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Schweizer R, Lösch-Binder M, Hayn C, Friz S, Uber J, Ziegler J, Liebrich F, Neu A. Transition From Childhood to Adult Care in Patients with Type 1 Diabetes: 20 Years of Experience From the Tübinger Transition Study. Exp Clin Endocrinol Diabetes 2023; 131:532-538. [PMID: 37467782 DOI: 10.1055/a-2132-9585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
AIMS Transition from pediatric to adult care is difficult for patients with chronic diseases. In this study, factors associated with metabolic control in childhood-onset type 1 diabetes (T1D) after transfer to adult care were analyzed. METHODS Overall, 224 persons with T1D were contacted yearly from 1998 to 2019. They voluntarily answered a questionnaire about their current hemoglobin A1c (HbA1c) levels, diabetes-associated complications, kind of care, living conditions, and family situation. Then, mixed longitudinal-cross-sectional analyses were carried out. RESULTS Overall, 190 patients answered at least once (mean age: 26.6 years). Diabetes complications were mentioned by 10 patients (5 microalbuminuria, 5 retinopathy). Most patients (92.6%) were in diabetes-specific care during the first year after transfer, with a trend to leave diabetes-specific care during the observation period. Patients in diabetes-specific care displayed lower HbA1c levels (%/mmol/mol) (7.1/54 vs. 7.5/58). An important predictor for HbA1c after transfer was HbA1c during the year before transfer (r=0.67, p <0.001). Patients living alone showed no difference in HbA1c levels from those living with their parents. Married patients had lower HbA1c levels (7.0/53 vs. 7.3/56, p<0.05) than unmarried ones. Patients with children (15.8%) presented lower HbA1c levels (6.9/52 vs. 7.3/56, p <0.01) than those without. CONCLUSIONS Good metabolic results are favored in patients followed-up in specialized care, are married, and are parents. We recommend transfer to a diabetologist with experience in T1D at an individual age.
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Affiliation(s)
- Roland Schweizer
- Pediatric Diabetology, University Children's Hospital, Tübingen, Germany
| | | | - Clara Hayn
- Pediatric Diabetology, University Children's Hospital, Tübingen, Germany
| | - Silas Friz
- Pediatric Diabetology, University Children's Hospital, Tübingen, Germany
| | - Julia Uber
- Pediatric Diabetology, University Children's Hospital, Tübingen, Germany
| | - Julian Ziegler
- Pediatric Diabetology, University Children's Hospital, Tübingen, Germany
| | - Franziska Liebrich
- Pediatric Diabetology, University Children's Hospital, Tübingen, Germany
| | - Andreas Neu
- Pediatric Diabetology, University Children's Hospital, Tübingen, Germany
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2
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Polonsky WH, Soriano EC. Psychosocial and Glycemic Benefits for Insulin-Using Adults With Type 2 Diabetes After Six Months of Pump Therapy: A Quasi-Experimental Approach. J Diabetes Sci Technol 2023:19322968231198533. [PMID: 37667482 DOI: 10.1177/19322968231198533] [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] [Indexed: 09/06/2023]
Abstract
BACKGROUND Continuous subcutaneous insulin infusion (CSII) use in adults with type 1 diabetes offers psychosocial and clinical benefits, but little is known about its impact on such outcomes in the type 2 diabetes (T2D) population. To address this gap, we conducted a quasi-experimental prospective study to assess psychosocial, glycemic, and behavioral changes over six months in T2D adults on multiple daily injections (MDI) who were interested in starting Omnipod DASH, comparing those who did versus did not start on it. METHODS In total, 458 adults with T2D completed baseline questionnaires assessing psychosocial dimensions (eg, diabetes distress), clinical metrics (eg, HbA1c [glycosylated hemoglobin]), and behavioral measures (eg, missed mealtime boluses). Six months later, 220 (48.0%) completed the same questionnaire again. To examine differences in outcomes over time between those who began CSII (n = 176) versus those who remained on MDI (n = 44), a latent change score approach was used. RESULTS The CSII users reported greater gains than MDI users on all major psychosocial metrics, including overall well-being (P < .001) diabetes distress (P < .001), perceived T2D impact on quality of life (P = .003), and hypoglycemic worries and concerns (P < .001). The CSII users similarly reported a larger decline in HbA1c than MDI users (P < .05) and greater declines in two critical self-care behaviors: number of missed mealtime boluses (P < .001) and number of days of perceived overeating (P = .001). CONCLUSIONS The introduction of CSII (Omnipod DASH) in T2D adults can contribute to significant psychosocial, glycemic, and behavioral benefits, indicating that broader use of CSII in the T2D population may be of value.
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Affiliation(s)
- William H Polonsky
- Behavioral Diabetes Institute, San Diego, CA, USA
- University of California, San Diego, San Diego, CA, USA
| | - Emily C Soriano
- Scripps Whittier Diabetes Institute, Scripps Health, La Jolla, CA, USA
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3
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Amato LA, Kalolo R, Yu W, Simmons D. Provision of continuous subcutaneous insulin infusion to type 1 diabetes 'frequent flyers'. Intern Med J 2023; 53:1706-1711. [PMID: 37665715 DOI: 10.1111/imj.16213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 07/27/2023] [Indexed: 09/06/2023]
Abstract
A few people with type 1 diabetes undergo multiple hospital admissions for acute glycaemic events. We report on a series of five such 'frequent flyers' who were provided with continuous subcutaneous insulin infusion (CSII) therapy. Mean HbA1c decreased from 9.7 ± 2.5% (83 ± 27 mmol/mol) to 7.9 ± 0.4% (63 ± 4.7 mmol/mol) after 2-4 months. Frequency of admissions for acute glycaemic events reduced in three but increased in two patients within 6 months. Total insulin dose and body mass index decreased in some patients and satisfaction was anecdotally higher. Some, but not all, 'frequent flyers' benefited from a trial of CSII.
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Affiliation(s)
- Lisa A Amato
- Macarthur Diabetes Service, Campbelltown Hospital, Sydney, New South Wales, Australia
| | - Romana Kalolo
- Macarthur Diabetes Service, Campbelltown Hospital, Sydney, New South Wales, Australia
| | - William Yu
- Macarthur Diabetes Service, Campbelltown Hospital, Sydney, New South Wales, Australia
| | - David Simmons
- Macarthur Diabetes Service, Campbelltown Hospital, Sydney, New South Wales, Australia
- Macarthur Clinical School, Western Sydney University, Sydney, New South Wales, Australia
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Talbo MK, Katz A, Hill L, Peters TM, Yale JF, Brazeau AS. Effect of diabetes technologies on the fear of hypoglycaemia among people living with type 1 diabetes: a systematic review and meta-analysis. EClinicalMedicine 2023; 62:102119. [PMID: 37593226 PMCID: PMC10430205 DOI: 10.1016/j.eclinm.2023.102119] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 07/06/2023] [Accepted: 07/10/2023] [Indexed: 08/19/2023] Open
Abstract
Background Fear of hypoglycaemia (FOH) significantly disrupts the daily management of type 1 diabetes (T1D) and increases the risk of complications. Recent technological advances can improve glucose metrics and reduce hypoglycaemia frequency, yet their impact on FOH is unclear. This systematic review and meta-analysis (SRMA) aimed to synthesize the current literature to understand the impact of diabetes technologies on FOH in T1D. Methods In this SRMA, we searched PubMed, Medline, Scopus, and Web of Science from inception up to May 21st, 2023 for studies assessing the effect of using real-time or intermittently scanned continuous glucose monitors (rtCGM or isCGM); insulin pumps (CSII); and their combinations on FOH as the primary outcome, measured using the Hypoglycaemia Fear Survey (HFS; including total, worries [HFS-W], and behaviours [HFS-B] scores), in non-pregnant adults with T1D. Data was extracted by the first and second authors. Results were pooled using a random-effects model based on study design (RCT and non-RCT), with subgroup analysis based on the type of technology, reported change in hypoglycaemia frequency, and duration of use. Risk of bias was evaluated with Cochrane and Joanna Briggs Institute tools. This study is registered with PROSPERO, CRD42021253618. Findings A total of 51 studies (n = 8966) were included, 22 of which were RCTs. Studies on rtCGM and CSII reported lower FOH levels with ≥8 weeks of use. Studies on CSII and rtCGM combinations reported lower FOH levels after ≥13 weeks of automated insulin delivery (AID) use or 26 weeks of sensor-augmented pump (SAP) use. The meta-analysis showed an overall lower FOH with technologies, specifically for the HFS-W subscale. The RCT meta-analysis showed lower HFS-W scores with rtCGM use (standard mean difference [95%CI]: -0.14 [-0.23, -0.05], I2 = 0%) and AID (-0.17 [-0.33, -0.01], I2 = 0%). Results from non-RCT studies show that SAP users (-0.33 [-0.38, -0.27], I2 = 0%) and rtCGM users (-0.38 [-0.61, -0.14], I2 = 0%) had lower HFS-W. Interpretation We found consistent, yet small to moderate, effects supporting that diabetes technologies (specifically rtCGM, SAP, and AID) may reduce hypoglycaemia-related worries in adults with T1D. Current literature, however, has limitations including discrepancies in baseline characteristics and limited, mainly descriptive, statistical analysis. Thus, future studies should assess FOH as a primary outcome, use validated surveys, and appropriate statistical analysis to evaluate the clinical impacts of technology use beyond just glucose metrics. Funding Canadian Institutes of Health Research, Juvenile Diabetes Research Foundation Ltd.
