Emerging diabetes therapies and technologies

Emerging Diabetes Technologies: Continuous Glucose Monitors/Artificial Pancreases

Over the past decade there have been many advances in diabetes technologies, such as continuous glucose monitors (CGM s), insulin-delivery devices, and hybrid closed loop systems . Now most CGMs (Medtronic-Guardian, Dexcom-G6, and Abbott-Libre-2) have MARD values of < 10%, in contrast to two decades ago when the MARD used to be > 20%. In addition, the majority of the new CGMs do not require calibrations, and the latest CGMs last for 10-14 days. An implantable 6-months CGM by Eversense-3 is now approved in the USA and Europe. Recently, the FDA approved Libre 3 which provides real-time glucose values every minute. Even though it is approved as an iCGM it is not interoperable with automatic-insulin-delivery (AID) systems. The newer CGMs that are likely to be launched in the next few months in the USA include the 10-11 days Dexcom G7 (60% smaller than the existing G6), and the 7-days Medtronic Guardian 4. Most of the newer CGM have several features like automatic initialization, easy insertion, predictive alarms, and alerts. It has also been noticed that an arm insertion site might have better accuracy than abdomen or other sites, like the buttock for kids. Lag time between YSI and different sensors have been reported differently, sometimes it is down to 2-3 min; however, in many instances, it is still 15-20 min, especially when the rate of change of glucose is > 2 mg/min. We believe that in the next decade there will be a significant increase in the number of people who use CGM for their day-to-day diabetes care.

Quantitative efficacy of L-carnitine supplementation on glycemic control in type 2 diabetes mellitus patients

OBJECTIVES

This study aimed to explore the quantitative efficacy of L-carnitine supplementation on glycemic control in type 2 diabetes mellitus patients using model-based meta-analysis (MBMA).

METHODS

Literatures were retrieved from the public database and data from these trials were extracted. The quantitative efficacy of L-carnitine on fasting plasma glucose (FPG) and glycated hemoglobin (HbA1c) in type 2 diabetes mellitus patients were evaluated by maximal effect (E_max) models with nonlinear mixed effects modeling (NONMEM).

RESULTS

In the model of FPG, E_max and _treatment duration to reach half of the maximal effects (ET₅₀) were -9.8% and 36.1 weeks, respectively. In the model of HbA1c, E_max and ET₅₀ were -19.6% and 106 weeks, respectively. In addition, the durations for achieving 25%, 50%, 75%, 80%, and 90% E_max of L-carnitine on FPG were 13, 36.1, 118, 160, and 390 weeks, respectively. The durations for achieving 25%, 50%, 75%, 80%, and 90% E_max of L-carnitine on HbA1c were 38, 106, 334, 449, and 1058 weeks, respectively.

CONCLUSIONS

It was the first time to provide valuable quantitative information for efficacy of L-carnitine supplementation on glycemic control in type 2 diabetes mellitus patients.

Pharmacokinetics, tissue distribution and excretion of a novel long-acting human insulin analogue - recombinant insulin LysArg in rats

As a novel long-acting recombinant human insulin analogue, it is necessary to carry out the preclinical research for insulin LysArg. The purpose of this study was to characterise the pharmacokinetic, tissue distribution and excretion of insulin LysArg and provide a reference for its development. Three methods were used to measure the content of insulin LysArg in biological samples after a single subcutaneous administration in rats, including radioassay, radioassay after precipitation with TCA and separation by HPLC. After Subcutaneous administration of recombinant insulin LysArg 1, 2, 4 U/kg in rats, it showed both C_max and AUC_0-t were positively correlated with the dose. In the meanwhile, after a single subcutaneous administration of recombinant insulin LysArg at 2 U/kg in rats, the amount of radioactivity in most organs was highest at 1.5 h and then decreased gradually, no accumulation was found. The highest level of insulin LysArg was observed in the kidney. Like other macromolecules, insulin LysArg was mainly excreted from urine. The study fully illustrated the pharmacokinetic pattern of insulin LysArg, provided valuable informations to support its further development about safety and toxicology.

Quality of Life in Children With Diabetes Treated With Insulin Pump Compared With Multiple Daily Injections in Tertiary Care Center

Background:

Continuous Subcutaneous Insulin Infusion (CSII) and Multiple Daily Injections (MDI) have been widely used as options in treating diabetes in childhood. Glycemic control is important to reduce diabetes complications; however, more focus needs to be on patients’ Quality of Life (QoL). Diabetes and QoL have strong associations in terms of patients’ overall health including their psychology, physical well-being, compliance with medication. A previous systematic review stressed that strong evidence to deny or prove the benefits of insulin pump therapy on health-related quality of life is deficient. The aim of this study is to assess the health-related quality of life and the psychological impacts of children with diabetes who use CSII and MDI treatment.

