstrate lipohypertrophy early in the course of its development. CONCLUSIONS The physiological and psychological consequences of developing insulin lipohypertrophy can be prevented and treated with education focusing on insulin injection techniques.
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Affiliation(s)
- Jingtong Huang
- Diabetes Technology Society, Burlingame, California, USA.
| | - Andrea M Yeung
- Diabetes Technology Society, Burlingame, California, USA
| | - David Kerr
- Diabetes Technology Society, Burlingame, California, USA
| | - Sandro Gentile
- Department of Internal Medicine, Campania University "Luigi Vanvitelli", Naples, Italy; NefroCenter Research Network, Torre del Greco, Naples, Italy
| | | | - Mohammed E Al-Sofiani
- Division of Endocrinology, Department of Internal Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia; Division of Endocrinology, Diabetes and Metabolism, The Johns Hopkins University, Baltimore, Maryland, USA; Strategic Center for Diabetes Research, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Jeffrey I Joseph
- Jefferson Artificial Pancreas Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - David C Klonoff
- Diabetes Technology Society, Burlingame, California, USA; Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, California, USA
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Ucieklak D, Mrozińska S, Wojnarska A, Małecki MT, Klupa T, Matejko B. Type 1 Diabetes Mellitus and Lipohypertrophy - Impact of the Intervention on Glycemic Control via Patient's Examination and Retraining on Change of Infusion Set. Endocr Pract 2023; 29:174-178. [PMID: 36581082 DOI: 10.1016/j.eprac.2022.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 12/18/2022] [Accepted: 12/21/2022] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Lipohypertrophy (LH) is a common complication of insulin therapy in type 1 diabetes mellitus (T1DM). We examined whether an intervention consisting of LH assessment and retraining on insulin infusion set use improves glycemic control on subcutaneous insulin infusion (CSII) in patients with T1DM. METHODS The intervention was conducted in 79 consecutive patients with T1DM. Data on glucose levels, glycated hemoglobin (HbA1c), and insulin doses were collected at baseline and after a median of 22 weeks (20-31.75 weeks). RESULTS A total of 46 patients with T1DM (23 [50%] women) participating in the follow-up were characterized by a median age of 29 years (25-33.8 years), body mass index of 24.6 ± 3.3 kg/m2, T1DM duration of 16.5 years (8.3-20 years), and subcutaneous insulin infusion duration of 7 years (4-10.8 years). Patients' median HbA1c fell from 7.4% (6.7%-8.2%) to 7.05% (6.4%-7.6%) (P < .001), daily insulin dose/kg decreased (0.7 ± 0.20 vs 0.68 ± 0.15 IU/kg; P = .017) together with the total daily insulin dose (50.3 [40.5-62.7] vs 47.6 [39.8-62.1] IU; P = .019]. Furthermore, the percentage of basal insulin dose increased (43.0% [36-50] vs 44.0% [39.0-50.0]; P = .010], whereas the percentage of bolus dose decreased (57% [50-64] vs 56% [50-61], P = .010). CONCLUSIONS The structured LH-related intervention in patients with T1DM on insulin pumps resulted in better glycemic control and a decrease in total daily insulin dose.
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Affiliation(s)
- Damian Ucieklak
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland; Department of Metabolic Diseases, University Hospital, Krakow, Poland
| | - Sandra Mrozińska
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland; Department of Metabolic Diseases, University Hospital, Krakow, Poland; Department of Pathophysiology, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Aleksandra Wojnarska
- Department of Metabolic Diseases, University Hospital, Krakow, Poland; Department of Radiology, Jagiellonian University Medical College, Krakow, Poland
| | - Maciej T Małecki
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland; Department of Metabolic Diseases, University Hospital, Krakow, Poland
| | - Tomasz Klupa
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland; Department of Metabolic Diseases, University Hospital, Krakow, Poland
| | - Bartłomiej Matejko
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland; Department of Metabolic Diseases, University Hospital, Krakow, Poland.
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Barlas T, Yalcin MM, Coskun M, Demirel D, Altinova AE, Toruner FB, Karakoc MA, Yetkin I, Akturk M. Evaluation of Lipohypertrophy in Patients With Type 1 Diabetes Mellitus on Multiple Daily Insulin Injections or Continuous Subcutaneous Insulin Infusion. Endocr Pract 2023; 29:119-126. [PMID: 36423861 DOI: 10.1016/j.eprac.2022.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 11/10/2022] [Accepted: 11/15/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine lipohypertrophy (LH) in patients with type 1 diabetes mellitus (T1DM) on multiple daily insulin injections (MDII) or continuous subcutaneous insulin infusion (CSII) and to reveal the factors associated with the development and severity of LH. METHODS Sixty-six patients with T1DM treated with MDII (n = 35, 53%) or CSII (n = 31, 47%) for at least 1 year were included. LH localizations were detected with palpation and ultrasonography (USG). RESULTS The LH detection rate with USG was significantly higher than that by palpation in the whole group (P < .001). The LH was detected with USG in 30 (85.7%) patients in the MDII group and 22 (71.0%) patients in the CSII group (P = .144). Advanced LH was detected in 13 (37.1%) of the patients treated with MDII and in 3 (9.7%) of the patients treated with CSII. LH was more severe in the MDII group than in the CSII group (P = .013). Diabetes duration and length of infusion set use were significantly longer and body mass index, hypoglycemia, and complication rates were higher in patients with LH than those in patients without LH (P < .05). A positive correlation was found between LH severity and HbA1C and insulin dose (P < .05, for both). MDII as insulin administration method, incorrect rotation, and a history of ketosis were found to be the most related factors with LH severity in a multiple linear regression analysis (P < .05). CONCLUSION USG might be an effective approach for detecting and evaluating the severity of LH. MDII might cause more severe LH than CSII in patients with T1DM. In this study, LH was found to be associated mostly with incorrect rotation technique and a history of ketosis.
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Affiliation(s)
- Tugba Barlas
- Department of Endocrinology and Metabolism, Faculty of Medicine, Gazi University, Ankara, Turkey.
| | - Mehmet Muhittin Yalcin
- Department of Endocrinology and Metabolism, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Meric Coskun
- Department of Endocrinology and Metabolism, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Dilek Demirel
- Department of Endocrinology and Metabolism, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Alev Eroglu Altinova
- Department of Endocrinology and Metabolism, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Fusun Balos Toruner
- Department of Endocrinology and Metabolism, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Mehmet Ayhan Karakoc
- Department of Endocrinology and Metabolism, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Ilhan Yetkin
- Department of Endocrinology and Metabolism, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Mujde Akturk
- Department of Endocrinology and Metabolism, Faculty of Medicine, Gazi University, Ankara, Turkey
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Gentile S, Guarino G, Della Corte T, Marino G, Satta E, Pasquarella M, Romano C, Alfarone C, Giordano L, Loiacono F, Capece M, Lamberti R, Strollo F. Why Do So Many People with Type 2 Diabetes Who Take Insulin Have Lipohypertrophy? Fate or Educational Deficiencies? Diabetes Ther 2023; 14:179-191. [PMID: 36472805 PMCID: PMC9735184 DOI: 10.1007/s13300-022-01341-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 11/07/2022] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Cutaneous lipohypertrophy (LH) is a thickened, "rubbery" lesion in the subcutaneous tissue following multiple injections performed at the same site, i.e., an incorrect injection technique. It is widespread, averaging 47% of insulin patients worldwide, and has severe direct and indirect consequences. Direct consequences consist mainly of poor metabolic control and frequent hypoglycemic events (HYPOs), and indirect ones of markedly increased healthcare costs related to hospital access due to acute events and long-term disease complications. This observation also holds for Italy, despite the National Health System organization expecting every patient with diabetes to undergo a series of visits by different care team members, each performing a specific treatment/education task. Indeed, the recent literature points to poor awareness of LH relevance and metabolic consequences among doctors from general and diabetic hospital wards, with educational deficiencies on correct injection practice in nurses too. The aim was to establish if, to what extent, and by whom they had received training on correct insulin injection techniques, and how many initially received notions had persisted over time. METHODS We investigated the possible causes of such a failure from the point of view of 1160 insulin-requiring subjects with type 2 diabetes (T2DM), reporting for the first time to specialized diabetic structures through a validated questionnaire and, in the same patients, we searched for LH by inspection/palpation according to international guidelines, further confirmed by ultrasound scans. We then analyzed differences in education and injecting behavior between subjects classified as LH+ or LH- depending on the presence or absence of LH lesions. RESULTS We documented significant educational gaps, with 50% of patients failing to refer to healthcare professionals and relying on their peers with diabetes, thought to be more experienced in 15% of the cases. Seventy-five percent of LH- patients received education from healthcare providers, while 90% of LH+ learned from another patient or could not remember how they knew, and 68% of LH+ versus 52% of LH- (p < 0.01) patients had failed to receive training on injection techniques by healthcare providers. All of this enabled the most disabling features of diabetes from the very beginning of the disease history. CONCLUSIONS This study documents, from the patients' point of view, that educational gaps are significant and that, even in initially trained subjects, education on correct injection techniques has a fleeting effect if not regularly recalled. Therefore, to rehabilitate LH+ patients as soon as possible and prevent LH- patients from inadvertently slipping into the other group, there is an urgent need to educate doctors and nurses repeatedly on the importance of correctly injecting insulin to improve patients' knowledge and skills.