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Affiliation(s)
- Meryem K. Talbo
- School of Human Nutrition, McGill University, 21111 Lakeshore Road, Ste-Anne-de-Bellevue, Québec H9X 3V9, Canada
| | - Alexandra Katz
- School of Human Nutrition, McGill University, 21111 Lakeshore Road, Ste-Anne-de-Bellevue, Québec H9X 3V9, Canada
- Faculté de Médecine, Université de Montréal, 2900 Edouard Montpetit Blvd, Montréal, Québec H3T 1J4, Canada
| | - Lee Hill
- School of Human Nutrition, McGill University, 21111 Lakeshore Road, Ste-Anne-de-Bellevue, Québec H9X 3V9, Canada
- Department of Paediatrics, Research Institute of the McGill University Health Centre, 5252 de Maisonneuve Boulevard W, Montréal, Québec H4A 3S9, Canada
| | - Tricia M. Peters
- Centre for Clinical Epidemiology, and Division of Endocrinology, Lady Davis Research Institute, Jewish General Hospital, 3755 Cote Ste Catherine, Montréal, Québec H3T 1E2, Canada
| | - Jean-François Yale
- Division of Endocrinology and Metabolism, Department of Medicine, McGill University Health Centre, 687 Pine Avenue West Montreal, Montréal, Québec H3A 1A1, Canada
| | - Anne-Sophie Brazeau
- School of Human Nutrition, McGill University, 21111 Lakeshore Road, Ste-Anne-de-Bellevue, Québec H9X 3V9, Canada
- Montréal Diabetes Research Centre, 900, Saint-Denis, Montréal, Québec H2X 0A9, Canada
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5
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Personalized hybrid artificial pancreas using unidirectional sliding-modes control algorithm. Biocybern Biomed Eng 2022. [DOI: 10.1016/j.bbe.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Tsarkova P, Chakarova N, Dimova R, Grozeva G, Todorova A, Serdarova M, Salkova M, Tankova T. CSII is related to more stable glycemia in adults with type 1 diabetes. Endocrine 2022; 75:776-780. [PMID: 34694598 DOI: 10.1007/s12020-021-02913-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 10/13/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The purpose of the present study was to compare the basic glycemic control parameters-HbA1c, CV%, and hypoglycemia, as well as quality of life and depression score in patients with type 1 diabetes using continuous subcutaneous insulin infusion (CSII) versus multiple daily injections (MDI). METHODS 324 adult patients with type 1 diabetes-146 using CSII and 178 on MDI, were enrolled in this cross-sectional study. HbA1c was assessed in whole blood by immuno-turbidimetric NGSP certified method. CV% was derived from CGM or was calculated from a 9-point capillary blood glucose profile. Hypoglycemia frequency, severity, and awareness were assessed using Clarke's hypoglycemia questionnaire. Quality of life (QOL) was assessed using a questionnaire by the Psychiatric Research Unit and the CES-D scale. RESULTS CSII group compared to MDI group showed significantly lower HbA1c-7.3% (6.6-8.0%) vs 8.2% (7.2-9.6%) (p < 0.0001), lower CV 27.2% (±9.8) vs 34.7% (±11.3) (p < 0.0001), fewer hypoglycemia episodes (p < 0.0001). There was no significant difference in the frequency of severe hypoglycemia, hypoglycemia awareness, QOL, and depression scores between the two groups. CONCLUSIONS CSII in type 1 diabetes is related to better and more stable glycemic control compared to MDI.
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Affiliation(s)
- Polina Tsarkova
- Division of Diabetology, Department of Endocrinology, Medical University of Sofia, Sofia, Bulgaria.
| | - Nevena Chakarova
- Division of Diabetology, Department of Endocrinology, Medical University of Sofia, Sofia, Bulgaria
| | - Rumyana Dimova
- Division of Diabetology, Department of Endocrinology, Medical University of Sofia, Sofia, Bulgaria
| | - Greta Grozeva
- Division of Diabetology, Department of Endocrinology, Medical University of Sofia, Sofia, Bulgaria
| | - Ani Todorova
- Division of Diabetology, Department of Endocrinology, Medical University of Sofia, Sofia, Bulgaria
| | - Mina Serdarova
- Division of Diabetology, Department of Endocrinology, Medical University of Sofia, Sofia, Bulgaria
| | - Martina Salkova
- Division of Diabetology, Department of Endocrinology, Medical University of Sofia, Sofia, Bulgaria
| | - Tsvetalina Tankova
- Division of Diabetology, Department of Endocrinology, Medical University of Sofia, Sofia, Bulgaria
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7
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Effects of continuous subcutaneous insulin infusion on clinical parameters in patients with different sociodemographic and clinical characteristics. Int J Diabetes Dev Ctries 2021. [DOI: 10.1007/s13410-021-01025-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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8
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Song C, Booth GL, Perkins BA, Weisman A. Impact of government-funded insulin pump programs on insulin pump use in Canada: a cross-sectional study using the National Diabetes Repository. BMJ Open Diabetes Res Care 2021; 9:9/1/e002371. [PMID: 34615649 PMCID: PMC8496375 DOI: 10.1136/bmjdrc-2021-002371] [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: 05/07/2021] [Accepted: 09/15/2021] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Insulin pump access in type 1 diabetes may be inequitable. We studied the association between government funding programs for insulin pumps and rates of insulin pump use and disparities between pump users and non-users. RESEARCH DESIGN AND METHODS Adults with type 1 diabetes were identified in the National Diabetes Repository, a primary care electronic medical record database of individuals with diabetes from five Canadian provinces. Proportions of individuals using insulin pumps were compared between provinces with and without pump funding programs. Multivariable logistic regression models were used to estimate the odds of insulin pump use adjusting for confounders. Univariate logistic regression models were used to estimate the odds of insulin pump use according to each predictor, according to pump funding program status. RESULTS Of 1559 adults with type 1 diabetes, proportions using insulin pumps were 47.8% (95% CI 45.1% to 50.5%) and 37.7% (95% CI 31.5% to 44.1%) in provinces with and without pump funding programs (p=0.0038). Adjusting for age, sex, HbA1c, income quintile, and rural/urban location, the OR for insulin pump use was 1.45 (1.08-1.94) for provinces with pump funding programs compared with provinces without. Higher income was associated with a greater odds of insulin pump use in provinces with pump funding programs, and rural/urban location was not associated with insulin pump use. CONCLUSIONS Insulin pump use is more common in regions with government funding programs. Further research is required to best understand and comprehensively address persistent income disparities between pump users and non-users despite the availability of reimbursement programs.
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Affiliation(s)
- Cimon Song
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Gillian L Booth
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Bruce A Perkins
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Alanna Weisman
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
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9
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Berg AK, Thorsen SU, Thyssen JP, Zachariae C, Keiding H, Svensson J. Cost of Treating Skin Problems in Patients with Diabetes Who Use Insulin Pumps and/or Glucose Sensors. Diabetes Technol Ther 2020; 22:658-665. [PMID: 31800294 DOI: 10.1089/dia.2019.0368] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background: The use of insulin pump and glucose sensor is advantageous, but unfortunately many experience skin problems. To reduce or overcome skin problems, patients use additional products or change their sets preterm. Therefore, the aim was to investigate costs related to skin problems. Materials and Methods: Two hundred sixty-three patients from four different hospitals in Denmark participated in a cross-sectional survey about skin problems related to insulin pump and/or glucose sensor use. Additional costs aside technology and diabetes treatment were calculated based on adhesives, patches, lotion, and preterm shifts of infusion or sensor sets due to skin problems. Descriptive statistics and linear regression were used. Results: The total costs for all these expenses were 11493.9 U.S. dollars (USD) in 145 pediatric patients and 4843 USD in 118 adult patients. The costs were higher in patients with, than without, skin problems and for skin problems due to the glucose sensor compared with insulin pump. Pediatric patients with eczema and/or wound due to the glucose sensor did cost 154.3 USD more, than patients without these skin problems (P < 0.01). We found a clear dose/response relationship between costs and severity of skin problems, especially in pediatric patients. Conclusions: Our data show that skin problems due to use of insulin pump and/or glucose sensor have significant costs on the Danish welfare system. This leaves an economic incentive for developing more skin-sensitive adhesive for the infusion set and sensors, at least for a certain subgroup of patients.
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Affiliation(s)
- Anna Korsgaard Berg
- Copenhagen Diabetes Research Center (CPH-DIRECT), Department of Pediatrics and Adolescent Medicine, Herlev and Gentofte Hospital, Herlev, Denmark
- Faculty of Medical and Health Science, University of Copenhagen, Kobenhavn, Denmark
| | - Steffen Ullitz Thorsen
- Copenhagen Diabetes Research Center (CPH-DIRECT), Department of Pediatrics and Adolescent Medicine, Herlev and Gentofte Hospital, Herlev, Denmark
| | - Jacob P Thyssen
- Department of Dermatology and Allergy, Herlev and Gentofte Hospital, Hellerup, Denmark
| | - Claus Zachariae
- Department of Dermatology and Allergy, Herlev and Gentofte Hospital, Hellerup, Denmark
| | - Hans Keiding
- Department of Economics, University of Copenhagen, Kobenhavn, Denmark
| | - Jannet Svensson
- Copenhagen Diabetes Research Center (CPH-DIRECT), Department of Pediatrics and Adolescent Medicine, Herlev and Gentofte Hospital, Herlev, Denmark
- Faculty of Medical and Health Science, University of Copenhagen, Kobenhavn, Denmark
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10
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Oldham V, Mumford B, Lee D, Jones J, Das G. Impact of insulin pump therapy on key parameters of diabetes management and diabetes related emotional distress in the first 12 months. Diabetes Res Clin Pract 2020; 166:108281. [PMID: 32628980 DOI: 10.1016/j.diabres.2020.108281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/11/2020] [Accepted: 06/19/2020] [Indexed: 12/21/2022]
Abstract
AIMS To evaluate the effect of continuous subcutaneous insulin infusion (CSII) on glycaemic control, hypoglycaemia and emotional distress in adults with type 1 diabetes (T1D) during the first 12 months. METHODS 47 patients were started on CSII as per NICE guidelines. Anthropometric, clinical and biochemical parameters, hypoglycaemia rates and emotional distress measured by Problem Areas in Diabetes questionnaires (PAID) were recorded at baseline and during follow up at 3-6 months and 6-12 months. RESULTS Mean HbA1c dropped by 1.1% (11.8 mmol/mol; p < 0.0001) at 3-6 months and by 0.8% (8.6 mmol/mol; p = 0.008) at 6-12 months. Most patients had improved HbA1c between 6.5 and 8.5% (48-69 mmol/mol) during these follow ups (68.3% and 71.5% respectively). Frequency of hypoglycaemia reduced from 338.2 to 187.2 and 155.3 per 100 patient years during follow ups. Severe hypoglycaemia also decreased from 48.9 to 8.5 and 6.3 per 100 patient years respectively. PAID scores improved from 29.8 ± 18.5 to 17.2 ± 14.0 (p = 0.0002) at 3-6 months and to 12.8 ± 11.7 (p < 0.00001) at 6-12 months. Reduction in HbA1c, insulin dose and PAID scores was more significant in group with HbA1c > 8.5% (69 mmol/mol) at baseline whereas improvement in episodes of hypoglycaemia and severe hypoglycaemic was more in patients who had HbA1c ≤ 8.5% before commencement of CSII therapy. CONCLUSIONS CSII therapy led to early improvement in glycaemic control, rates of hypoglycaemia and diabetes specific emotional distress. As beneficial effects are recorded within the first few months, CSII therapy should be started more proactively in T1D.