Methods:

A cross-sectional study included 68 pediatric patients with type 1 Diabetes (T1DM) who were treated in a tertiary center in Jeddah, Saudi Arabia. We used the Pediatric Quality of Life Inventory 3.0 Diabetes Module and this module assesses the health-related quality of life of children with diabetes.

Results:

Thirty-four (50%) participants found to be on MDI, of which 21 (61.8%) are males, compared to 34 (50%) patients using CSII, of which 12 (35.2%) are females. Participants using CSII had statistically significant better symptom control, less treatment difficulties but were more worrisome than MDI participants.

Conclusion:

CSII group had better quality of life in almost all aspects even though they were more worrisome. Further studies with a larger sample size are needed to give comprehensive generalizations.

Resveratrol for adults with type 2 diabetes mellitus

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a chronic disorder that is characterised by insulin resistance and hyperglycaemia, which over time may give rise to vascular complications. Resveratrol is a plant-derived nutritional supplement shown to have anti-diabetic properties in many animal models. Less evidence is available on its safety and efficacy in the management of T2DM in humans.

OBJECTIVES

To assess the efficacy and safety of resveratrol formulations for adults with type 2 diabetes mellitus.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and International Pharmaceutical Abstracts, as well as the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. The date of the last search was December 2018 for all databases. No language restrictions were applied.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing effects of oral resveratrol (any dose or formulation, duration, or frequency of administration) with placebo, no treatment, other anti-diabetic medications, or diet or exercise, in adults with a diagnosis of T2DM.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified and included RCTs, assessed risk of bias, and extracted study-level data. Study authors were contacted for any missing information or for clarification of reported data. We assessed studies for certainty of the evidence using the GRADE instrument.

MAIN RESULTS

We identified three RCTs with a total of 50 participants. Oral resveratrol not combined with other plant polyphenols was administered at 10 mg, 150 mg, or 1000 mg daily for a period ranging from four weeks to five weeks. The comparator intervention was placebo. Overall, all three included studies had low risk of bias. None of the three included studies reported long-term, patient-relevant outcomes such as all-cause mortality, diabetes-related complications, diabetes-related mortality, health-related quality of life, or socioeconomic effects. All three included studies reported that no adverse events were observed, indicating that no deaths occurred (very low-quality evidence for adverse events, all-cause mortality, and diabetes-related mortality). Resveratrol versus placebo showed neutral effects for glycosylated haemoglobin A1c (HbA1c) levels (mean difference (MD) 0.1%, 95% confidence interval (CI) -0.02 to 0.2; P = 0.09; 2 studies; 31 participants; very low-certainty evidence). Due to the short follow-up period, HbA1c results have to be interpreted cautiously. Similarly, resveratrol versus placebo showed neutral effects for fasting blood glucose levels (MD 2 mg/dL, 95% CI -2 to 7; P = 0.29; 2 studies; 31 participants), and resveratrol versus placebo showed neutral effects for insulin resistance (MD -0.35, 95% CI -0.99 to 0.28; P = 0.27; 2 studies; 36 participants). We found eight ongoing RCTs with approximately 800 participants and two studies awaiting assessment, which, when published, could contribute to the findings of this review.

AUTHORS' CONCLUSIONS

Currently, research is insufficient for review authors to evaluate the safety and efficacy of resveratrol supplementation for treatment of adults with T2DM. The limited available research does not provide sufficient evidence to support any effect, beneficial or adverse, of four to five weeks of 10 mg to 1000 mg of resveratrol in adults with T2DM. Adequately powered RCTs reporting patient-relevant outcomes with long-term follow-up periods are needed to further evaluate the efficacy and safety of resveratrol supplementation in the treatment of T2DM.

A Diabetes Management Information System with Glucose Prediction

Diabetes has become a serious health concern. The use and popularization of blood glucose measurement devices have led to a tremendous increase on health for diabetics. Tracking and maintaining traceability between glucose measurements, insulin doses and carbohydrate intake can provide useful information to physicians, health professionals, and patients. This paper presents an information system, called GLUMIS (GLUcose Management Information System), aimed to support diabetes management activities. It is made of two modules, one for glucose prediction and one for data visualization and a reasoner to aid users in their treatment. Through integration with glucose measurement devices, it is possible to collect historical data on the treatment. In addition, the integration with a tool called the REALI System allows GLUMIS to also process data on insulin doses and eating habits. Quantitative and qualitative data were collected through an experimental case study involving 10 participants. It was able to demonstrate that the GLUMIS system is feasible. It was able to discover rules for predicting future values of blood glucose by processing the past history of measurements. Then, it presented reports that can help diabetics choose the amount of insulin they should take and the amount of carbohydrate they should consume during the day. Rules found by using one patient’s measurements were analyzed by a specialist that found three of them to be useful for improving the patient’s treatment. One such rule was “if glucose before breakfast ∈ [ 47 , 89 ] , then glucose at afternoon break in [ 160 , 306 ]”. The results obtained through the experimental study and other verifications associated with the algorithm created had a double objective. It was possible to show that participants, through a questionnaire, viewed the visualizations as easy, or very easy, to understand. The secondary objective showed that the innovative algorithm applied in the GLUMIS system allows the decision maker to have much more precision and less loss of information than in algorithms that require the data to be discretized.