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Affiliation(s)
- Sandro Gentile
- Nefrocenter Research and Nyx Start-Up, Naples, Italy
- Department of Internal Medicine, University ''Luigi Vanvitelli'', Naples, Campania, Italy
| | - Giuseppina Guarino
- Nefrocenter Research and Nyx Start-Up, Naples, Italy
- Department of Internal Medicine, University ''Luigi Vanvitelli'', Naples, Campania, Italy
| | - Teresa Della Corte
- Nefrocenter Research and Nyx Start-Up, Naples, Italy
- Department of Internal Medicine, University ''Luigi Vanvitelli'', Naples, Campania, Italy
| | - Giampiero Marino
- Department of Internal Medicine, University ''Luigi Vanvitelli'', Naples, Campania, Italy
| | - Ersilia Satta
- Nefrocenter Research and Nyx Start-Up, Naples, Italy
- Polyspecialistic Nephrologic Center CNP Srl, Fratta Maggiore, Italy
| | | | | | | | - Laura Giordano
- Emodialysis Center Srl, Nefrocenter Network, Naples, Italy
| | | | - Maurizio Capece
- Vomero Center Crisci Bersabea and C SNC, Nefrocenter Network, Naples, Italy
| | | | - Felice Strollo
- Endocrinology and Diabetes, IRCCS San Raffaele Pisana, Rome, Italy.
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Kalra S, Unnikrishnan AG, Prasanna Kumar KM, Sahay R, Chandalia HB, Saboo B, Annamalai S, Kesavadev J, Shukla R, Wangnoo SK, Baruah MP, Jacob J, Arora S, Singla R, Sharma SK, Damodaran S, Bantwal G. Addendum 1: Forum for Injection Technique and Therapy Expert Recommendations, India. Diabetes Ther 2023; 14:29-45. [PMID: 36380217 PMCID: PMC9880128 DOI: 10.1007/s13300-022-01332-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 10/25/2022] [Indexed: 11/17/2022] Open
Abstract
With the emerging complexities in chronic diseases and people's lifestyles, healthcare professionals (HCPs) need to update their methods to manage and educate patients with chronic lifestyle disorders, particularly diabetes. The insulin injection technique (IIT), along with various parameters, must also be updated with newer methods. Forum for Injection Technique and Therapy Expert Recommendations (FITTER), India, has updated its recommendations to cover newer ways of detecting hypoglycaemia and lipohypertrophy, preventing needlestick injuries (NSIs), discouraging the reuse of insulin needles and encouraging good disposal. FITTER, India, is also introducing recommendations to calculate insulin bolus dose. These updated recommendations will help HCPs better manage patients with diabetes and achieve improved outcomes.
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11
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Fröhlich-Reiterer E, Elbarbary NS, Simmons K, Buckingham B, Humayun KN, Johannsen J, Holl RW, Betz S, Mahmud FH. ISPAD Clinical Practice Consensus Guidelines 2022: Other complications and associated conditions in children and adolescents with type 1 diabetes. Pediatr Diabetes 2022; 23:1451-1467. [PMID: 36537532 DOI: 10.1111/pedi.13445] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Elke Fröhlich-Reiterer
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | | | - Kimber Simmons
- Barbara Davis Center for Diabetes, University of Colorado, Denver, Colorado, USA
| | - Bruce Buckingham
- Division of Endocrinology and Diabetes, Department of Pediatrics, Stanford University Medical Center, Stanford, California, USA
| | - Khadija N Humayun
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Jesper Johannsen
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital, Herlev and Steno Diabetes Center Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Reinhard W Holl
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany
| | - Shana Betz
- Parent/Advocate for people with diabetes, Markham, Canada
| | - Farid H Mahmud
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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12
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Murao S, Murao K, Nagata T, Shimizu M, Miyai Y. Repeated insulin injection without site rotation affects skin thickness - ultrasonographic and histological evaluation. J Diabetes Investig 2022; 13:997-1003. [PMID: 35060349 PMCID: PMC9153835 DOI: 10.1111/jdi.13753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 01/04/2022] [Accepted: 01/19/2022] [Indexed: 12/03/2022] Open
Abstract
AIMS/INTRODUCTION The influence of repeated insulin injection on subcutaneous tissue is known, but its impact on the skin is unclear. Therefore, this study aimed to elucidate the impact of repeated insulin injections on the skin. MATERIAL AND METHODS The properties of the skin and the subcutaneous tissue were evaluated in 52 insulin-treated adult patients with diabetes with abnormal findings at the site of self-injection (36 with subcutaneous nodules, 16 with suspected subcutaneous tissue induration) by ultrasonography. In all subjects, both normal and abnormal areas were examined. In addition, skin biopsies were performed in four subjects. RESULTS The skin thickness of the normal and abnormal skin sites was 1.95 (1.60, 2.50) and 2.80 (2.27, 3.30) mm, respectively (median (first quartile, third quartile)), (P < 0.001). The biopsy specimens revealed slightly thickened and tight bundles of collagen in the dermis. Three patients had amyloid deposits in the subcutaneous tissue, and one also showed these in the dermis. These were positively stained for insulin antibody. CONCLUSIONS Repeated insulin injection procedures result in skin thickening. Increased collagen fibers and possibly amyloid deposition in the dermis may be involved. The results reaffirmed the importance of appropriate site rotation in insulin injection and revealed the usefulness of ultrasonographic skin examination in evaluating the self-injection procedure.