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Affiliation(s)
- Victoria Oldham
- Department of Diabetes and Endocrinology, Diabetes Centre, Prince Charles Hospital, Cwm Taf Morgannwg University Health Board, Merthyr Tydfil CF47 9DT, United Kingdom
| | - Beth Mumford
- Department of Diabetes and Endocrinology, Diabetes Centre, Prince Charles Hospital, Cwm Taf Morgannwg University Health Board, Merthyr Tydfil CF47 9DT, United Kingdom
| | - Dawn Lee
- Department of Diabetes and Endocrinology, Diabetes Centre, Prince Charles Hospital, Cwm Taf Morgannwg University Health Board, Merthyr Tydfil CF47 9DT, United Kingdom
| | - Julie Jones
- Department of Diabetes and Endocrinology, Diabetes Centre, Prince Charles Hospital, Cwm Taf Morgannwg University Health Board, Merthyr Tydfil CF47 9DT, United Kingdom
| | - Gautam Das
- Department of Diabetes and Endocrinology, Diabetes Centre, Prince Charles Hospital, Cwm Taf Morgannwg University Health Board, Merthyr Tydfil CF47 9DT, United Kingdom.
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Abstract
The success of diabetes technologies depends on the attitudes and behavior of the individuals who choose to adopt them. Real-time continuous glucose monitoring, continuous subcutaneous insulin infusion, and sensor-augmented pump systems may positively affect diabetes-related quality of life (QOL), although the influence on QOL outcomes seems to be modest and the results from randomized controlled trials are limited and controversial. In contrast, more consistently positive QOL-related responses are apparent from observational data. The newer generations of devices hold the promise for more strongly enhancing diabetes-related QOL. Appropriate training and ongoing support are likely to be the key to successful uptake.
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Affiliation(s)
- William H Polonsky
- Behavioral Diabetes Institute, 5405 Oberlin Drive, Suite 100, San Diego, CA 92121, USA; University of California, San Diego, San Diego, CA, USA.
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12
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Somali M, Paschou SA, Mouslech Z. Insulin pumps use in Greece: Efficacy and safety data from 140 patients with type 1 diabetes mellitus. Diabetes Res Clin Pract 2020; 160:108026. [PMID: 31954749 DOI: 10.1016/j.diabres.2020.108026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 12/18/2019] [Accepted: 01/13/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the efficacy and safety of continuous subcutaneous insulin infusion (CSII) regarding glycaemic control and quality of life in patients with type 1 diabetes mellitus (T1DM), who were previously treated with multiple daily injections (MDI). PATIENTS AND METHODS 140 patients with T1DM [mean age 33.7 ± 22.1 years; 54 males, 76 females, 10 children; duration of diabetes 19.1 ± 8.4 years; total daily insulin usage while on MDI (IU/day) 57.86 ± 15.32; HbA1c at the beginning of CSII treatment 8.67 ± 1.54%] were included in the study. HbA1c, glucose levels, BMI, severe hypoglycemic and diabetic ketoacidosis (DKA) episodes were recorded and compared to the data prior to CSII introduction. The evaluation of the quality of life was assessed with a self-questionnaire adjusted from the SF-12 and diabetes quality of life (DQoL) questionnaires. RESULTS HbA1c was reduced from 8.67 ± 1.54 to 6.85 ± 0.52% (p < 0.001). This reduction was independent of age, gender, body mass index (BMI) and diabetes duration. Daily insulin requirements were lower at the end of the follow-up (36.40 ± 12.20 IU/day) compared with the needs during enrolment (57.86 ± 15.32 IU/day) (p < 0.001). BMI presented no significant alterations. Ten (10) severe hypoglycemic episodes were recorded but the overall rate was decreased by 71.5% (p < 0.001). Only 3 cases of ketoacidosis were recorded. Quality of life parameters were remarkably improved. CONCLUSIONS This study provided evidence that CSII treatment was superior to MDI for patients with T1DM in Greece. CSII offered a safe, effective alternative to MDI, while improving glycaemic control, side-effects and quality of life.
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Affiliation(s)
- Maria Somali
- Department of Endocrinology, Diabetes and Metabolism, Euromedica General Clinic, Thessaloniki, Greece
| | - Stavroula A Paschou
- Division of Endocrinology and Diabetes, "Aghia Sophia" Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Zadalla Mouslech
- Department of Endocrinology, Diabetes and Metabolism, Euromedica General Clinic, Thessaloniki, Greece.
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Blair J, McKay A, Ridyard C, Thornborough K, Bedson E, Peak M, Didi M, Annan F, Gregory JW, Hughes D, Gamble C. Continuous subcutaneous insulin infusion versus multiple daily injections in children and young people at diagnosis of type 1 diabetes: the SCIPI RCT. Health Technol Assess 2019; 22:1-112. [PMID: 30109847 DOI: 10.3310/hta22420] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The risk of developing long-term complications of type 1 diabetes (T1D) is related to glycaemic control and is reduced by the use of intensive insulin treatment regimens: multiple daily injections (MDI) (≥ 4) and continuous subcutaneous insulin infusion (CSII). Despite a lack of evidence that the more expensive treatment with CSII is superior to MDI, both treatments are used widely within the NHS. OBJECTIVES (1) To compare glycaemic control during treatment with CSII and MDI and (2) to determine safety and cost-effectiveness of the treatment, and quality of life (QoL) of the patients. DESIGN A pragmatic, open-label randomised controlled trial with an internal pilot and 12-month follow-up with 1 : 1 web-based block randomisation stratified by age and centre. SETTING Fifteen diabetes clinics in hospitals in England and Wales. PARTICIPANTS Patients aged 7 months to 15 years. INTERVENTIONS Continuous subsutaneous insulin infusion or MDI initiated within 14 days of diagnosis of T1D. DATA SOURCES Data were collected at baseline and at 3, 6, 9 and 12 months using paper forms and were entered centrally. Data from glucometers and CSII were downloaded. The Health Utilities Index Mark 2 was completed at each visit and the Pediatric Quality of Life Inventory (PedsQL, diabetes module) was completed at 6 and 12 months. Costs were estimated from hospital patient administration system data. OUTCOMES The primary outcome was glycosylated haemoglobin (HbA1c) concentration at 12 months. The secondary outcomes were (1) HbA1c concentrations of < 48 mmol/mol, (2) severe hypoglycaemia, (3) diabetic ketoacidosis (DKA), (4) T1D- or treatment-related adverse events (AEs), (5) change in body mass index and height standard deviation score, (6) insulin requirements, (7) QoL and (8) partial remission rate. The economic outcome was the incremental cost per quality-adjusted life-year (QALY) gained. RESULTS A total of 293 participants, with a median age of 9.8 years (minimum 0.7 years, maximum 16 years), were randomised (CSII, n = 149; MDI, n = 144) between May 2011 and January 2015. Primary outcome data were available for 97% of participants (CSII, n = 143; MDI, n = 142). At 12 months, age-adjusted least mean squares HbA1c concentrations were comparable between groups: CSII, 60.9 mmol/mol [95% confidence interval (CI) 58.5 to 63.3 mmol/mol]; MDI, 58.5 mmol/mol (95% CI 56.1 to 60.9 mmol/mol); and the difference of CSII - MDI, 2.4 mmol/mol (95% CI -0.4 to 5.3 mmol/mol). For HbA1c concentrations of < 48 mmol/mol (CSII, 22/143 participants; MDI, 29/142 participants), the relative risk was 0.75 (95% CI 0.46 to 1.25), and for partial remission rates (CSII, 21/86 participants; MDI, 21/64), the relative risk was 0.74 (95% CI 0.45 to 1.24). The incidences of severe hypoglycaemia (CSII, 6/144; MDI, 2/149 participants) and DKA (CSII, 2/144 participants; MDI, 0/149 participants) were low. In total, 68 AEs (14 serious) were reported during CSII treatment and 25 AEs (eight serious) were reported during MDI treatment. Growth outcomes did not differ. The reported insulin use was higher with CSII (mean difference 0.1 unit/kg/day, 95% CI 0.0 to 0.2 unit/kg/day; p = 0.01). QoL was slightly higher for those randomised to CSII. From a NHS perspective, CSII was more expensive than MDI mean total cost (£1863, 95% CI £1620 to £2137) with no additional QALY gains (-0.006 QALYs, 95% CI -0.031 to 0.018 QALYs). LIMITATIONS Generalisability beyond 12 months is uncertain. CONCLUSIONS No clinical benefit of CSII over MDI was identified. CSII is not a cost-effective treatment in patients representative of the study population. FUTURE WORK Longer-term follow-up is required to determine if clinical outcomes diverge after 1 year. A qualitative exploration of patient and professional experiences of MDI and CSII should be considered. TRIAL REGISTRATION Current Controlled Trials ISRCTN29255275 and EudraCT 2010-023792-25. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 42. See the NIHR Journals Library website for further project information. The cost of insulin pumps and consumables supplied by F. Hoffman-La Roche AG (Basel, Switzerland) for the purpose of the study were subject to a 25% discount on standard NHS costs.