Adaptive fuzzy integral sliding mode control of blood glucose level in patients with type 1 diabetes: In silico studies

Currently, artificial pancreas is an alternative treatment instead of insulin therapy for patients with type 1 diabetes mellitus. Closed-loop control of blood glucose level (BGL) is one of the difficult tasks in biomedical engineering field due to nonlinear time-varying dynamics of insulin-glucose relation that is combined with time delays and model uncertainties. In this paper, we propose a novel adaptive fuzzy integral sliding mode control scheme for BGL regulation. System dynamics is identified online using fuzzy logic systems. The presented method is evaluated in silico studies by nine different virtual patients in three different groups for two continuous days. Simulation results demonstrate effective performance of the proposed control scheme of BGL regulation in presence of simultaneous meal and physical exercise disturbances. Comparison of the proposed control method with proportional-integral-derivative (PID) control and model predictive control (MPC) shows a superiority of the adaptive fuzzy integral sliding mode control with regard to two conventional methods of BGL regulation (PID and MPC) and sliding mode control.

Fatalities Due to Failure of Continuous Subcutaneous Insulin Infusion Devices: A Report of Six Cases

Diabetes mellitus type 1 and type 2 are diseases characterized by impaired regulation of blood glucose due to decreased insulin production and insulin resistance, respectively. Management of diabetes mellitus often requires injection of exogenous insulin. Continuous subcutaneous insulin infusion (CSII or insulin pump) is a diabetes treatment modality utilizing a device to aid in regulation of glycemic control. Malfunctions in device components can have rare fatal consequences. Described in this report are six fatalities due to one such malfunction, the failure of plastic cannulas of CSII devices to penetrate the skin and deliver insulin, resulting in fatal diabetic ketoacidosis (DKA). The cases derive from four different death investigation systems. For each case, scene and autopsy findings are presented, as well as selected toxicology and histology findings. These cases illustrate the importance of careful examination of CSII devices in death investigations and introduce a discussion on discrepant manner of death classifications.

Effect of telemedicine intervention on hypoglycaemia in diabetes patients: A systematic review and meta-analysis of randomised controlled trials

INTRODUCTION

Hypoglycaemia is a clinical syndrome from various causes, which happens when the blood glucose concentration is too low. Many studies show that telemedicine intervention can improve glycemic control and has a positive impact on the management of diabetic patients. The purpose of this study was to evaluate the effect of telemedicine intervention on hypoglycemic event occurrences and results on hemoglobin A1c (HbA1c) and body mass index (BMI).

METHODS

We searched the Cochrane Library, PubMed, Web of Science, the EBSCO host, and OVID to identify relevant studies published from January 2006 to December 2017. The work of searching, selecting and assessing risk of bias was administrated by two independent reviewers. The primary outcomes were hypoglycemic event rate and HbA1c; the secondary outcome was BMI.

RESULTS

From 1246 articles, we identified 14 eligible RCTs (n = 1324). Compared to usual care, telemedicine was found to reduce the odds of hypoglycaemia (odds ratio (OR) = 0.42; 95% confidence interval (CI) = 0.29-0.59; I² = 32%; p < 0.00001). We found that the clinical relevance declined in HbA1c level compared to control group (mean difference = -0.28; 95% CI = -0.45 to -0.12; I² = 53%; p = 0.0005), but that telemedicine had no effect on BMI (mean difference = -0.27; 95% CI = -0.86-0.31; I² = 40%; p = 0.35).

DISCUSSION

Compared to usual care, the use of telemedicine was found to improve HbA1c and reduce the risk of moderate hypoglycaemia in diabetic patients, but without significant difference in BMI.