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Affiliation(s)
- Satoshi Murao
- Department of Metabolism and EndocrinologyTakamatsu HospitalKagawaJapan
| | - Kazutoshi Murao
- Department of DermatologyTokushima University Graduate School of Biomedical SciencesTokushimaJapan
| | - Tsuyoshi Nagata
- Department of Laboratory MedicineTakamatsu HospitalKagawaJapan
| | - Misato Shimizu
- Department of Laboratory MedicineTakamatsu HospitalKagawaJapan
| | - Yumi Miyai
- Department of Pathology and Host DefenseFaculty of MedicineKagawa UniversityKagawaJapan
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13
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Korkmaz FN, Gökçay Canpolat A, Güllü S. Determination of insulin-related lipohypertrophy frequency and risk factors in patients with diabetes. ENDOCRINOL DIAB NUTR 2022; 69:354-361. [PMID: 35697467 DOI: 10.1016/j.endien.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/05/2021] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Insulin, which is used in the treatment of diabetes mellitus (DM), may lead to the development of lipohypertrophy (LH) which can negatively affect the management of diabetes mellitus. Two common methods to detect LH are palpation and superficial subcutaneous ultrasonography (SSU). We investigated the frequency of non-palpable LH using SSU, as well as examining risk factors. METHOD We included in our study patients who had been receiving insulin injections at least twice a day for over one year without palpable LH. The epidermis and the subcutaneous tissue thickness of each region were examined using SSU. The presence of LH and associated risk factors for LH were evaluated. RESULTS We included 136 patients in our study. The mean age of all patients was 52.87±14.93 years, 59.6% were female and 73.5% had type 2 DM. The duration of DM and insulin usage were 15.76±9.20 and 11.42±8.26 years, respectively. The mean body mass index (BMI) of all patients was 30.59±7.40kg/m2. Non-palpable LH was detected in 87.5% (n=116) of the patients using SSU. In the multivariate logistic regression analyses, total cholesterol level, short-acting insulin dose and coronary artery disease (CAD) were associated with LH presence. CONCLUSION Non-palpable LH can be seen at high rates in patients who have multiple insulin injections. Palpation is likely not enough to detect LH and we believe it would be appropriate to evaluate the presence of LH using SSU, especially for those who need high-dose insulin to control hyperglycaemia.
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Affiliation(s)
- Fatma Nur Korkmaz
- Ankara University, School of Medicine, Department of Internal Medicine, Division of Endocrinology, Ankara, Turkey.
| | - Asena Gökçay Canpolat
- Ankara University, School of Medicine, Department of Internal Medicine, Division of Endocrinology, Ankara, Turkey
| | - Sevim Güllü
- Ankara University, School of Medicine, Department of Internal Medicine, Division of Endocrinology, Ankara, Turkey
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14
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Lin Y, Lin L, Wang W, Hong J, Zeng H. Insulin-related lipohypertrophy: ultrasound characteristics, risk factors, and impact of glucose fluctuations. Endocrine 2022; 75:768-775. [PMID: 34648113 DOI: 10.1007/s12020-021-02904-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 10/06/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Lipohypertrophy (LHT) has been suggested as an outcome of the adipogenic effects of insulin injection-related tissue trauma. It commonly occurs in the clinical setting, but the current understanding of LHT by the medical staff and diabetes patients remains insufficient; moreover, it has not garnered attention as a research topic. OBJECTIVE To investigate the ultrasound characterization of LHT, to identify the factors associated with LHT development by assessing the prevalence of LHT and compare the accuracy of clinical palpation with that of ultrasonography in LHT detection, and to further evaluate the possible impact of LHT on patients' blood glucose fluctuations. METHOD A cross-sectional study was conducted in 120 patients with type 2 diabetes. Patients' general information were obtained using a questionnaire, and the patients were evaluated for LHT by ultrasonography and clinical palpation of the abdomen. The patients were instructed to inject equal amounts of insulin in tissues with LHT and in normal adipose tissues (NATs) in two non-consecutive d in a selected week; the possible effect of LHT on patients' blood glucose fluctuations was assessed using a continuous glucose monitoring system. RESULTS LHT has characteristic ultrasonic signs. We found a high rate of missed LHT detection on clinical palpation compared with that on ultrasonography (P < 0.05). The duration of insulin treatment, rotation of injection sites, frequency of needle reuse, and number of insulin injections per day were the primary factors influencing the development of LHT (P < 0.05). Compared with NATs, LHT tissues showed extremely elevated amplitude of glycemic excursion, mean blood glucose levels, standard deviation of blood glucose levels and postprandial glucose excursion, and large fluctuations in blood glucose levels (P < 0.05). CONCLUSION Ultrasonography can more accurately detect LHT than can clinical palpation. LHT development is associated with several factors and can lead to significant fluctuations in blood glucose levels; thus, sufficient attention should be paid to investigating the underlying mechanism of LHT.
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Affiliation(s)
- Yiyang Lin
- 900 Hospital of the Joint Logistics Team, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, 350025, Fujian, China
| | - Lu Lin
- 900 Hospital of the Joint Logistics Team, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, 350025, Fujian, China
| | - Wei Wang
- 900 Hospital of the Joint Logistics Team, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, 350025, Fujian, China
| | - Junfeng Hong
- 900 Hospital of the Joint Logistics Team, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, 350025, Fujian, China
| | - Hua Zeng
- 900 Hospital of the Joint Logistics Team, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, 350025, Fujian, China.
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15
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Ucieklak D, Mrozinska S, Wojnarska A, Malecki MT, Klupa T, Matejko B. Insulin-induced Lipohypertrophy in Patients with Type 1 Diabetes Mellitus Treated with an Insulin Pump. Int J Endocrinol 2022; 2022:9169296. [PMID: 35111222 PMCID: PMC8803446 DOI: 10.1155/2022/9169296] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 12/23/2021] [Accepted: 12/27/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Lipohypertrophy (LH) of subcutaneous tissue is an insulin-induced complication occurring in patients with diabetes. We aimed to define the prevalence of LH and identify its risk factors in type 1 diabetes (T1DM) patients treated with continuous subcutaneous insulin infusion (CSII). MATERIALS AND METHODS The study included 79 consecutive CSII-treated T1DM patients. The diagnose of LH was based on ultrasonography (US) as a reference method, physical examination was also performed. Clinical characteristics were available from the medical records. RESULTS The median age of patients was 28 years (interquartile range [IQR], 24-30.5) with a body mass index (BMI) of 24.5 ± 3.5 kg/m2, HbA1c 7.1% (IQR, 6.7-8.1), T1DM duration 15 (9-20) years, and CSII use duration of 8 year (IQR, 5-11). LH was detected by US in 75 (94.9%) patients. This value was much higher than this obtained by visual assessment (n = 39, 49.4%) or palpation (n = 59, 74.7%). In univariate analyses, the following risk factors for occurrence of 5 and more LH lesions were identified: the ratio of insulin dose to body mass exceeding 0.7 IU/kg (OR, 3.69; 95% CI, 1.43-10.01) and the total daily insulin dose (OR, 1.05; 95% CI, 1.02-1.09). A higher dose of insulin per kg remained a significant risk factor of LH amount in multivariate analysis. CONCLUSION This selected T1DM cohort treated with CSII had a very high prevalence of LH. US assessment should be considered as a reference method for LH screening in T1DM patients. The identified risk factors for the number of LH lesions were related to insulin dosing.
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Affiliation(s)
- Damian Ucieklak
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland
- University Hospital, Krakow, Poland
| | - Sandra Mrozinska
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland
- University Hospital, Krakow, Poland
| | - Aleksandra Wojnarska
- University Hospital, Krakow, Poland
- Department of Radiology, Jagiellonian University Medical College, Krakow, Poland
| | - Maciej T. Malecki
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland
- University Hospital, Krakow, Poland
| | - Tomasz Klupa
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland
- University Hospital, Krakow, Poland
| | - Bartłomiej Matejko
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland
- University Hospital, Krakow, Poland
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16
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Shen M, Shi Y, Zheng S, Fan H, Xu J, Yang T. A Systematic Survey of Physicians' Insights Into Lipohypertrophy. Front Public Health 2021; 9:738179. [PMID: 34888280 PMCID: PMC8650682 DOI: 10.3389/fpubh.2021.738179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 10/27/2021] [Indexed: 11/22/2022] Open
Abstract
Background: It is important that physicians be aware of LH. We designed a questionnaire to determine physician awareness, knowledge, and behaviors regarding LH in clinical practice. Participants: A total of 499 questionnaires were completed by physicians in hospitals from 13 cities in Jiangsu Province, China. Key Results: Compared with physicians at tertiary hospitals, significantly fewer physicians at primary hospitals reported awareness of LH and its screening methods. The proportion of resident physicians aware of LH was significantly lower than the proportion of senior physicians. The proportion of physicians who could identify all LH risk factors among the low-GDP group was significantly higher than the high-GDP group. Only 38.7% of doctors could successfully identify all the hazards associated with LH, but more doctors in tertiary hospitals were able to do so compared to those in secondary and primary hospitals. Compared with tertiary hospitals, the proportions of primary and secondary hospitals with management processes were significantly lower. The proportion of doctors who educated patients regarding LH prevention and treatment in primary hospitals was markedly lower than in tertiary hospitals. Conclusions: Overall, physicians have an inadequate understanding of LH, especially in primary hospitals.