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Affiliation(s)
- Joanne Blair
- Department of Endocrinology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Andrew McKay
- Clinical Trials Research Centre, University of Liverpool, Liverpool, UK
| | - Colin Ridyard
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Keith Thornborough
- Department of Diabetes, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Emma Bedson
- Clinical Trials Research Centre, University of Liverpool, Liverpool, UK
| | - Matthew Peak
- Department of Research, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Mohammed Didi
- Department of Endocrinology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Francesca Annan
- Paediatric and Adolescent Division, University College Hospital, London, UK
| | - John W Gregory
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Dyfrig Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Carrol Gamble
- Clinical Trials Research Centre, University of Liverpool, Liverpool, UK
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Affiliation(s)
- John C Pickup
- 1 Faculty of Life Sciences and Medicine, King's College London, Guy's Hospital, London, UK
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15
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Taleb N, Messier V, Ott-Braschi S, Ardilouze JL, Rabasa-Lhoret R. Perceptions and experiences of adult patients with type 1 diabetes using continuous subcutaneous insulin infusion therapy: Results of an online survey. Diabetes Res Clin Pract 2018; 144:42-50. [PMID: 30077691 DOI: 10.1016/j.diabres.2018.07.035] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 06/28/2018] [Accepted: 07/30/2018] [Indexed: 01/22/2023]
Abstract
AIMS To assess perceptions of patients using subcutaneous insulin infusion (CSII) about metabolic control, pump malfunctions, technical and insertion site adverse events (AEs) related to infusion sets/catheters as well as patients' practices. METHODS Online survey (from June 2016 to January 2017) using an actualized 39-item questionnaire directed to adults with type 1 diabetes (T1D) using CSII therapy and living in the province of Quebec, Canada. RESULTS Participants with T1D (n = 115, 72% females, 39.7 ± 14.0 years, diabetes duration: 20.9 ± 12.2 years, CSII use: 6.2 ± 4.1 years) adequately completed the survey. Infusion sets were changed every 3.3 ± 0.9 day. Improved glucose control and decreased number/severity of hypoglycemic episodes were reported by 80% and 68%/50% of subjects, respectively. Over the past year of CSII use, participants perceived no increase in anxiety/worry (84%), no negative impact on life (89%) or on time off from work/school (82%). Conversely, many experienced at least one clinical AEs at insertion site [pain (84%), adhesion (76%), irritation (69%), lipodystrophy (45%)] and technical issues [blockage (52%), cannula kinking (50%), pump stop (55%), air bubbles (46%)]. No significant association was observed between catheter wear-time and AEs. All participants had one or more problems related to CSII use, although only 37% reported addressing these issues with health professionals. CONCLUSION Our study suggests that patients positively perceived CSII use although they experienced a high frequency of clinical and technical AEs. This warrants further attention by health professionals, investigators and manufacturers to optimize CSII therapy.
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Affiliation(s)
- Nadine Taleb
- Institut de recherches cliniques de Montréal, 110, avenue des Pins Ouest, Montreal, Quebec H2W 1R7, Canada; Department of Biomedical Sciences, Faculty of Medicine, Université de Montréal, 2900, Édouard-Montpetit, Montreal, Quebec H3T 1J4, Canada
| | - Virginie Messier
- Institut de recherches cliniques de Montréal, 110, avenue des Pins Ouest, Montreal, Quebec H2W 1R7, Canada
| | - Sylvie Ott-Braschi
- Institut de recherches cliniques de Montréal, 110, avenue des Pins Ouest, Montreal, Quebec H2W 1R7, Canada; Centre Hospitalier de l'Université de Montréal, 3840, rues Saint-Urbain, Montreal, Quebec H2W 1T8, Canada
| | - Jean-Luc Ardilouze
- Department of Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001-12(e) Avenue Nord, Sherbrooke, Québec J1H 5N4, Canada
| | - Rémi Rabasa-Lhoret
- Institut de recherches cliniques de Montréal, 110, avenue des Pins Ouest, Montreal, Quebec H2W 1R7, Canada; Centre Hospitalier de l'Université de Montréal, 3840, rues Saint-Urbain, Montreal, Quebec H2W 1T8, Canada; Department of Nutrition, Faculty of Medicine, Université de Montréal, 2405, chemin de la Côte-Sainte-Catherine, Montréal, Québec H3T 1A8, Canada; Montreal Diabetes Research Center, 900 Saint-Denis, Montréal, Québec H2X 0A9, Canada.
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16
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Berg AK, Nørgaard K, Thyssen JP, Zachariae C, Hommel E, Rytter K, Svensson J. Skin Problems Associated with Insulin Pumps and Sensors in Adults with Type 1 Diabetes: A Cross-Sectional Study. Diabetes Technol Ther 2018; 20:475-482. [PMID: 29893593 DOI: 10.1089/dia.2018.0088] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND In the future, widespread use of closed-loop infusion (artificial pancreas) systems to treat type 1 diabetes (T1D) may significantly improve glycemic control and enhance treatment flexibility. However, the infusion sets and plasters necessary for these treatments can cause dermatological complications that may hamper the spread of the new technology; few studies have investigated these complications in adults. The aim of this study was to describe the dermatological complications associated with continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring (CGM) in adults. METHODS A total of 118 adult patients from two different diabetes clinics completed a questionnaire concerning the dermatological complications associated with their CSII and/or CGM treatment, other treatment variables, duration of diabetes, allergies, skin care, and other pathologies. RESULTS CGM or CSII use was associated with current eczema, scars, and wounds. In total, 34% of CSII users and 35% of CGM users currently had one or more skin lesions due to the use of these devices. We found no significant association with glycated hemoglobin (HbA1c) levels, a history of atopic dermatitis, or other skin pathologies. However, multivariate analysis revealed associations with a history of atopy and CSII-associated dermatological complications. CONCLUSIONS Dermatological complications were present in one in every three patients and represent a significant challenge to using CSII and CGM to treat adults with T1D. Prospective studies on the causes of these complications will be required to develop preventive strategies and ensure that optimal diabetes treatment approaches that take advantage of the latest technology can be implemented.
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Affiliation(s)
- Anna Korsgaard Berg
- 1 Department of Pediatrics, Copenhagen Diabetes Research Center (CPH-DIRECT), Copenhagen University Hospital , Herlev and Gentofte, Herlev, Denmark
- 2 Faculty of Health Science, University of Copenhagen , Denmark
| | - Kirsten Nørgaard
- 2 Faculty of Health Science, University of Copenhagen , Denmark
- 3 Department of Endocrinology, Copenhagen University Hospital , Hvidovre, Denmark
| | - Jacob P Thyssen
- 4 Department of Dermatology and Allergy, Copenhagen University Hospital , Herlev and Gentofte, Hellerup, Denmark
| | - Claus Zachariae
- 4 Department of Dermatology and Allergy, Copenhagen University Hospital , Herlev and Gentofte, Hellerup, Denmark
| | - Eva Hommel
- 5 Steno Diabetes Center Copenhagen , Gentofte, Denmark
| | - Karen Rytter
- 5 Steno Diabetes Center Copenhagen , Gentofte, Denmark
| | - Jannet Svensson
- 1 Department of Pediatrics, Copenhagen Diabetes Research Center (CPH-DIRECT), Copenhagen University Hospital , Herlev and Gentofte, Herlev, Denmark
- 2 Faculty of Health Science, University of Copenhagen , Denmark
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17
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Shaban C, Knott J, Jenkins E, Weiss M, Ryder J, Charman J, Partridge H. Diabetes distress and fear of hypoglycaemia: what are the psychological benefits of insulin pump therapy? PRACTICAL DIABETES 2017. [DOI: 10.1002/pdi.2135] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Clare Shaban
- Bournemouth Diabetes and Endocrine Centre; Royal Bournemouth Hospital; Bournemouth UK
| | - Julia Knott
- Bournemouth Diabetes and Endocrine Centre; Royal Bournemouth Hospital; Bournemouth UK
| | - Emma Jenkins
- Bournemouth Diabetes and Endocrine Centre; Royal Bournemouth Hospital; Bournemouth UK
| | - Melanie Weiss
- Bournemouth Diabetes and Endocrine Centre; Royal Bournemouth Hospital; Bournemouth UK
| | - Jacqueline Ryder
- Bournemouth Diabetes and Endocrine Centre; Royal Bournemouth Hospital; Bournemouth UK
| | - Julie Charman
- Bournemouth Diabetes and Endocrine Centre; Royal Bournemouth Hospital; Bournemouth UK
| | - Helen Partridge
- Bournemouth Diabetes and Endocrine Centre; Royal Bournemouth Hospital; Bournemouth UK
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18
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Maker AV, Sheikh R, Bhagia V. Perioperative management of endocrine insufficiency after total pancreatectomy for neoplasia. Langenbecks Arch Surg 2017; 402:873-883. [PMID: 28733926 DOI: 10.1007/s00423-017-1603-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Accepted: 07/07/2017] [Indexed: 12/14/2022]
Abstract
PURPOSE Indications for total pancreatectomy (TP) have increased, including for diffuse main duct intrapapillary mucinous neoplasms of the pancreas and malignancy; therefore, the need persists for surgeons to develop appropriate endocrine post-operative management strategies. The brittle diabetes after TP differs from type 1/2 diabetes in that patients have absolute deficiency of insulin and functional glucagon. This makes glucose management challenging, complicates recovery, and predisposes to hospital readmissions. This article aims to define the disease, describe the cause for its occurrence, review the anatomy of the endocrine pancreas, and explain how this condition differs from diabetes mellitus in the setting of post-operative management. The morbidity and mortality of post-TP endocrine insufficiency and practical treatment strategies are systematically reviewed from the literature. Finally, an evidence-based treatment algorithm is created for the practicing pancreatic surgeon and their care team of endocrinologists to aid in managing these complex patients. METHODS A PubMed, Science Citation Index/Social sciences Citation Index, and Cochrane Evidence-Based Medicine database search was undertaken along with extensive backward search of the references of published articles to identify studies evaluating endocrine morbidity and treatment after TP and to establish an evidence-based treatment strategy. RESULTS Indications for TP and the etiology of pancreatogenic diabetes are reviewed. After TP, ~80% patients develop hypoglycemic episodes and 40% experience severe hypoglycemia, resulting in 0-8% mortality and 25-45% morbidity. Referral to a nutritionist and endocrinologist for patient education before surgery followed by surgical reevaluation to determine if the patient has the appropriate understanding, support, and resources preoperatively has significantly reduced morbidity and mortality. The use of modern recombinant long-acting insulin analogues, continuous subcutaneous insulin infusion, and glucagon rescue therapy has greatly improved management in the modern era and constitute the current standard of care. A simple immediate post-operative algorithm was constructed. CONCLUSION Successful perioperative surgical management of total pancreatectomy and resulting pancreatogenic diabetes is critical to achieve acceptable post-operative outcomes, and we review the pertinent literature and provide a simple, evidence-based algorithm for immediate post-resection glycemic control.