Leea macrophylla Roxb. leaf extract potentially helps normalize islet of β-cells damaged in STZ-induced albino rats

This research aims to investigate the protective effects Leea macrophylla Roxb polyphenols on streptozotocin-induced diabetic rats. Polyphenolic assays were undertaken through established methods. To conduct animal intervention study, forty Wistar albino male rats (average body weight 188.42 ± 7.13 g) of different groups were diabetized by streptozotocin (60 mg/kg) only in the animals of diabetic control (DC) and L. macrophylla extract (LM) groups. At the end of 4 weeks of intervention, serum was analyzed for insulin, liver and cardiac enzymes, lipid profiles, uric acid, and creatinine using ELISA method. In vitro α-amylase inhibition of LM was evaluated and compared with reference drug acarbose. Pancreatic tissues were undertaken for histopathological screening. Food and fluid intake, weekly blood glucose level, liver glycogen, aspartate transaminase (AST), creatinine kinase (CK-MB), cholesterol, and lactate dehydrogenase (LDH) were significantly decreased, whereas oral glucose tolerance (OGTT) ability, serum insulin concentration, and pancreatic islets morphology were significantly improved in the LM300 treatment group compared to the DC group. Alpha-amylase inhibition was not found to be very promising for guiding the α-amylase inhibition pathway. Results suggest that L. macrophylla can exert a potential effort to restore pancreatic β-cell damaged by streptozotocin induction.

Characterization of carrier erythrocytes for biosensing applications

Erythrocyte abundance, mobility, and carrying capacity make them attractive as a platform for blood analyte sensing as well as for drug delivery. Sensor-loaded erythrocytes, dubbed erythrosensors, could be reinfused into the bloodstream, excited noninvasively through the skin, and used to provide measurement of analyte levels in the bloodstream. Several techniques to load erythrocytes, thus creating carrier erythrocytes, exist. However, their cellular characteristics remain largely unstudied. Changes in cellular characteristics lead to removal from the bloodstream. We hypothesize that erythrosensors need to maintain native erythrocytes’ (NEs) characteristics to serve as a long-term sensing platform. Here, we investigate two loading techniques and the properties of the resulting erythrosensors. For loading, hypotonic dilution requires a hypotonic solution while electroporation relies on electrical pulses to perforate the erythrocyte membrane. We analyze the resulting erythrosensor signal, size, morphology, and hemoglobin content. Although the resulting erythrosensors exhibit morphological changes, their size was comparable with NEs. The hypotonic dilution technique was found to load erythrosensors much more efficiently than electroporation, and the sensors were loaded throughout the volume of the erythrosensors. Finally, both techniques resulted in significant loss of hemoglobin. This study points to the need for continued development of loading techniques that better preserve NE characteristics.

Role of Mobile Technology to Improve Diabetes Care in Adults with Type 1 Diabetes: The Remote-T1D Study iBGStar® in Type 1 Diabetes Management

INTRODUCTION

The role of mobile technology in patient-reported outcomes (PRO) and glycemic control in adults with type 1 diabetes (T1D) needs further evaluation.

METHODS

The single-center, prospective, 6-month, open-label, investigator-initiated study randomized 100 subjects with T1D in a 1:1 fashion to a control group using self-monitoring of blood glucose (SMBG) with Accu-Chek Nano® and an intervention group using SMBG with iPhone plus glucose meter (iBGStar®). The primary endpoint was the change in PRO (hypoglycemia fear score, behavior and worry subscores). Secondary outcomes were the improvement in glycemic variability indices and the reduction in A1c values.

RESULTS

Baseline demographics and glycosylated hemoglobin (A1c) values were similar in the two groups. There was a significant decrease in A1c value at 6 months in iBGStar® group compared to the control group (-0.16 vs. -0.51, p = 0.04). The total insulin dose increased significantly in the iBGStar® group at 3 months but did not change at 6 months. The hypoglycemia fear scale (PRO) improved in both groups at 6 months (-1.4 ± 10.0 vs. -3.9 ± 12.5, p = 0.32).

CONCLUSION

The use of iBGStar® resulted in better glycemic control and improvement in some PRO (hypoglycemia fear and behavior scores) compared to the control group at 6 months with no increased risk of hypoglycemia.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov: NCT01825382.

FUNDING

Sanofi.

Continuous subcutaneous insulin infusion versus multiple daily injections in individuals with type 1 diabetes: a systematic review and meta-analysis

The relative efficacy of continuous subcutaneous insulin infusion and multiple daily injections in individuals with type 1 diabetes is unclear. We sought to synthesize the existing evidence about the effect of continuous subcutaneous insulin infusion on glycosylated hemoglobin, hypoglycemic events, and time spent in hypoglycemia compared to multiple daily injections. We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and Database of Systematic Reviews, and Scopus from January 2008 through November 2015 for randomized controlled trials that enrolled children or adults with type 1 diabetes. Trials identified in a previous systematic review and published prior to 2008 were also included. We included 25 randomized controlled trials at moderate risk of bias. Meta-analysis showed a significant reduction in glycosylated hemoglobin in patients treated with continuous subcutaneous insulin infusion compared to multiple daily injections (mean difference 0.37; 95 % confidence interval, 0.24-0.51). This effect was demonstrated in both children and adults. There was no significant difference in minor or severe hypoglycemic events. Continuous subcutaneous insulin infusion was associated with lower incidence of nocturnal hypoglycemia. There was no significant difference in the time spent in hypoglycemia. In children and adults with type 1 diabetes and compared to multiple daily injections, continuous subcutaneous insulin infusion is associated with a modest reduction in glycosylated hemoglobin. There was no difference in severe or minor hypoglycemia, but likely a lower incidence of nocturnal hypoglycemia with continuous subcutaneous insulin infusion.