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Affiliation(s)
- Min Shen
- Department of Endocrinology and Metabolism, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yun Shi
- Department of Endocrinology and Metabolism, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shuai Zheng
- Department of Endocrinology and Metabolism, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hongqi Fan
- Department of Endocrinology and Metabolism, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jingjing Xu
- Department of Endocrinology and Metabolism, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Tao Yang
- Department of Endocrinology and Metabolism, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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17
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Hashem R, Mulnier H, Abu Ghazaleh H, Halson-Brown S, Duaso M, Rogers R, Karalliedde J, Forbes A. Characteristics and morphology of lipohypertrophic lesions in adults with type 1 diabetes with ultrasound screening: an exploratory observational study. BMJ Open Diabetes Res Care 2021; 9:9/2/e002553. [PMID: 34876413 PMCID: PMC8655520 DOI: 10.1136/bmjdrc-2021-002553] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 11/14/2021] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Lipohypertrophy is a common complication of exposure to insulin therapy. Despite the prevalence of lipohypertrophy and its potentially hazardous effects on glucose regulation, it remains a relatively understudied problem in diabetes. The objective of this study was to characterize lipohypertrophic tissue using ultrasound in adults with type 1 diabetes. RESEARCH DESIGN AND METHODS An observational study of 74 people with type 1 diabetes from a diabetes center in South East London. Participants' insulin exposed areas were scanned with ultrasound, with a high-frequency linear probe (6-13 MHz). The observed tissue changes were described, measured and graded according to nodule size and thickness of the dermal layer. RESULTS Participants mean age and diabetes duration were 40.6 (±14.2) and 18.3 (±10.9) years, respectively, and 60% (n=44) were male. A total of 740 lipohypertrophic nodules were observed, ranging from 1.8 mm to 40 mm in width. The mean (SD/range) number of nodules per participants was 10.4 (±6.2/1-29). Delineation between the dermal layers was disrupted in all current injection sites. In 52 participants (70%), there was a 30% increase in dermal thickness compared with local none injected tissue, and in 36 participants (48%) the increase was 50%. The level of thickness was >3 mm in the abdominal areas of 22 (40%) of these participants and in thighs of eight participants (17.8%). Hypoechogenic areas suggestive of necrotic tissue were observed within the lipohypertrophic nodules of 22 (30%) participants. Needle length and nodule depth were correlated (r=0.69, p<0.001). A conceptual model of the insulin exposed tissue changes observed was constructed. CONCLUSIONS The study confirms that insulin-exposed tissue changes are heterogenous and has provided conceptual and grading frameworks for classifying these changes. Further studies are required to establish the clinical implications of these classifications, in relation to glucose regulation and other clinical parameters.
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Affiliation(s)
- Rabab Hashem
- Division of Care in Long-term Conditions, King's College London, London, UK
| | - Henrietta Mulnier
- Division of Care in Long-term Conditions, King's College London, London, UK
| | - Haya Abu Ghazaleh
- Division of Care in Long-term Conditions, King's College London, London, UK
| | - Susan Halson-Brown
- Department of Women & Children's Health, King's College London, London, UK
| | - Maria Duaso
- Division of Care in Long-term Conditions, King's College London, London, UK
| | - Rebecca Rogers
- Division of Care in Long-term Conditions, King's College London, London, UK
| | | | - Angus Forbes
- Division of Care in Long-term Conditions, King's College London, London, UK
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18
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Korkmaz FN, Gökçay Canpolat A, Güllü S. Determination of insulin-related lipohypertrophy frequency and risk factors in patients with diabetes. ENDOCRINOL DIAB NUTR 2021; 69:S2530-0164(21)00184-1. [PMID: 34452876 DOI: 10.1016/j.endinu.2021.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/28/2021] [Accepted: 07/05/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Insulin, which is used in the treatment of diabetes mellitus (DM), may lead to the development of lipohypertrophy (LH) which can negatively affect the management of diabetes mellitus. Two common methods to detect LH are palpation and superficial subcutaneous ultrasonography (SSU). We investigated the frequency of non-palpable LH using SSU, as well as examining risk factors. METHOD We included in our study patients who had been receiving insulin injections at least twice a day for over one year without palpable LH. The epidermis and the subcutaneous tissue thickness of each region were examined using SSU. The presence of LH and associated risk factors for LH were evaluated. RESULTS We included 136 patients in our study. The mean age of all patients was 52.87±14.93 years, 59.6% were female and 73.5% had type 2 DM. The duration of DM and insulin usage were 15.76±9.20 and 11.42±8.26 years, respectively. The mean body mass index (BMI) of all patients was 30.59±7.40kg/m2. Non-palpable LH was detected in 87.5% (n=116) of the patients using SSU. In the multivariate logistic regression analyses, total cholesterol level, short-acting insulin dose and coronary artery disease (CAD) were associated with LH presence. CONCLUSION Non-palpable LH can be seen at high rates in patients who have multiple insulin injections. Palpation is likely not enough to detect LH and we believe it would be appropriate to evaluate the presence of LH using SSU, especially for those who need high-dose insulin to control hyperglycaemia.
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Affiliation(s)
- Fatma Nur Korkmaz
- Ankara University, School of Medicine, Department of Internal Medicine, Division of Endocrinology, Ankara, Turkey.
| | - Asena Gökçay Canpolat
- Ankara University, School of Medicine, Department of Internal Medicine, Division of Endocrinology, Ankara, Turkey
| | - Sevim Güllü
- Ankara University, School of Medicine, Department of Internal Medicine, Division of Endocrinology, Ankara, Turkey
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desJardins-Park HE, Wan DC. Leveraging Mechanical Forces to Target Insulin Injection-Induced Lipohypertrophy and Fibrosis. Diabetes Spectr 2021; 34:308-312. [PMID: 34511858 PMCID: PMC8387605 DOI: 10.2337/ds20-0048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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20
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Wang W, Huang R, Chen Y, Tu M. Values of ultrasound for diagnosis and management of insulin-induced lipohypertrophy: A prospective cohort study in China. Medicine (Baltimore) 2021; 100:e26743. [PMID: 34398053 PMCID: PMC8294902 DOI: 10.1097/md.0000000000026743] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 06/28/2021] [Indexed: 01/04/2023] Open
Abstract
The aim of this study was to explore the values of ultrasound for diagnosis and management of insulin-induced lipohypertrophy and further analyzing the impact of body mass index and subcutaneous fat thickness on ultrasound manifestations of lipohypertrophy.In this 3-month, prospective cohort study, a total of 162 patients with diabetes who used insulin therapy more than 1 year with unknown lipohypertrophy status were enrolled into this study. Demographic information, assessment of glycemic control and insulin injection technique were evaluated. Physical and ultrasound examination were separately performed to detect lipohypertrophy by a team of diabetes educator nurses or ultrasonographer in a blinded fashion. Patients with lipohypertrophy received insulin injection technique education based on ultrasound examination and Chinese guideline.Ultrasound examination detected 41.1% more patients (74.1% vs 52.5%; P < .001) with lipohypertrophy and 61.2% more lesions (216 vs 134; P < .001) than physical examination. Glycosylated hemoglobin A1c and fasting blood glucose were significantly decreased in patients with lipohypertrophy or subclinical lipohypertrophy (lipohypertrophy without visual and palpation changes) after receiving insulin injection technique education based on ultrasound examination and Chinese guideline than baseline at 3 months (P < .001). The proportion of lesions with ultrasound manifestation 2 (distortion of surrounding connective tissue) in obese and STF (>15 mm) groups were no more than 50% and showed a decreased trend with increased subcutaneous fat thickness and body mass index (P < .001).Lipohypertrophy has characteristic ultrasound manifestations which can detect more accurate results than palpation alone and provide detailed information to promote effective education on lipohypertrophy management, thereby improving glycemic control.