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Affiliation(s)
- Ajay V Maker
- Department of Surgery, Division of Surgical Oncology, University of Illinois at Chicago, 835 S. Wolcott Ave. MC790, Chicago, IL, 60612, USA.
- Creticos Cancer Center, Advocate Illinois Masonic Medical Center, University of Illinois Metropolitan Group Hospitals Residency Program in General Surgery, Chicago, IL, USA.
| | - Raashid Sheikh
- Creticos Cancer Center, Advocate Illinois Masonic Medical Center, University of Illinois Metropolitan Group Hospitals Residency Program in General Surgery, Chicago, IL, USA
| | - Vinita Bhagia
- Department of Medicine, Division of Endocrinology, University of Illinois at Chicago and Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA
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19
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Haase M, Kahle M, Janert M, Meier JJ, Nauck MA. Basal rate tests (24-hour fasts) performed in type-1 diabetic subjects with either absolute fasting or snacks containing negligible carbohydrate amounts result in similar glucose profiles: A randomized controlled prospective trial. Diabetes Obes Metab 2017; 19:783-790. [PMID: 28058800 DOI: 10.1111/dom.12868] [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: 11/17/2016] [Revised: 12/19/2016] [Accepted: 12/30/2016] [Indexed: 11/30/2022]
Abstract
AIMS Basal rate tests (24-hour fasting periods) may be necessary to optimize basal insulin replacement in type 1 diabetes. It was the aim of this study to prospectively compare the allowance of negligible carbohydrate snacks vs absolute fasting. METHODS A total of 20 patients with type 1 diabetes (age, 48 ± 15 years (9 women, 11 men); BMI, 28.5 ± 4.5 kg/m2 ; HbA1c, 8.8% ± 2.0% (73.0 ± 21.9 mmol/mol); insulin dose, 0.69 ± 0.31 IU/kg body weight and per day) participated in 2 basal rate tests lasting 24 hours in random order with unchanged basal insulin replacement. On 1 occasion, negligible carbohydrate snacks (salads and vegetables, up to 5.1 g carbohydrate and 276.3 kJ per portion) were allowed; during the second test subjects were obliged to fast absolutely. Plasma glucose profiles were determined using an exact laboratory method. Hypoglycaemic episodes (plasma glucose < 70 mg/dL) were compared. RESULTS Plasma glucose concentrations during fasting periods, with and without negligible carbohydrate snacks, did not differ significantly ( P = .65) and differences were negligible (95% confidence intervals always included a difference of 0 mmol/L). Also, there was no difference in the number of hypoglycaemic plasma glucose values (P = .40) or in compensatory carbohydrate intake. Basal rate testing with negligible carbohydrate snacks was better tolerated (questionnaire, P = .046) and the desire to discontinue the fasting period was significantly reduced (P = .023). CONCLUSIONS Allowing negligible carbohydrate snacks results in unchanged plasma glucose profiles during basal rate testing and is better tolerated by patients with type 1 diabetes.
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Affiliation(s)
- Maike Haase
- Diabeteszentrum Bad Lauterberg, Bad Lauterberg im Harz, Germany
- Division of Diabetology, Department of Internal Medicine I, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Melanie Kahle
- Diabeteszentrum Bad Lauterberg, Bad Lauterberg im Harz, Germany
- Division of Diabetology, Department of Internal Medicine I, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Martin Janert
- Diabeteszentrum Bad Lauterberg, Bad Lauterberg im Harz, Germany
| | - Juris J Meier
- Division of Diabetology, Department of Internal Medicine I, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Michael A Nauck
- Diabeteszentrum Bad Lauterberg, Bad Lauterberg im Harz, Germany
- Division of Diabetology, Department of Internal Medicine I, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
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20
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Abstract
Giving a bolus is one major part in multiple dose insulin therapy (MDI) along with basal insulin substitution. To adjust the bolus optimally, different factors like carbohydrate content and composition of the meal, correction factors, and timing have to be considered. Advances in technologies like bolus advisors can assist the patients but still there a several open questions and technical challenges regarding boluses. This commentary provides an opportunity to address several of the above-mentioned factors influencing the result of bolusing. It shall draw attention to those factors and address the current opportunities, for example, continuous subcutaneous insulin infusion (CSII), as well as the need for further studies which can help to improve diabetes insulin therapy by means of the correct use of boluses.
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Affiliation(s)
- Ralph Ziegler
- Diabetes Clinic for Children and Adolescents, Muenster, Germany
- Ralph Ziegler, MD, Diabetes Clinic for Children and Adolescents, Mondstrasse 148, 48155 Muenster, Germany.
| | - Guido Freckmann
- Institut für Diabetes-Technologie Forschungs- und Entwicklungsgesellschaft mbH an der Universität Ulm, Ulm, Germany
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21
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Ozgen Saydam B, Yilmazmis F, Aydin N, Bektas B, Yilmaz S, Cavdar U, Ozisik S, Akinci B. The Effect of Retraining on Treatment Success, Quality of Life, and Metabolic Parameters in Patients with Type 1 Diabetes Using an Insulin Pump. Med Princ Pract 2017; 26:325-330. [PMID: 28437786 PMCID: PMC5768113 DOI: 10.1159/000475935] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Accepted: 04/23/2017] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To investigate the effect of insulin pump user retraining on treatment success, quality of life, and metabolic parameters of patients with type 1 diabetes using continuous subcutaneous insulin infusion. SUBJECTS AND METHODS A total of 35 subjects participated in this prospective study. All patients were given insulin pump user retraining. Their knowledge level and application skills, metabolic parameters, quality of life, and satisfaction from treatment were evaluated at baseline and after 6 months. RESULTS There was significant improvement in patients' knowledge and application skills after insulin pump user retraining (self-assessment of user skills: 69.7 ± 11.5 vs. 76.3 ± 11.3, p < 0.001; knowledge level on technical issues: 3.3 ± 1.1 vs. 4.1 ± 1.8, p = 0.003; glucose monitoring: 27.1 ± 5.8 vs. 29.2 ± 5.6, p = 0.006; management of hyperglycemia: 13.1 ± 3.2 vs. 15.7 ± 3.4, p < 0.001; management of pump and infusion site problems: 8.8 ± 2.6 vs. 10.6 ± 2.6, p = 0.001). Hemoglobin (Hb)A1c levels of patients with poor glycemic control improved after retraining (8.61% ± 0.78 vs. 8.23% ± 0.79, p = 0.02). However, no significant improvement in quality of life and treatment satisfaction parameters were found. CONCLUSION Management of type 1 diabetes in insulin pump users can be significantly improved by retraining. Even a basic short-term retraining program helps patients to increase their knowledge level and ability to more effectively use the insulin pump. The fact that retraining significantly improves glycemic parameters in patients with poor metabolic control indicates that priority should be given to this group of patients. Further studies with individualized training programs in larger sample sizes with long-term follow-up are needed to establish the importance of retraining and create re-education plans for patients with type 1 diabetes using an insulin pump.
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Affiliation(s)
- Basak Ozgen Saydam
- *Basak Ozgen Saydam, MD, Division of Endocrinology, Dokuz Eylul University, Mithatpasa Street 1606, TR-35340 Izmir (Turkey), E-Mail
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22
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Hammond P. Continuous subcutaneous insulin infusion: short-term benefits apparent, long-term benefits speculative. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/14746514040040020701] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Continuous subcutaneous insulin infusion (CSII) is increasingly used as a means of insulin delivery for those with type 1 diabetes, and has recently been endorsed by NICE for this purpose. CSII improves glycaemic control compared to other intensified insulin regimens, with a small decrease in HbA1C and mean blood glucose, and a larger reduction in glucose fluctuation. This improved control is not associated with an increased risk of hypoglycaemia and CSII probably results in significantly lower rates of severe hypoglycaemia. There is no evidence that those using CSII are at increased risk of diabetic ketoacidosis. CSII is uniquely associated with a small risk of application site infection. CSII has a positive impact on quality of life. There is much less evidence concerning the benefits of CSII in reducing microvascular or macrovascular complication rates. Small studies, mostly from the 1980s, show improvements in markers of early nephropathy, retinopathy progression and neuropathy, but the potential long-term impact of CSII has not been proven. Recently CSII has been used in the management of those Br J Diabetes Vasc Dis 2004;4:104—08 with type 2 diabetes but evidence is lacking with regard to the benefits of using it in this group.