Assessment of anti-diabetic activity of the aqueous extract of leaves of Astilboides tabularis

ETHNOPHARMACOLOGICAL RELEVANCE

Astilboides tabularis has a long history of usage as the functional food with the effect of adjunctive therapy of diabetic in northeast of China. The present study was undertaken to assess anti-diabetic activity of the aqueous extract of leaves of A. tabularis and provided experimental evidence for the clinical usage of A. tabularis in the treatment of diabetes mellitus.

MATERIALS AND METHODS

The aqueous extracts of leaves of A. tabularis (EAT) were orally administered at 300 and 600mg/kg dose to epinephrine-induced and alloxan-induced diabetes mice. Hypoglycemic effects, change in body weight, water intake, food intake, lipid profile and lipid peroxidant were assessed. Furthermore, the main chemical components of EAT were isolated and high performance liquid chromatography (HPLC) analysis was employed to identify the phytochemical composition of the plant extract. The finally, total flavonoids content and total phenolic content were quantified by colorimetric assay.

RESULTS

EAT showed a significant reduction in blood glucose level at both 300 and 600mg/kg (ig). In addition, EAT also exhibited a profound antioxidant effect for increasing SOD and GSH-px activity and decreasing TBARS activity at both low and high dose. Furthermore, EAT also could significantly decrease the contents of TC and TG. The 8 main constituents of EAT are also isolated and characterized and the content of total flavonoid and total phenolic are 22% and 25% in EAT respectively.

CONCLUSION

The present investigation revealed that EAT possess potent anti-diabetic activity and polyphenol compounds may be the main active ingredients.

Self-care for people coping with long-term health conditions in the community: the views of patients and GPs

Purpose

Long-term health problems put great pressures on health and social care services. Supporting ‘self-care’ has measurable benefits in helping patients cope better, but is difficult to do in practice. This review aims to help improve services by exploring existing evidence about the views of patients and GPs.

Design/methodology/approach

The search terms were identified following detailed discussion with service users. Five databases (PUBMED, CINAHL, TRIP, SCIE and PSYCINFO) were interrogated against pre-set questions and criteria. The data were managed in EndNote v6 and analysed in a series of Word tables.

Findings

37 community-based studies were identified, covering diverse chronic illnesses. Analysis of ‘barriers and enablers’ showed a very complex picture, with health systems often actively inhibiting the responsiveness and flexibility which support self-care. Directly seeking service user and practitioner views could shape more effective services

Research limitations/implications

Further research is needed into: the purpose and outcomes of user involvement, the relationship between integrated care and self-care, how patient motivation and resilience can be encouraged in primary care and the effect of current incentive schemes on self-care support Due to organisational changes, eligible studies were reviewed by one researcher only and these were mainly qualitative studies lacking generalisability. However, the results spanned a range of settings and health conditions. They are also clearly supported by later primary research findings

Practical implications

Several evidence-based, achievable opportunities to improve self-care support in primary care settings are identified

Originality/value

This service-user study, offers detailed analysis of what helps or hinders self-care in everyday life

Insulin delivery methods: Past, present and future

Many patients with advanced type 2 diabetes mellitus (T2DM) and all patients with T1DM require insulin to keep blood glucose levels in the target range. The most common route of insulin administration is subcutaneous insulin injections. There are many ways to deliver insulin subcutaneously such as vials and syringes, insulin pens, and insulin pumps. Though subcutaneous insulin delivery is the standard route of insulin administration, it is associated with injection pain, needle phobia, lipodystrophy, noncompliance and peripheral hyperinsulinemia. Therefore, the need exists for delivering insulin in a minimally invasive or noninvasive and in most physiological way. Inhaled insulin was the first approved noninvasive and alternative way to deliver insulin, but it has been withdrawn from the market. Technologies are being explored to make the noninvasive delivery of insulin possible. Some of the routes of insulin administration that are under investigation are oral, buccal, nasal, peritoneal and transdermal. This review article focuses on the past, present and future of various insulin delivery techniques. This article has focused on different possible routes of insulin administration with its advantages and limitation and possible scope for the new drug development.