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21
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Szunerits S, Melinte S, Barras A, Pagneux Q, Voronova A, Abderrahmani A, Boukherroub R. The impact of chemical engineering and technological advances on managing diabetes: present and future concepts. Chem Soc Rev 2021; 50:2102-2146. [PMID: 33325917 DOI: 10.1039/c9cs00886a] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Monitoring blood glucose levels for diabetic patients is critical to achieve tight glycaemic control. As none of the current antidiabetic treatments restore lost functional β-cell mass in diabetic patients, insulin injections and the use of insulin pumps are most widely used in the management of glycaemia. The use of advanced and intelligent chemical engineering, together with the incorporation of micro- and nanotechnological-based processes have lately revolutionized diabetic management. The start of this concept goes back to 1974 with the description of an electrode that repeatedly measures the level of blood glucose and triggers insulin release from an infusion pump to enter the blood stream from a small reservoir upon need. Next to the insulin pumps, other drug delivery routes, including nasal, transdermal and buccal, are currently investigated. These processes necessitate competences from chemists, engineers-alike and innovative views of pharmacologists and diabetologists. Engineered micro and nanostructures hold a unique potential when it comes to drug delivery applications required for the treatment of diabetic patients. As the technical aspects of chemistry, biology and informatics on medicine are expanding fast, time has come to step back and to evaluate the impact of technology-driven chemistry on diabetics and how the bridges from research laboratories to market products are established. In this review, the large variety of therapeutic approaches proposed in the last five years for diabetic patients are discussed in an applied context. A survey of the state of the art of closed-loop insulin delivery strategies in response to blood glucose level fluctuation is provided together with insights into the emerging key technologies for diagnosis and drug development. Chemical engineering strategies centered on preserving and regenerating functional pancreatic β-cell mass are evoked in addition as they represent a permanent solution for diabetic patients.
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Affiliation(s)
- Sabine Szunerits
- Univ. Lille, CNRS, Centrale Lille, Univ. Polytechnique Hauts-de-France, UMR 8520-IEMN, F-59000 Lille, France.
| | - Sorin Melinte
- Institute of Information and Communication Technologies, Electronics and Applied Mathematics, Université catholique de Louvain, 1348 Louvain-la-Neuve, Belgium
| | - Alexandre Barras
- Univ. Lille, CNRS, Centrale Lille, Univ. Polytechnique Hauts-de-France, UMR 8520-IEMN, F-59000 Lille, France.
| | - Quentin Pagneux
- Univ. Lille, CNRS, Centrale Lille, Univ. Polytechnique Hauts-de-France, UMR 8520-IEMN, F-59000 Lille, France.
| | - Anna Voronova
- Univ. Lille, CNRS, Centrale Lille, Univ. Polytechnique Hauts-de-France, UMR 8520-IEMN, F-59000 Lille, France.
| | - Amar Abderrahmani
- Univ. Lille, CNRS, Centrale Lille, Univ. Polytechnique Hauts-de-France, UMR 8520-IEMN, F-59000 Lille, France.
| | - Rabah Boukherroub
- Univ. Lille, CNRS, Centrale Lille, Univ. Polytechnique Hauts-de-France, UMR 8520-IEMN, F-59000 Lille, France.
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22
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Singha A, Bhattacharjee R, Dalal BS, Biswas D, Choudhuri S, Chowdhury S. Associations of insulin-induced lipodystrophy in children, adolescents, and young adults with type 1 diabetes mellitus using recombinant human insulin: a cross-sectional study. J Pediatr Endocrinol Metab 2021; 34:503-508. [PMID: 33662195 DOI: 10.1515/jpem-2020-0556] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 12/21/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Insulin-induced lipodystrophy is of two types, lipohypertrophy and lipoatrophy. Lipodystrophy often leads to worsening of glycemic control in type 1 diabetes mellitus. Our objective was to identify the clinical, immunological, and other factor(s) associated with the development of lipodystrophy. METHODS In this observational cross-sectional hospital-based study, 95 children, adolescents, and young adults with type 1 diabetes mellitus were observed for the development of lipodystrophy. Injection technique, insulin dose, and glycemic parameters were noted. Serum TNF-α, IL-1β, and anti-insulin antibody levels were measured. Histopathological examination of the lipodystrophic area was done in a small number of people. RESULTS Among the participants, 45.2% of participants had lipohypertrophy and 4.2% had lipoatrophy exclusively; 3.1% of participants had coexisting lipohypertrophy and lipoatrophy. Improper injection site rotation technique was more common in participants with lipohypertrophy in comparison to those without lipodystrophy. The age of onset of diabetes, duration of insulin use, and the number of times of needle reuse were not significantly different between the lipohypertrophy and nonlipodystrophy groups. Serum TNF-α, IL-1β, and anti-insulin antibody levels; HbA1c; rate of hypoglycemia; and body weight-adjusted dose requirement were higher among the participants with lipohypertrophy. On histopathology, scant, or no inflammatory infiltrate was found in lipoatrophic and lipohypertrophic areas, respectively. CONCLUSION Improper insulin injection technique and higher levels of proinflammatory cytokines and anti-insulin antibody are associated with lipodystrophy in type 1 diabetes mellitus. HbA1c and rate of hypoglycemia are higher in people with lipodystrophy.
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Affiliation(s)
- Arijit Singha
- Department of Endocrinology & Metabolism, Institute of Post Graduate Medical Education & Research, Kolkata, India
| | - Rana Bhattacharjee
- Department of Endocrinology & Metabolism, Institute of Post Graduate Medical Education & Research, Kolkata, India
| | - Bibhas Saha Dalal
- Department of Pathology, ESI-PGIMSR &ESIC Medical College, Kolkata, India
| | - Dibakar Biswas
- Department of Endocrinology & Metabolism, Institute of Post Graduate Medical Education & Research, Kolkata, India
| | - Subhadip Choudhuri
- Microbiology & Immunology, University of Texas Medical Branch, Houston, TX, USA
| | - Subhankar Chowdhury
- Department of Endocrinology & Metabolism, Institute of Post Graduate Medical Education & Research, Kolkata, India
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Point-of-Care Ultrasound (POCUS) in the Field of Diabetology. Int J Chronic Dis 2021; 2021:8857016. [PMID: 33763467 PMCID: PMC7964119 DOI: 10.1155/2021/8857016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 02/16/2021] [Accepted: 02/23/2021] [Indexed: 11/17/2022] Open
Abstract
Ultrasound is increasingly used in daily clinical practice to improve the efficiency of the clinical examination. In this article, we reviewed its various possible uses in the field of diabetology. The ultrasonic evaluation of the carotid arteries (plaques and intima media thickness) allows improving the assessment of the cardiovascular risk. Steatosis can be detected relatively easily on liver ultrasound. Ultrasound also allows a more sensitive detection of lipohypertrophy resulting in glycemic fluctuations and thus increasing the risk of hypoglycemia than the clinical examination. Finally, muscle ultrasound appears to be a promising tool to assess the nutritional status and its consequences (e.g., falls).