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Affiliation(s)
- Peter Hammond
- Harrogate District Hospital, Lancaster Park Road, HG2 7SX, UK,
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23
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Boulet G, Halpern EM, Lovblom LE, Weisman A, Bai JW, Eldelekli D, Keenan HA, Brent MH, Paul N, Bril V, Cherney DZI, Perkins BA. Prevalence of Insulin Pump Therapy and Its Association with Measures of Glycemic Control: Results from the Canadian Study of Longevity in Type 1 Diabetes. Diabetes Technol Ther 2016; 18:298-307. [PMID: 27023749 DOI: 10.1089/dia.2015.0216] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE We aimed to determine cross-sectional insulin pump prevalence and factors associated with measures of glycemic control as a secondary analysis in a long-standing type 1 diabetes mellitus (T1DM) national cohort. RESEARCH DESIGN AND METHODS Canadian participants with ≥50 years of T1DM (n = 305) were administered a comprehensive mail-based questionnaire including acquisition of contemporaneous laboratory results. Factors associated with pump use, glycosylated hemoglobin (HbA1c), and hypoglycemia were analyzed by regression. RESULTS The 305 participants had a median age of 65 [interquartile range, 59, 71] years, median diabetes duration of 54 [51, 59] years, and mean HbA1c level of 7.5 ± 1.1%. Prevalence of pump use was 44% (133/305), with median duration of use 8 [4, 13] years. Compared with the non-pump subgroup, the pump subgroup had numerically lower but similar HbA1c levels (7.4 ± 0.9% vs. 7.6 ± 1.2%; P = 0.22) and reported greater numbers of minor hypoglycemia events (6.5 vs. 5.1 events/patient·month; P = 0.004) and fewer severe hypoglycemia events (0.5 vs. 1.3 events/patient·year; P = 0.02) in the past year. More frequent daily glucose tests and more frequent minor hypoglycemia events-but not pump therapy or its prescription parameters-were independently associated with lower HbA1c level in multivariable regression. However, use of insulin pump and habitual use of continuous glucose monitoring (≥1 week/month) were each independently associated with lower risk of severe hypoglycemia (risk ratio = 0.50 [P < 0.0001] and 0.30 [P = 0.001], respectively). CONCLUSIONS Insulin pump and continuous glucose monitoring technologies were associated with lower risk of severe hypoglycemia, while frequent daily glucose testing was associated with lower HbA1c level. These findings imply that basic self-management skill and technology play complementary roles in glycemic control among older adults with long-standing T1DM.
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Affiliation(s)
- Geneviève Boulet
- 1 Division of Endocrinology and Metabolism, Department of Medicine, Mount Sinai Hospital, University of Toronto , Toronto, Ontario, Canada
| | - Elise M Halpern
- 1 Division of Endocrinology and Metabolism, Department of Medicine, Mount Sinai Hospital, University of Toronto , Toronto, Ontario, Canada
| | - Leif E Lovblom
- 1 Division of Endocrinology and Metabolism, Department of Medicine, Mount Sinai Hospital, University of Toronto , Toronto, Ontario, Canada
| | - Alanna Weisman
- 1 Division of Endocrinology and Metabolism, Department of Medicine, Mount Sinai Hospital, University of Toronto , Toronto, Ontario, Canada
| | - Johnny-Wei Bai
- 1 Division of Endocrinology and Metabolism, Department of Medicine, Mount Sinai Hospital, University of Toronto , Toronto, Ontario, Canada
| | - Devrim Eldelekli
- 1 Division of Endocrinology and Metabolism, Department of Medicine, Mount Sinai Hospital, University of Toronto , Toronto, Ontario, Canada
| | - Hillary A Keenan
- 2 Research Division, Joslin Diabetes Center , Boston, Massachusetts
| | - Michael H Brent
- 3 Departments of Ophthalmology and Vision Sciences and of Medicine, University of Toronto, Toronto , Ontario, Canada
| | - Narinder Paul
- 4 Joint Department of Medical Imaging, Division of Cardiothoracic Radiology, University Health Network , Toronto, Ontario, Canada
| | - Vera Bril
- 5 The Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Krembil Neuroscience Centre, Division of Neurology, Department of Medicine, University Health Network, University of Toronto , Toronto, Ontario, Canada
| | - David Z I Cherney
- 6 Division of Nephrology, Department of Medicine, University of Toronto , Toronto, Ontario, Canada
| | - Bruce A Perkins
- 1 Division of Endocrinology and Metabolism, Department of Medicine, Mount Sinai Hospital, University of Toronto , Toronto, Ontario, Canada
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Martyn-Nemeth P, Schwarz Farabi S, Mihailescu D, Nemeth J, Quinn L. Fear of hypoglycemia in adults with type 1 diabetes: impact of therapeutic advances and strategies for prevention - a review. J Diabetes Complications 2016; 30:167-77. [PMID: 26439754 DOI: 10.1016/j.jdiacomp.2015.09.003] [Citation(s) in RCA: 108] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 09/01/2015] [Accepted: 09/04/2015] [Indexed: 02/01/2023]
Abstract
PURPOSE This review summarizes the current state of the science related to fear of hypoglycemia (FOH) in adults with type 1 diabetes. Fear of hypoglycemia is a critical deterrent to diabetes self-management, psychological well-being, and quality of life. We examine the influence of contemporary treatment regimens, technology, and interventions to identify gaps in knowledge and opportunities for research and practice. BASIC PROCEDURES A literature search was conducted of MEDLINE, PsycINFO, and EMBASE. Fifty-three studies that examined fear of hypoglycemia were included. MAIN FINDINGS Fear of hypoglycemia influences diabetes management and quality of life. Gender and age differences exist in experiences and responses. Responses vary from increased vigilance to potentially immobilizing distress. Fear of hypoglycemia is greater at night and may contribute to poor sleep quality. Strategies to reduce fear of hypoglycemia have had varying success. Newer technologies hold promise but require further examination. CONCLUSIONS Fear of hypoglycemia remains a problem, despite advances in technology, insulin analogs, and evidence-based diabetes management. Clinical care should consistently include assessment for its influence on diabetes self-management and psychological health. Further research is needed regarding the influence of newer technologies and individualized strategies to reduce fear of hypoglycemia while maintaining optimal glucose control.
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Affiliation(s)
- Pamela Martyn-Nemeth
- University of Illinois at Chicago, College of Nursing, Department of Biobehavioral Health Science, 845S. Damen Ave. (MC 802), Chicago, IL 60612.
| | - Sarah Schwarz Farabi
- University of Illinois at Chicago, College of Nursing, Department of Biobehavioral Health Science, 845S. Damen Ave. (MC 802), Chicago, IL 60612.
| | - Dan Mihailescu
- University of Illinois at Chicago, Department of Medicine, Chicago, IL 60612.
| | - Jeffrey Nemeth
- Linden Oaks, Edward Hospital and Health Center, Naperville, IL 60540.
| | - Laurie Quinn
- University of Illinois at Chicago, College of Nursing, Department of Biobehavioral Health Science, 845S. Damen Ave. (MC 802), Chicago, IL 60612.
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Thabit H, Hovorka R. Continuous subcutaneous insulin infusion therapy and multiple daily insulin injections in type 1 diabetes mellitus: a comparative overview and future horizons. Expert Opin Drug Deliv 2015; 13:389-400. [PMID: 26618219 DOI: 10.1517/17425247.2016.1115013] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Continuous subcutaneous insulin infusion (CSII) therapy is currently accepted as a treatment strategy for type 1 diabetes. Transition from multiple daily injection therapy (MDI; including basal-bolus regimens) to CSII is based on expectations of better metabolic control and fewer hypoglycaemic events. Evidence to date has not been always conclusive. AREAS COVERED Evidence for CSII and MDI in terms of glycaemic control, hypoglycaemia and psychosocial outcomes is reviewed in the adult and paediatric population with type 1 diabetes. Findings from studies on threshold-based insulin pump suspension and predictive low glucose management (PLGM) are outlined. Limitations of current CSII application and future technological developments are discussed. EXPERT OPINION Glycaemic control and quality of life (QOL) may be improved by CSII compared to MDI depending on baseline HbA1c and hypoglycaemia rates. Future studies are expected to provide evidence on clinical and cost effectiveness in those who will benefit the most. Training, structured education and support are important to benefit from CSII. Novel technological approaches linking continuous glucose monitoring (CGM) and CSII may help mitigate against frequent hypoglycaemia in those at risk. Development of glucose-responsive automated closed-loop insulin delivery systems may reduce the burden of disease management and improve outcomes in type 1 diabetes.
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Affiliation(s)
- Hood Thabit
- a Wellcome Trust-MRC Institute of Metabolic Science , University of Cambridge , Cambridge , UK.,b Department of Diabetes & Endocrinology , Cambridge University Hospitals NHS Foundation Trust , Cambridge , UK
| | - Roman Hovorka
- a Wellcome Trust-MRC Institute of Metabolic Science , University of Cambridge , Cambridge , UK.,c Department of Paediatrics , University of Cambridge , Cambridge , UK
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Joshi M, Choudhary P. Multiple Daily Injections OR Insulin Pump Therapy: Choosing the Best Option for Your Patient-An Evidence-based Approach. Curr Diab Rep 2015; 15:81. [PMID: 26338287 DOI: 10.1007/s11892-015-0644-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Achieving optimal glucose control with minimal hypoglycemia and minimizing the impact of diabetes on quality of life are the aims of management of type 1 diabetes. The main therapeutic options for patients include multiple daily injections (MDI) and continuous subcutaneous insulin therapy (CSII). It is important to differentiate fixed dose MDI with more flexible use, based on carbohydrate counting and structured education programmes, often termed functional insulin therapy (FIT), shown to deliver better outcomes. A significant proportion of patients can achieve optimal glucose control with either therapy, and for those who are unable to achieve desired glucose control with MDI, there is a large body of observational data showing CSII enables them to reduce HbA1c and hypoglycemia, with associated improvements in diabetes-related quality of life. However, in many healthcare systems, guidelines restrict the use of CSII on the basis of cost, with only 20-35 % of patients with type 1 diabetes across Europe using CSII. Although data support improved glucose control and quality of life with CSII, we must recognize that insulin pump therapy is not for everyone and has some downsides such as being attached to a device or issues with cannulas. When we sit down with our patients, we have a responsibility to support those patients with the therapeutic strategy that is best suited to them. In this paper, we review some of the literature that informs this decision-making, highlighting areas where CSII offers clear benefits and also some areas where it may not be appropriate.