Impact of postprandial glucose control on diabetes-related complications: How is the evidence evolving?

Conflicting findings in the literature and lack of long-term definitive outcome studies have led to difficulty in drawing conclusions about the role of postprandial hyperglycemia in diabetes and its complications. Recent scientific publications support the role of postprandial glucose (PPG) as a key contributor to overall glucose control and a predictor of microvascular and macrovascular events. However, the need remains for definitive evidence to support the precise relationship between PPG excursions and the development and progression of cardiovascular complications of diabetes. Drawing firm conclusions on the relationship between PPG and microvascular and macrovascular complications is challenged by the absence of antidiabetic agents that can specifically exert their action on PPG alone, without a basal glucose-lowering effect. Areas under investigation include interventions that more closely approximate 'normal' physiological postprandial responses, as well as technologies that advance the mode of insulin delivery or optimize methods to sense glycemic levels and variation. In conclusion, the precise role of postprandial hyperglycemia in relation to development of diabetic complications is unclarified and is one of the remaining unanswered questions in diabetes. Nevertheless, current evidence supports PPG control as an important strategy to consider in the comprehensive management plan of individuals with diabetes.

Managing diabetes in the digital age

The prevalence of diabetes is rising globally. Poor glucose control results in higher rates of diabetes-related complications and an increase in health care expenditure. Diabetes self-management education (DSME) training has shown to improve glucose control, and thus may reduce long-term complications. Implementation of diabetes self-management education programs may not be feasible for all the institutions or in developing countries due to lack of resources and higher costs associated with DSME training. With the increasing use of smartphones and Internet, there is an opportunity to use digital tools for training people with diabetes to self-manage their disease. A number of mobile applications, Internet portal, and websites are available to help patients to improve their diabetes care. However, the studies are limited to show its effectiveness and cost-benefits in diabetes self-management. In addition, there are many challenges ahead for the digital health industry. In this review, we assess the use of newer technologies and digital health in diabetes self-management with a focus on future directions and potential challenges.

Diabetes mellitus in elderly

Diabetes mellitus (DM) frequency is a growing problem worldwide, because of long life expectancy and life style modifications. In old age (≥60-65 years old), DM is becoming an alarming public health problem in developed and even in developing countries as for some authors one from two old persons are diabetic or prediabetic and for others 8 from 10 old persons have some dysglycemia. DM complications and co-morbidities are more frequent in old diabetics compared to their young counterparts. The most frequent are cardiovascular diseases due to old age and to precocious atherosclerosis specific to DM and the most bothersome are visual and cognitive impairments, especially Alzheimer disease and other kind of dementia. Alzheimer disease seems to share the same risk factors as DM, which means insulin resistance due to lack of physical activity and eating disorders. Visual and physical handicaps, depression, and memory troubles are a barrier to care for DM treatment. For this, old diabetics are now classified into two main categories as fit and independent old people able to take any available medication, exactly as their young or middle age counterparts, and fragile or frail persons for whom physical activity, healthy diet, and medical treatment should be individualized according to the presence or lack of cognitive impairment and other co-morbidities. In the last category, the fundamental rule is "go slowly and individualize" to avoid interaction with poly medicated elder persons and fatal iatrogenic hypoglycemias in those treated with sulfonylureas or insulin.

Efficacy of Insulin Pump Therapy on Diabetes Treatment Satisfaction and Glycemic Control Among Patients with Type 1 Diabetes Mellitus in Saudi Arabia: A Prospective Study

INTRODUCTION

The aim of this study was to explore the impact of insulin pump therapy on diabetes treatment satisfaction and glycemic control among patients with type 1 diabetes mellitus (T1DM) in Saudi Arabia.

METHODS

A 6-month, prospective study was conducted among 47 patients (aged 17-24 years) with T1DM who attended the Insulin Pump Clinic at Prince Sultan Military Medical City, Riyadh, Saudi Arabia, between April 2014 and November 2014. The respondents were purposively and conveniently selected and were interviewed using the Arabic version of the Diabetes Treatment Satisfaction Questionnaire at baseline, 3, and 6 months. Demographics and clinical variables including hemoglobin A1c (HbA1c) were also collected.

RESULTS

The mean (±standard deviation) age of the study cohort was 19.1 ± 1.93 years. Seventeen patients were male (36.2%) and 30 were female (63.8%). Compared to baseline, significant positive differences were found in treatment satisfaction among female patients and patients with long-standing T1DM at 6 months. Frequency of hyperglycemia and hypoglycemia declined significantly in female patients at 6 months and in patients who had a shorter duration of T1DM. Furthermore, significant positive differences were found in HbA1c levels among female patients and among those who had a shorter duration of T1DM compared to baseline. Both female and male patients and those with a shorter duration of T1DM showed a significant decline in insulin necessity at 6 months when compared to baseline.