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Luo D, Shi Y, Zhu M, Wang H, Yan D, Yu J, Ji J, Liu X, Fan B, Xu Y, Zhang M, He W, Xu J, Yang T. Subclinical lipohypertrophy--Easily ignored complications of insulin therapy. J Diabetes Complications 2021; 35:107806. [PMID: 33280982 DOI: 10.1016/j.jdiacomp.2020.107806] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/18/2020] [Accepted: 11/20/2020] [Indexed: 12/28/2022]
Abstract
AIMS Subclinical lipohypertrophy is a lesion meeting ultrasonic criteria for lipohypertrophy that was not detected by inspection and palpation. Little information is published on subclinical lipohypertrophy among insulin injection people with diabetes. We aimed to investigate the subclinical lipohypertrophy prevalence, risk factors, and the association between subclinical lipohypertrophy and glycemic control. METHODS This observational study included 316 people with diabetes who had continuously received insulin therapy for at least one year. We performed ultrasound scanning and clinical examination for evidence of subclinical lipohypertrophy. Demographic characteristics, clinical information, and glycated hemoglobin were measured. RESULTS The overall prevalence of subclinical lipohypertrophy was 19.9%. By stepwise logistic regression, higher BMI (OR = 1.44, 95%CI: 1.15-1.81, P = 0.002), incorrect rotation of sites (OR = 3.11, 95%CI: 1.02-9.47, P = 0.046), insulin needle reusage for more than four times (OR = 10.00, 95%CI: 3.23-31.02, P = 0.000) and type 1 diabetes (OR = 6.33, 95%CI: 1.32-30.47, P = 0.021) remained associated with subclinical lipohypertrophy. Subclinical lipohypertrophy demonstrated a significant independent correlation with the nonoptimal glycemic control (OR = 9.97, 95% CI: 3.46-28.75, P = 0.000) when accounting for demographic and diabetes-related parameters. CONCLUSIONS Subclinical lipohypertrophy is common among insulin-injecting patients with diabetes and is related to glycemic control deterioration. Ultrasonography may be an ideal adjunct in the evaluation of easily ignored lipohypertrophy lesions, especially where poor glycemic control, incorrect injection behaviors, overweight or obesity are documented.
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Affiliation(s)
- Dan Luo
- School of Nursing, Nanjing Medical University, 101 Longmian Dadao, Jiangning District, Nanjing, China
| | - Yun Shi
- Department of Endocrinology, First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), 300 Guangzhou Road, Gulou District, Nanjing, China
| | - Min Zhu
- Department of Endocrinology, First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), 300 Guangzhou Road, Gulou District, Nanjing, China
| | - Hong Wang
- Department of Endocrinology, First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), 300 Guangzhou Road, Gulou District, Nanjing, China
| | - Dan Yan
- Department of Endocrinology, First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), 300 Guangzhou Road, Gulou District, Nanjing, China
| | - Jian Yu
- Department of Endocrinology, First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), 300 Guangzhou Road, Gulou District, Nanjing, China
| | - JiaJia Ji
- Department of Endocrinology, First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), 300 Guangzhou Road, Gulou District, Nanjing, China
| | - Xiaoyun Liu
- Department of Endocrinology, First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), 300 Guangzhou Road, Gulou District, Nanjing, China
| | - Boqiang Fan
- Department of Radiology, First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), 300 Guangzhou Road, Gulou District, Nanjing, China
| | - Yang Xu
- Department of Dermatology, First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), 300 Guangzhou Road, Gulou District, Nanjing, China
| | - Mei Zhang
- Department of Endocrinology, First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), 300 Guangzhou Road, Gulou District, Nanjing, China
| | - Wei He
- Department of Endocrinology, First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), 300 Guangzhou Road, Gulou District, Nanjing, China.
| | - Jingjing Xu
- Department of Endocrinology, First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), 300 Guangzhou Road, Gulou District, Nanjing, China.
| | - Tao Yang
- Department of Endocrinology, First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), 300 Guangzhou Road, Gulou District, Nanjing, China
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Gentile S, Guarino G, Della Corte T, Marino G, Fusco A, Corigliano G, Colarusso S, Piscopo M, Improta MR, Corigliano M, Martedi E, Oliva D, Russo V, Simonetti R, Satta E, Romano C, Vaia S, Strollo F. Lipohypertrophy in Elderly Insulin-Treated Patients With Type 2 Diabetes. Diabetes Ther 2021; 12:107-119. [PMID: 33219928 PMCID: PMC7843727 DOI: 10.1007/s13300-020-00954-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 10/20/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The number of older adults with insulin-treated diabetes mellitus (DM) is steadily increasing worldwide. Errors in the insulin injection technique can lead to skin lipohypertrophy (LH), which is the accumulation of fat cells and fibrin in the subcutaneous tissue. While lipohypertrophic lesions/nodules (LHs) due to incorrect insulin injection techniques are very common, they are often flat and hardly visible and thus require thorough deep palpation examination and ultrasonography (US) for detection. Detection is crucial because such lesions may eventually result in poor diabetes control due to their association with unpredictable insulin release patterns. Skin undergoes fundamental structural changes with aging, possibly increasing the risk for LH. We have therefore investigated the effect of age on the prevalence of LHs and on factors potentially associated with such lesions. METHODS A total of 1227 insulin-treated outpatients with type 2 DM (T2DM) referred to our diabetes centers were consecutively enrolled in the study. These patients underwent a thorough clinical and US evaluation of the skin at injection sites, as previously described, with up to 95% concordance betweenthe clinical and US screening techniques. Of these 1227 patients, 718 (59%) had LH (LH+) and 509 (41%) were LH-free (LH-). These patients were then assigned to two age class groups (≤ 65 years and > 65 years), and several clinical features, diabetes complication rates, and injection habits were investigated. RESULTS Comparison of the two age subgroups revealed that 396 (48%) and 322 (79%) patients in the younger and older groups, respectively, had LHs (p < 0.001). Compared to the younger subgroup, the older subgroup displayed a higher LH rate in the abdomen (52.9 vs. 38.3%; p < 0.01) and a lower rate in the arms (25.4 vs. 35.8%; p < 0.05), thighs (26.7 vs. 33.4%; p < 0.05), and buttocks (4.9 vs. 26.2%; p < 0.01). In older subjects, the most relevant parameters were: habit of injecting insulin into LH nodules (56 vs. 47% [younger subjects]; p < 0.01), rate of post-injection leakage of insulin from injection site (drop-leaking rate; 47 vs. 39% [younger subjects]; p < 0.05), and rate of painful injections (5 vs. 16% [younger subjects]; p < 0.001). Multivariate analysis showed a stronger association between LH and poor habits, as well as between several clinical parameters, among which the most relevant were hypoglycemic events and glycemic variability. DISCUSSION The higher rate of post-injection drop-leaking and pain-free injections might find an explanation in skin changes typically observed in older adults, including lower thickness, vascularity and elasticity, and a more prominent fibrous texture, all of which negatively affect tissue distensibility. Consequently, in addition to the well-known association between aging skin impaired drug absorption rate, aging skin displays a progressively decreasing ability to accommodate large volumes of insulin-containing fluid. CONCLUSIONS The strong association between LH rate and hypoglycemic events plus glycemic variability suggests the need (1) to take specific actions to prevent and control the high risk of acute cardiovascular events expected to occur in older subjects in the case of hypoglycemic events, and (2) to identify suitable strategies to fulfill the difficult task of performing effective educational programs specifically targeted to the elderly. TRIAL REGISTRATION Trial registration number 172-11:12.2019, Scientific and Ethical Committee of Campania University "Luigi Vanvitelli", Naples, Italy).