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Affiliation(s)
- Mamta Joshi
- Specialist Registrar in Diabetes and Endocrinology, King's College Hospital, Denmark Hill, SE5 9RS, London, UK,
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Overgaard Ingeholm I, Svensson J, Olsen B, Lyngsøe L, Thomsen J, Johannesen J. Characterization of metabolic responders on CSII treatment amongst children and adolescents in Denmark from 2007 to 2013. Diabetes Res Clin Pract 2015; 109:279-86. [PMID: 26070217 DOI: 10.1016/j.diabres.2015.05.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 01/29/2015] [Accepted: 05/03/2015] [Indexed: 10/23/2022]
Abstract
AIM This prospective study aimed to identify and estimate the frequency of responders offered Continuous subcutaneous insulin infusion (CSII) from baseline data and during follow-up, and secondly to characterize CSII users with good adherence to pump therapy among 463 children and adolescents with Type 1 diabetes mellitus. METHODS A response was defined as lowering HbA1c with 1% or achieving an HbA1c<7.5% (58 mmol/mol). Good adherence was defined as measuring ≥7 self monitored blood glucoses (SMBGs) and taking ≥7 boluses daily. Logistic regression was used to estimate the effect of demographic and clinical variables prior to and during pump treatment. RESULTS At 24 months follow-up 32% qualified as responders. Stratifying for age at onset, 45% of the children aged <6 yrs qualified as responders vs. 32% and 28% of the youngsters and adolescents aged 6-12 yrs. and 12-19 yrs., respectively (p=0.02). Responders were characterized by their HbA1c-level at pump onset (p=0.001), taking more daily boluses (7.64 ± 3.33 vs. 6.40 ± 3.18 p=0.003) and measuring more SMBGs per day at follow-up (6.88 ± 2.35 vs. 6.31 ± 2.54 p=0.03). The incidence of severe hypoglycemia decreased from 14.3 to 3.3 events per 100 person years (p<0.0001). Twenty percent did not respond despite a good adherence toward CSII therapy. CONCLUSION Age <6 years, high or low HbA1c at pump initiation and number of daily boluses were associated with improved or sustained near-normal metabolic outcome. The incidence of severe hypoglycemia was significantly reduced. Twenty percent of the population had good adherence without any metabolic improvement.
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Affiliation(s)
| | - J Svensson
- The Pediatric Department at Copenhagen University Hospital, Herlev, Denmark; Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark
| | - B Olsen
- The Pediatric Department at Copenhagen University Hospital, Herlev, Denmark
| | - L Lyngsøe
- The Pediatric Department at Hillerød Hospital, Hillerød, Denmark
| | - J Thomsen
- The Pediatric Department at Kolding Hospital, Kolding, Denmark
| | - J Johannesen
- The Pediatric Department at Copenhagen University Hospital, Herlev, Denmark; Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark.
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Arranz Martín A, Calle Pascual A, del Cañizo Gómez FJ, González Albarrán O, Lisbona Gil A, Botella Serrano M, Pallardo Sánchez LF. Estado actual de los sistemas de infusión subcutánea continua de insulina y monitorización continua de glucosa en la Comunidad de Madrid. ACTA ACUST UNITED AC 2015; 62:171-9. [DOI: 10.1016/j.endonu.2015.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 12/19/2014] [Accepted: 01/13/2015] [Indexed: 11/16/2022]
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Nørgaard K, Shin J, Welsh JB, Gjessing H. Performance and acceptability of a combined device for insulin infusion and glucose sensing in the home setting. J Diabetes Sci Technol 2015; 9:215-20. [PMID: 25591857 PMCID: PMC4604571 DOI: 10.1177/1932296814567326] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The use of sensor-augmented insulin pump (SAP) therapy is increasing. Currently, glucose sensors and insulin infusion cannulas are inserted separately. A new device, MiniMed Duo, combines sensing and infusion capabilities on the same platform and is intended to simplify device insertion and site management. We evaluated the device's performance with respect to insulin delivery and glucose sensing, and its acceptability with patients. Forty-five patients (mean ± SD age, 45.5 ± 10.9 years, 48% female) with type 1 diabetes and previous use of SAP participated. Each subject was to wear 5 devices connected to insulin pumps over 15 days (3 days/device) and test capillary blood glucose (SMBG) 7 times/day. The primary endpoint was the percentage of sensor-SMBG paired values within 20% of one another. Subject experiences were assessed via questionnaires. Overall, 74.8% of sensor-SMBG paired values were within 20%, meeting the primary accuracy endpoint, and the mean absolute relative difference was 15.5 ± 17.1%. Consensus error grid analysis showed that >95% of points were within the A+B zones, exceeding the threshold for adequate clinical accuracy. Insulin dosage and SMBG values did not change significantly compared to prestudy values. The functional survival of the device entering day 3 was 90.5%. There were no serious adverse events. Mean questionnaire results indicated overall satisfaction with the device. Duo provided insulin infusion and glucose sensing capabilities in a single device, which provided accurate glucose readings during routine use, was safe to wear, and was acceptable to most patients. It may improve satisfaction and convenience for patients using sensor-augmented insulin pumps.
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Affiliation(s)
- Kirsten Nørgaard
- Department of Endocrinology, Hvidovre Hospital, Hvidovre, Denmark
| | - John Shin
- Medtronic, Inc., Northridge, CA, USA
| | | | - Hans Gjessing
- Department of Internal Medicine, Fredericia Hospital, Fredericia, Denmark
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Clements M, Matuleviciene V, Attvall S, Ekelund M, Pivodic A, Dahlqvist S, Fahlén M, Haraldsson B, Lind M. Predicting the effectiveness of insulin pump therapy on glycemic control in clinical practice: a retrospective study of patients with type 1 diabetes from 10 outpatient diabetes clinics in Sweden over 5 years. Diabetes Technol Ther 2015; 17:21-8. [PMID: 25470010 DOI: 10.1089/dia.2014.0139] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Multicenter long-term studies of predictors for the effectiveness of continuous subcutaneous insulin infusion (CSII) in clinical practice are lacking. We hypothesized that there are substantially greater reductions in hemoglobin A1c (HbA1c) in patients with poor glycemic control and that other predictors may also exist. SUBJECTS AND METHODS We used data from 10 outpatient diabetic clinics in Sweden and studied CSII treatment over 5 years. Patients with HbA1c values available ≤ 6 months before starting CSII and at 5 years were included (n = 272, 82% of CSII patients) along with 2,437 contemporaneous controls on multiple daily insulin injections (MDI). Baseline variables evaluated were age, sex, diabetes duration, insulin dose, body mass index (BMI), HbA1c at baseline, and outpatient clinical care unit. RESULTS At 5 years, significantly greater reductions in HbA1c by CSII compared with MDI were found for patients with higher baseline HbA1c (P = 0.032) and lower baseline BMI (P = 0.013). For baseline HbA1c levels of 7.0%, 8.0%, and 9.0% and a BMI of 25 kg/m(2), the reduction in HbA1c level by CSII was 0.08% (difference not significant), 0.16% (95% confidence interval, 0.03-0.29%), and 0.25% (95% confidence interval, 0.11-0.39%), respectively. Corresponding analyses for the change in HbA1c level from start to 1 and 2 years revealed a significant interaction of insulin pump therapy only with baseline HbA1c levels (P < 0.001 and P = 0.030, respectively). The interaction term between outpatient clinical care unit and CSII treatment was statistically significant for some care units, with some care units demonstrating a benefit from CSII and others demonstrating a detriment. CONCLUSIONS Patients with high HbA1c levels have a greater probability of improved HbA1c after initiating pump therapy, but effects remain relatively modest even for patients with poor control. Factors predicting successful insulin pump use need further study.
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Affiliation(s)
- Mark Clements
- 1 Children's Mercy Hospital and University of Missouri-Kansas City , Kansas City, Missouri
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31
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McCoy RG, Van Houten HK, Ziegenfuss JY, Shah ND, Wermers RA, Smith SA. Self-report of hypoglycemia and health-related quality of life in patients with type 1 and type 2 diabetes. Endocr Pract 2014; 19:792-9. [PMID: 23757608 DOI: 10.4158/ep12382.or] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To establish the prevalence of self-reported hypoglycemia among ambulatory patients with diabetes and assess its impact on health-related quality of life (HRQoL). METHODS This study was a cross-sectional analysis of a postal survey disbursed during the first quarter of 2010 to 875 adults with type 1 or 2 diabetes identified on the basis of an index clinical encounter for diabetes management between August 1, 2005 and June 30, 2006. The survey included questions regarding hypoglycemia, self-rating of health, and questions adapted from Confidence in Diabetes Self-Care, Generalized Anxiety Disorder-7, EuroQol5-D, and the Hypoglycemic Fear Survey. Data were analyzed using a two-sample t test for continuous variables and a chi-square test for categorical variables, with multivariate analysis to adjust for age, gender, diabetes duration, and Charlson comorbidity index. RESULTS The survey was completed by 418 patients (47.8% response rate). Of the respondents, 26 of 92 (28.3%) with type 1 and 55 of 326 (16.9%) with type 2 diabetes reported at least one episode of severe hypoglycemia within the previous 6 months. Fear of hypoglycemia, including engagement in anticipatory avoidance behaviors, was highest in patients with type 2 diabetes reporting severe hypoglycemia and all patients with type 1 diabetes (P<.001). HRQoL was lower in patients with type 2 (but not type 1) diabetes reporting severe hypoglycemia (P<.01). CONCLUSION Clinicians and health systems should incorporate screening for hypoglycemia into the routine health assessment of all patients with diabetes. Fear of hypoglycemia places patients at risk for counterproductive behaviors, impairs HRQoL, and should be considered in individualizing glycemic goals.