CONCLUSION

Although multiple daily injections is a feasible preference for insulin supply, insulin pumps should also be considered for patients with T1DM as it appears to increase patients' treatment satisfaction, decrease the frequency of hypoglycemia, hyperglycemia, and reduce HbA1c levels.

Prevalence, correlates, and description of self-reported diabetes in brazilian capitals - results from a telephone survey

INTRODUCTION

The prevalence of diabetes is increasing worldwide. The objective of this study is to estimate the prevalence of self-reported diabetes in Brazilian adults and to describe its population correlates as well as the clinical characteristics of the reported cases.

METHODS

We analyzed basic and supplementary data of 54.144 subjects participating in VIGITEL 2011 (Surveillance System for Risk and Protective Factors for Chronic Diseases), a telephone survey based on a probabilistic sample of subjects ≥ 18 years old residing in Brazilian state capitals and the Federal District. Estimates reported are weighted so as to represent the surveyed population.

RESULTS

The prevalence of self-reported diabetes was 6.3% (95% CI 5.9-6.7), increasing markedly with age and nutritional status, and decreasing with level of education. Prevalence was higher among those self-declaring their race/color as black. Most cases (90%) reported the diagnosis being made at 35 years or older. The vast majority (99.8%) of self-reported cases informed having previously performed at least one glucose test, and 76% of those not reporting diabetes also informed having previously performed glucose testing. Most cases (92.6%) reported following some form of diabetes treatment, 79% taking medication.

CONCLUSION

The estimated prevalence of known diabetes found, 6.3%, is consistent with estimates given by international summaries. The additional data collected in VIGITEL 2011 regarding previous glucose testing and current treatment support the use of telephone-based information to monitor the prevalence of known diabetes in Brazilian capitals.

Closed-loop system in the management of diabetes: past, present, and future

Intensive insulin therapy (IIT) has been shown to reduce micro- and macrovascular complications in patients with type 1 diabetes mellitus (T1DM). However, IIT is associated with a significant increase in severe hypoglycemic events, resulting in increased morbidity and mortality. Optimization of glycemic control without hypoglycemia (especially nocturnal) should be the next major goal for subjects on insulin treatment. The use of insulin pumps along with continuous glucose monitors (CGMs) has made it easier but requires significant resources and patient education. Research is ongoing to close the loop by integrating the pump and the CGM using different algorithms. The currently available closed-loop system is the threshold suspend. Steps needed to achieve a near-perfect closed-loop are (1) a control-to-range system that will reduce the incidence and/or severity of hyper- and/or hypoglycemia by adjusting the insulin dose and (2) a control-to-target system, a fully automated or hybrid system that sets target glucose levels to individual needs and maintains glucose levels throughout the day using insulin (unihormonal) alone or with other hormones such as glucagon or possibly pramlintide (bihormonal). Future research is also focusing on better insulin delivery devices (pumps), more accurate CGMs, better predictive algorithms, and ultra-rapid-acting insulin analogs to make the closed-loop system as physiological as possible.

Continuous glucose monitoring in the surgical intensive care unit: concordance with capillary glucose

BACKGROUND

The role of intensive glycemic control (IGC) in the surgical intensive care unit (SICU) remains controversial. Continuous glucose monitoring systems (CGMSs) may mitigate the major risk of IGC, namely hypoglycemia, and improve clinical outcomes.

METHODS

All patients admitted to the SICU requiring insulin infusion were eligible. CGMS (Medtronic Guardian REAL-Time CGM, Northridge, CA) was placed in the subcutaneous tissue of the abdomen or thigh and calibrated every 8 hours, based on capillary (fingerstick) blood glucose (CBG) readings. Monitors were changed every 72 hours until 144 hours of observation was complete or insulin infusion stopped. CGM data were compared with CBG at least every 2 hours. Other data collected included demographics, diagnoses, fluid balance, doses of vasopressors and/or steroids, and any intravenous or enteral glucose source. CGMS and CBG readings were compared (mean and median absolute difference, correlation coefficients, Bland-Altman plots, and Clarke error grids).

RESULTS

Twenty-four patients were enrolled (11 men; mean [SD] age, 59 [14.1] years; mean [SD] body mass index 37.9 [10.1] kg/m; mean [SD] fluid resuscitation in the first 24 hours, 6.1 [3.5] L; 17 requiring vasopressor therapy). Correlation coefficient between CGMS and CBG was 0.61 (p < 0.001). The mean (SD) absolute difference was 22.0 [21.9] mg/dL and the median absolute difference was 16.0 mg/dL (interquartile rage, 7-31 mg/dL). The Bland-Altman plot did not identify any trends in accuracy. Clarke error grid analysis demonstrated that 98.92% of data points were in Zone A (71.30%), indicating agreement with CBG ± 20%, or Zone B (27.62%) (divergent but discrepancy would likely not lead to patient harm). Just 0.81% of data points were in Zone C (potentially dangerous overcorrection likely), and only 0.27% were in Zones D or E (potentially dangerous failure to detect hypoglycemia/hyperglycemia).