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Affiliation(s)
- Sandro Gentile
- Department of Internal Medicine, Campania University “Luigi Vanvitelli”, Naples, Italy
- Diabetes Unit AID Stabia, Nefrocenter Research and Nyx Start-Up, Naples, Italy
| | - Giuseppina Guarino
- Department of Internal Medicine, Campania University “Luigi Vanvitelli”, Naples, Italy
| | - Teresa Della Corte
- Department of Internal Medicine, Campania University “Luigi Vanvitelli”, Naples, Italy
- Nutrition, Nefrocenter Research and Nyx Start-Up, Naples, Italy
| | - Giampiero Marino
- Department of Internal Medicine, Campania University “Luigi Vanvitelli”, Naples, Italy
| | - Alessandra Fusco
- Diabetes Unit, Italian Association for Diabetes (AID) Napoli, Naples, Italy
| | - Gerardo Corigliano
- Diabetes Unit, Italian Association for Diabetes (AID) Napoli, Naples, Italy
| | | | | | | | - Marco Corigliano
- Diabetes Unit, Italian Association for Diabetes (AID) Napoli, Naples, Italy
| | | | - Domenica Oliva
- Diabetes Unit, AID Cava dè Tirreni, Cava dè Tirreni, Italy
| | - Viviana Russo
- Diabetes Unit, Italian Association for Diabetes (AID) Napoli, Naples, Italy
| | | | - Ersilia Satta
- Dialysis Unit, Nefrocenter Research Network, Naples, Italy
| | - Carmine Romano
- Dialysis Unit, Nefrocenter Research Network, Naples, Italy
| | - Sebastiano Vaia
- Neuropsicology Unit, Nefrocenter Research Network, Naples, Italy
| | - Felice Strollo
- Diabetes, Endocrinology and Metabotic Disease, IRCCS San Raffaele Pisana, Rome, Italy
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Trabauer BM, Szag K, Krampla W. Incidental findings of clinical relevance. Wien Klin Wochenschr 2020; 133:509-510. [PMID: 33351154 DOI: 10.1007/s00508-020-01788-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 11/25/2020] [Indexed: 10/22/2022]
Affiliation(s)
| | - Kyra Szag
- , Landesklinikum Korneuburg-Stockerau, Austria
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Gentile S, Guarino G, Corte TD, Marino G, Fusco A, Corigliano G, Colarusso S, Piscopo M, Improta MR, Corigliano M, MartedÌ E, Oliva D, Russo V, Simonetti R, Satta E, Romano C, Alfarone C, Vetrano A, Martino C, Lamberti C, Vecchiato A, Cozzolino G, Brancario C, Strollo F. Insulin-Induced Skin Lipohypertrophy in Type 2 Diabetes: a Multicenter Regional Survey in Southern Italy. Diabetes Ther 2020; 11:2001-2017. [PMID: 32683659 PMCID: PMC7435140 DOI: 10.1007/s13300-020-00876-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Lipohypertrophies (LHs) due to incorrect insulin injection techniques have been described in the literature for decades. Their rate averages 38%, but this is still controversial because of the vast range reported by different publications, most of which fail to describe the selected detection protocol and therefore are not entirely reliable. We still need to identify the real LH rate, and only consistently using a standardized method in a large cohort of insulin-treated (IT) patients make this possible. METHODS Our group performed thorough clinical skin examinations on patients suffering from type 2 diabetes mellitus (T2DM): 1247 IT T2DM outpatients were examined according to a standardized protocol, previously published elsewhere, as well as an ultrasound scan of the same skin areas to assess the degree of concordance between the two methods and to evaluate the demographic, clinical, and behavioral risk factors (RF) as well as metabolic consequences of identified LHs. RESULTS The concordance between the two methods was 99%. Identified risk factors for LHs were needle reuse, failure to rotate injection sites, and ice-cold insulin injections. High HbA1c values, wide glycemic variability, and longstanding proneness to hypoglycemia with a high rate of ongoing hypoglycemic events proved to be significantly associated with LHs, too; the same applied to cardiovascular and renal complications as well as to living alone and being retired. CONCLUSIONS Based on a strict well-structured methodology, our data confirmed what has already been reported in the literature on factors leading to, or associated with, LHs and, for the first time in adults, indicated cryotrauma from ice-cold insulin injections and specific social conditions as factors facilitating LH occurrence. HCPs should therefore plan a yearly clinical examination of all injection sites to improve patient quality of life through better glucose control and a reduced rate of hypoglycemic events. TRIAL REGISTRATION Trial registration no. 127-11.01.2019, approved by the Scientific and Ethics Committee of Campania University "Luigi Vanvitelli," Naples, Italy.
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Affiliation(s)
- Sandro Gentile
- Department of Internal Medicine, Campania University "Luigi Vanvitelli" and Nefrocenter Research, Naples, Italy.
- Diabetes Unit AID Castellammare di Stabia, Castellammare di Stabia, Italy.
- Nefrocenter Research and Nyx Start-Up, Naples, Italy.
| | - Giuseppina Guarino
- Department of Internal Medicine, Campania University "Luigi Vanvitelli" and Nefrocenter Research, Naples, Italy
| | - Teresa Della Corte
- Department of Internal Medicine, Campania University "Luigi Vanvitelli" and Nefrocenter Research, Naples, Italy
- Diabetes Unit AID Castellammare di Stabia, Castellammare di Stabia, Italy
- Diabetes Unit AID Portici, Portici, Italy
- Diabetes Unit AID Cava de' Tirreni, Cava de' Tirreni, Italy
- Endocrinology and Diabetes, San Raffaele Termini Pisana Research Institute, Rome, Italy
- Nefrocenter Research and Nyx Start-Up, Naples, Italy
| | - Giampiero Marino
- Department of Internal Medicine, Campania University "Luigi Vanvitelli" and Nefrocenter Research, Naples, Italy
| | | | | | | | | | - Maria Rosaria Improta
- Diabetes Unit AID Castellammare di Stabia, Castellammare di Stabia, Italy
- Diabetes Unit AID Portici, Portici, Italy
- Diabetes Unit AID Cava de' Tirreni, Cava de' Tirreni, Italy
- Endocrinology and Diabetes, San Raffaele Termini Pisana Research Institute, Rome, Italy
- Nefrocenter Research and Nyx Start-Up, Naples, Italy
| | - Marco Corigliano
- Diabetes Unit AID Napoli, Napoli, Italy
- Diabetes Unit AID Benevento, Benevento, Italy
- Diabetes Unit AID Nola, Nola, Italy
- Diabetes Unit AID Castellammare di Stabia, Castellammare di Stabia, Italy
- Diabetes Unit AID Portici, Portici, Italy
- Diabetes Unit AID Cava de' Tirreni, Cava de' Tirreni, Italy
- Endocrinology and Diabetes, San Raffaele Termini Pisana Research Institute, Rome, Italy
- Nefrocenter Research and Nyx Start-Up, Naples, Italy
| | | | - Domenica Oliva
- Diabetes Unit AID Cava de' Tirreni, Cava de' Tirreni, Italy
- Endocrinology and Diabetes, San Raffaele Termini Pisana Research Institute, Rome, Italy
- Nefrocenter Research and Nyx Start-Up, Naples, Italy
| | | | | | - Ersilia Satta
- Nefrocenter Research and Nyx Start-Up, Naples, Italy
| | | | | | | | - Carmine Martino
- Diabetes Unit AID Castellammare di Stabia, Castellammare di Stabia, Italy
| | - Clelia Lamberti
- Diabetes Unit, AID Nocera Inferiore, Nocera Inferiore, Italy
| | | | | | | | - Felice Strollo
- Endocrinology and Diabetes, San Raffaele Termini Pisana Research Institute, Rome, Italy
- Nefrocenter Research and Nyx Start-Up, Naples, Italy
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Gentile S, Strollo F, Satta E, Della-Corte T, Romano C, Guarino G. Insulin-induced lypodistrophy in hemodialyzed patients: A new challenge for nephrologists? Diabetes Metab Syndr 2019; 13:3081-3084. [PMID: 31765982 DOI: 10.1016/j.dsx.2019.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 11/11/2019] [Indexed: 10/25/2022]
Abstract
Diabetes Mellitus (DM) is the most common cause of renal failure and ESRD all over the world, and often requires an individualized insulin treatment regimen. Malnutrition, depression-related eating behavior changes, high on-off-dialysis day-to-day glycemic variability and frequent hypoglycemic events occurring during or immediately after dialysis make it hard to identify best insulin dosage in hemodialyzed patients. This suggests a prudent attitude including non-stringent control, despite which repeated hypoglycemia quite often occurs in such patients. When looking for possible sources of hypoglycemia, health professionals too often overlook the identification of skin lipodystrophy (LD) due to an incorrect insulin injection technique. This mini-review focuses on the high frequency (57%) of LD in a cohort of 1004 insulin-treated people with DM on dialysis consecutively referring to our joint medical centers, and on its relationship with hypoglycemia and glycemic control/variability. When taking on such patients, care team members accept to face a complex disease burdened with several risk factors requiring high professional skills, and have to keep in mind also the possible presence of any LD areas eventually interfering with expected results. A timely educational intervention on the correct injection technique can help reduce the high risk of hypoglycemia and large glycemic variability in dialysed people with DM.
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Affiliation(s)
- S Gentile
- Campania University ''Luigi Vanvitelli", Naples, Italy; Nefrocenter Research Network, Naples, Italy.
| | - F Strollo
- Nefrocenter Research Network, Naples, Italy; Elle-Di and San Raffaele Research Institute, Rome, Italy
| | - E Satta
- Nefrocenter Research Network, Naples, Italy
| | - T Della-Corte
- Campania University ''Luigi Vanvitelli", Naples, Italy; Nefrocenter Research Network, Naples, Italy
| | - C Romano
- Nefrocenter Research Network, Naples, Italy
| | - G Guarino
- Campania University ''Luigi Vanvitelli", Naples, Italy
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Kaltheuner L, Kaltheuner M, Heinemann L. Lipohypertrophic Skin Changes in Patients With Diabetes: Visualization by Infrared Images. J Diabetes Sci Technol 2018; 12:1152-1158. [PMID: 29852742 PMCID: PMC6232733 DOI: 10.1177/1932296818777264] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Many patients with diabetes on insulin therapy develop lipohypertrophies (LHTs). So far, LHTs are diagnosed by conventional methods (CM; visual inspection, palpation and/or ultrasound). In everyday life, it would be advantageous to have a quick, simple and inexpensive alternative, for example, diagnosing them by obtaining infrared (IR) images. METHODS We obtained IR images from 43 subjects (21 patients with type 1 diabetes, conventional subcutaneous insulin therapy and known LHTs, 8 patients with CSII and LHTs, 7 patients without LHTs, and 7 healthy people), all from one specialized diabetes practice. The IR images were taken under standardized conditions with a high-resolution infrared camera (VarioCam® HDx Jenoptic, IR pixel 640 × 480, thermal resolution 0.003K) and compared with LHT diagnoses with CM. RESULTS In 14 of the 29 (48%) patients, CM diagnosed LHTs were "cold spots" in the IR images. The temperature difference to "healthy" skin (without LHTs) was up to 6°C. Of the 14 patients, 11 also showed such spots, without findings with CM. Four patients did not show clearly identifiable cold spots as LHT and 2 patients showed no changes in the IR images. The remaining 9 patients did not show clearly identifiable cold spots as LHT, but the diagnosis with CM was also ambiguous. CONCLUSIONS The results of this small (pilot) study do not clearly support the value of IR images for the diagnosis of LHTs, but they do not refute this approach. Diagnosis of LHT might be hampered due to the existence of different types of LHTs. Usage of IR images can apparently detect LHTs before they can be diagnosed with CM. Further targeted investigations are required to make statements about the usability of this method.
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Affiliation(s)
- Lars Kaltheuner
- University Medicine Greifswald,
Greifswald, Germany
- Lars Kaltheuner, University Medicine
Greifswald, Im Oberfeld 28, 51381, Leverkusen, Germany. E-mail:
| | | | - Lutz Heinemann
- Science Consulting in Diabetes GmbH,
Neuss, Deutschland, Germany
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Kapeluto JE, Paty BW, Chang SD, Meneilly GS. Ultrasound detection of insulin-induced lipohypertrophy in Type 1 and Type 2 diabetes. Diabet Med 2018; 35:1383-1390. [PMID: 29908078 DOI: 10.1111/dme.13764] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/14/2018] [Indexed: 11/26/2022]
Abstract
AIMS To define standard criteria for the detection of lipohypertrophy using ultrasonography and to determine the accuracy of this method. METHOD Individuals using insulin therapy for ≥2 years with unknown lipohypertrophy status were enrolled at a diabetes education centre. A team of diabetes educator nurses performed a clinical examination for evidence of lipohypertrophy and a separate team of ultrasonographers examined participants in a blinded fashion. RESULTS The echo signature for lipohypertrophy consisted of location in the subcutaneous layer and lesions that were 1) well circumscribed either by hyperechoic foci with defined borders or a nodular shape with a hypoechoic halo, 2) heterogeneous in echotexture compared with surrounding tissue, 3) associated with distortion of surrounding connective tissue with 4) absence of vascularity and 5) absence of capsule. Ultrasonography identified individuals with lipohypertrophy significantly more frequently than inspection or palpation (P<0.0001). Inter-observer agreement was moderate (κ=0.50) and limited by the presence of subclinical lesions in 73% of the participants. CONCLUSIONS The ultrasound detection of lipohypertrophy is consistent with clinical examination and is reproducible using a defined echo signature. (ClinicalTrials.gov registration no: NCT02348099).
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Affiliation(s)
- J E Kapeluto
- Division of Endocrinology, Department of Medicine, Vancouver General Hospital and University of British Columbia, Vancouver, Canada
| | - B W Paty
- Division of Endocrinology, Department of Medicine, Vancouver General Hospital and University of British Columbia, Vancouver, Canada
| | - S D Chang
- Department of Radiology, Vancouver General Hospital and University of British Columbia, Vancouver, Canada
| | - G S Meneilly
- Division of Geriatric Medicine, Department of Medicine, Vancouver General Hospital and University of British Columbia, Vancouver, Canada
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Abu Ghazaleh H, Hashem R, Forbes A, Dilwayo TR, Duaso M, Sturt J, Halson-Brown S, Mulnier H. A Systematic Review of Ultrasound-Detected Lipohypertrophy in Insulin-Exposed People with Diabetes. Diabetes Ther 2018; 9:1741-1756. [PMID: 30014243 PMCID: PMC6167307 DOI: 10.1007/s13300-018-0472-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Lipohypertrophy (LH) is a common complication occurring in diabetes individuals. The most common methods used include palpation, visual examination and/or ultrasound (US). To date, there is limited information on the detection sensitivity among the different techniques used to identify LH. This systematic review aimed to identify studies that examined insulin-related LH using US detection to identify the prevalence, characteristics and morphology of LH, and to compare US and clinical palpation methods for detecting LH. METHODS Three electronic databases were systematically searched for studies detecting LH using US in insulin users. Articles were screened for eligibility and included studies were appraised using quality assessment tools. The quality of the evidence was evaluated using Grading of Recommendations Assessment, Development and Evaluation, and the extracted data was synthesised narratively. RESULTS Sixteen articles were included in the review providing data on 1722 patients. The prevalence of LH prevalence varied from 14.5% to 88% (median 56.6%). Identified risk factors for the development of included insulin injection behaviour such as a lack of injection site rotation and social factors such as low education level. Four studies compared LH detection by US to palpation, providing inconsistent results. One study showed that palpation detected 64% more LH, whilst two studies demonstrated that US identified 50% more sites and extended areas of LH (additional ~ 5 cm2). Another study provided comparable estimates between palpation and US in clinicians trained to detect LH (97%). CONCLUSION The evidence highlights a lack of congruence in results pertaining to the detection sensitivity of US and palpation for LH sites. More research with robust study design is needed to verify whether clinically palpation is sufficient to detect LH, or whether US would increase the precision of LH assessment to help address this common clinically significant problem.
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Affiliation(s)
- Haya Abu Ghazaleh
- Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, UK.
| | - Rabab Hashem
- Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, UK
| | - Angus Forbes
- Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, UK
| | | | - Maria Duaso
- Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, UK
| | - Jackie Sturt
- Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, UK
| | - Susan Halson-Brown
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, St. Thomas' Hospital, London, UK
| | - Henrietta Mulnier
- Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, UK
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