CONCLUSION

CGMS seems reasonably accurate in the SICU, despite widespread use of pressors and large-volume resuscitation. Further investigation into the accuracy and precision of these devices to assist clinicians in achieving IGC is warranted.

LEVEL OF EVIDENCE

Diagnostic study, level III.

Identification of chicoric acid as a hypoglycemic agent from Ocimum gratissimum leaf extract in a biomonitoring in vivo study

Ocimum gratissimum L. is popularly used to treat diabetes mellitus. The hypoglycemic activity of this medicinal species has been confirmed by in vivo studies. The present study conducted a chemical investigation of a leaf decoction (10% p/v) of O. gratissimum monitored by in vivo hypoglycemic activity assays. Four phenolic substances were identified: L-caftaric acid (1), L-chicoric acid (2), eugenyl-β-D-glucopyranoside (3) and vicenin-2 (4). The acute hypoglycemic activity of the O. gratissimum decoction fractions Og1-S (300 mg/kg), Og1-A (240 mg/kg) and Og1-B (80 mg/kg) was evaluated intraperitoneally in normal and streptozotocin-induced diabetic mice. They reduced glycemia by 63%, 76% and 60% (in 120 min), respectively, in the diabetic mice. Subfractions of Og1-A were also evaluated under the same conditions: Og1-AS (200 mg/kg) and Og1-AP (40 mg/kg) produced a decrease of only 37% and 39%, respectively. Among the major phenolic substances, only chicoric acid (2; 3 mg/kg) reduced significantly the glycemic levels of diabetic mice by 53%, 120 min after treatment. This is the first study describing the hypoglycemic activity of chicoric acid in an animal model of diabetes mellitus. In addition, we suggest that there may be other substances contributing to this activity. Thus, for the first time, a correlation is established between the hypoglycemic activity of O. gratissimum and its chemical composition.

Continuous Glucose Monitoring Systems: A Review

There have been continuous advances in the field of glucose monitoring during the last four decades, which have led to the development of highly evolved blood glucose meters, non-invasive glucose monitoring (NGM) devices and continuous glucose monitoring systems (CGMS). Glucose monitoring is an integral part of diabetes management, and the maintenance of physiological blood glucose concentration is the only way for a diabetic to avoid life-threatening diabetic complications. CGMS have led to tremendous improvements in diabetic management, as shown by the significant lowering of glycated hemoglobin (HbA1c) in adults with type I diabetes. Most of the CGMS have been minimally-invasive, although the more recent ones are based on NGM techniques. This manuscript reviews the advances in CGMS for diabetes management along with the future prospects and the challenges involved.

Future Perspectives in Glucose Monitoring Sensors

The prevalence of diabetes is increasing. improved glucose control is fundamental to reduce both long-term micro- and macrovascular complications and short-term complications, such as diabetic ketoacidosis and severe hypoglycemia. Frequent blood glucose monitoring is an essential part of diabetes management. However, almost all available blood glucose monitoring devices are invasive. This determines a reduced patient compliance, which in turn reflects negatively on glucose control. Therefore, there is a need to develop noninvasive glucose monitoring devices that will reduce the need of invasive procedures, thus increasing patient compliance and consequently improving quality of life and health of patients with diabetes.

Challenges and Recent Progress in the Development of a Closed-loop Artificial Pancreas

Pursuit of a closed-loop artificial pancreas that automatically controls the blood glucose of individuals with type 1 diabetes has intensified during the past six years. Here we discuss the recent progress and challenges in the major steps towards a closed-loop system. Continuous insulin infusion pumps have been widely available for over two decades, but "smart pump" technology has made the devices easier to use and more powerful. Continuous glucose monitoring (CGM) technology has improved and the devices are more widely available. A number of approaches are currently under study for fully closed-loop systems; most manipulate only insulin, while others manipulate insulin and glucagon. Algorithms include on-off (for prevention of overnight hypoglycemia), proportional-integral-derivative (PID), model predictive control (MPC) and fuzzy logic based learning control. Meals cause a major "disturbance" to blood glucose, and we discuss techniques that our group has developed to predict when a meal is likely to be consumed and its effect. We further examine both physiology and device-related challenges, including insulin infusion set failure and sensor signal attenuation. Finally, we discuss the next steps required to make a closed-loop artificial pancreas a commercial reality.