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Affiliation(s)
- Rozalina G McCoy
- Division of Endocrinology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
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Tauschmann M, Hovorka R. Insulin pump therapy in youth with type 1 diabetes: toward closed-loop systems. Expert Opin Drug Deliv 2014; 11:943-55. [PMID: 24749563 DOI: 10.1517/17425247.2014.910192] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Insulin pump technology has advanced considerably over the past three decades, leading to more favorable metabolic control and less hypoglycemic events when compared with multiple daily injection therapy. The use of insulin pumps is increasing, particularly in children and adolescents with type 1 diabetes. AREAS COVERED This review outlines recent developments in insulin pump therapy from a pediatric perspective. 'Smart' pumps, sensor-augmented pump therapy and threshold-suspend feature of insulin pumps are reviewed in terms of efficacy, safety and psychosocial impact. The current status of closed-loop systems focusing on clinical outcomes is highlighted. EXPERT OPINION Closed-loop insulin delivery is gradually progressing from bench to the clinical practice. Longer and larger studies in home settings are needed to expand on short- to medium-term outpatient evaluations. Predictive low glucose management and overnight closed-loop delivery may be the next applications to be implemented in daily routine. Further challenges include improvements of control algorithms, sensor accuracy, duration of insulin action, integration and size of devices and connectivity and usability. Gradual improvements and increasing sophistication of closed-loop components lie on the path toward unsupervised hands-off fully closed-loop system.
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Affiliation(s)
- Martin Tauschmann
- University of Cambridge, Wellcome Trust-MRC Institute of Metabolic Science , Cambridge , UK
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Papargyri P, Ojeda Rodríguez S, Corrales Hernández JJ, Mories Álvarez MT, Recio Córdova JM, Delgado Gómez M, Sánchez Marcos AI, Iglesias López RA, Herrero Ruiz A, Beaulieu Oriol M, Miralles García JM. An observational 7-year study of continuous subcutaneous insulin infusion for the treatment of type 1 diabetes mellitus. ACTA ACUST UNITED AC 2013; 61:141-6. [PMID: 24355548 DOI: 10.1016/j.endonu.2013.09.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Revised: 08/13/2013] [Accepted: 09/25/2013] [Indexed: 01/22/2023]
Abstract
UNLABELLED This work reports the experience with use of continuous subcutaneous insulin infusion (CSII) in 112 type 1 diabetic patients followed up for 7 years and previously treated with multiple daily insulin injections (MDII). MATERIAL AND METHODS A retrospective, observational study in 112 patients with diabetes mellitus treated with CSII from 2005 to 2012, previously treated with MDII and receiving individualized diabetic education with a specific protocol. Variables analyzed included: prevalence of the different indications of pump treatment; mean annual HbA1c and fructosamine values before and after CSII treatment; and hypoglycemia frequency and symptoms. RESULTS The most common reason for pump treatment was brittle diabetes (74.1%), followed by frequent or severe hypoglycemia or hypoglycemia unawareness (44.6%). Other indications were irregular food intake times for professional reasons (20.2%), dawn phenomenon (15.7%), pregnancy (12.3%), requirement of very low insulin doses (8.9%), and gestational diabetes (0.9%). HbA1c decreased by between 0.6% and 0.9%, and fructosamine by between 5.1% and 12.26%. Nine percent of patients experienced hypoglycemia weekly, 24% every two weeks, and 48% monthly. No hypoglycemia occurred in 19% of patients. Only 10% had neuroglycopenic symptoms. Hypoglycemia unawareness was found in 21%. Hypoglycemia was more common at treatment start, and its frequency rapidly decreased thereafter. CONCLUSION CSII therapy provides a better glycemic control than MDII treatment. Specific patient training and fine adjustment of insulin infusion doses are required to prevent hypoglycemic episodes, which are the most common complications, mainly at the start of treatment.
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Affiliation(s)
- Panagiota Papargyri
- Servicio de Endocrinología y Nutrición, Hospital Clínico Universitario, Salamanca, España
| | - Sylvie Ojeda Rodríguez
- Servicio de Endocrinología y Nutrición, Hospital Clínico Universitario, Salamanca, España.
| | | | | | | | - Manuel Delgado Gómez
- Servicio de Endocrinología y Nutrición, Hospital Clínico Universitario, Salamanca, España
| | | | | | - Ana Herrero Ruiz
- Servicio de Endocrinología y Nutrición, Hospital Clínico Universitario, Salamanca, España
| | - Myriam Beaulieu Oriol
- Servicio de Endocrinología y Nutrición, Hospital Clínico Universitario, Salamanca, España
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Awoniyi O, Rehman R, Dagogo-Jack S. Hypoglycemia in patients with type 1 diabetes: epidemiology, pathogenesis, and prevention. Curr Diab Rep 2013; 13:669-78. [PMID: 23912765 DOI: 10.1007/s11892-013-0411-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Hypoglycemia is uncommon in the general, nondiabetic population but occurs frequently in persons with diabetes treated with insulin or insulin secretagogues. Thus, iatrogenic hypoglycemia explains the majority of cases among persons with type 1 diabetes (T1DM). Since T1DM is characterized by absolute insulin dependence, the current imperfections in insulin replacement therapies often lead to a mismatch between caloric supply and circulating insulin levels, thus increasing the risk for glycemic fluctuations. Hypoglycemia is the limiting factor to excellent glycemic control in insulin-treated subjects. Intensification of glycemic control was associated with a 300 % increase in the rate of hypoglycemia in the Diabetes Control and Complications Trial. Recent measurements using continuous glucose monitoring reveal an alarming rate of daytime and nocturnal episodes of hypoglycemia in patients with T1DM. Etiological factors underlying hypoglycemia in T1DM include predictable triggers (skipped meals, exercise, insulin over dosage) as well as defective counterregulation, a component of hypoglycemia-associated autonomic failure.
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Affiliation(s)
- Omodele Awoniyi
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism & Clinical Research Center, University of Tennessee Health Science Center, 920 Madison Avenue, Suite 300A, Memphis, TN, 38163, USA
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Seaquist ER, Anderson J, Childs B, Cryer P, Dagogo-Jack S, Fish L, Heller SR, Rodriguez H, Rosenzweig J, Vigersky R. Hypoglycemia and diabetes: a report of a workgroup of the American Diabetes Association and the Endocrine Society. Diabetes Care 2013; 36:1384-95. [PMID: 23589542 PMCID: PMC3631867 DOI: 10.2337/dc12-2480] [Citation(s) in RCA: 924] [Impact Index Per Article: 84.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To review the evidence about the impact of hypoglycemia on patients with diabetes that has become available since the past reviews of this subject by the American Diabetes Association and The Endocrine Society and to provide guidance about how this new information should be incorporated into clinical practice. PARTICIPANTS Five members of the American Diabetes Association and five members of The Endocrine Society with expertise in different aspects of hypoglycemia were invited by the Chair, who is a member of both, to participate in a planning conference call and a 2-day meeting that was also attended by staff from both organizations. Subsequent communications took place via e-mail and phone calls. The writing group consisted of those invitees who participated in the writing of the manuscript. The workgroup meeting was supported by educational grants to the American Diabetes Association from Lilly USA, LLC and Novo Nordisk and sponsorship to the American Diabetes Association from Sanofi. The sponsors had no input into the development of or content of the report. EVIDENCE The writing group considered data from recent clinical trials and other studies to update the prior workgroup report. Unpublished data were not used. Expert opinion was used to develop some conclusions. CONSENSUS PROCESS Consensus was achieved by group discussion during conference calls and face-to-face meetings, as well as by iterative revisions of the written document. The document was reviewed and approved by the American Diabetes Association's Professional Practice Committee in October 2012 and approved by the Executive Committee of the Board of Directors in November 2012 and was reviewed and approved by The Endocrine Society's Clinical Affairs Core Committee in October 2012 and by Council in November 2012. CONCLUSIONS The workgroup reconfirmed the previous definitions of hypoglycemia in diabetes, reviewed the implications of hypoglycemia on both short- and long-term outcomes, considered the implications of hypoglycemia on treatment outcomes, presented strategies to prevent hypoglycemia, and identified knowledge gaps that should be addressed by future research. In addition, tools for patients to report hypoglycemia at each visit and for clinicians to document counseling are provided.
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36
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Seaquist ER, Anderson J, Childs B, Cryer P, Dagogo-Jack S, Fish L, Heller SR, Rodriguez H, Rosenzweig J, Vigersky R. Hypoglycemia and diabetes: a report of a workgroup of the American Diabetes Association and the Endocrine Society. J Clin Endocrinol Metab 2013; 98:1845-59. [PMID: 23589524 DOI: 10.1210/jc.2012-4127] [Citation(s) in RCA: 171] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To review the evidence about the impact of hypoglycemia on patients with diabetes that has become available since the past reviews of this subject by the American Diabetes Association and The Endocrine Society and to provide guidance about how this new information should be incorporated into clinical practice. PARTICIPANTS Five members of the American Diabetes Association and five members of The Endocrine Society with expertise in different aspects of hypoglycemia were invited by the Chair, who is a member of both, to participate in a planning conference call and a 2-day meeting that was also attended by staff from both organizations. Subsequent communications took place via e-mail and phone calls. The writing group consisted of those invitees who participated in the writing of the manuscript. The workgroup meeting was supported by educational grants to the American Diabetes Association from Lilly USA, LLC and Novo Nordisk and sponsorship to the American Diabetes Association from Sanofi. The sponsors had no input into the development of or content of the report. EVIDENCE The writing group considered data from recent clinical trials and other studies to update the prior workgroup report. Unpublished data were not used. Expert opinion was used to develop some conclusions. CONSENSUS PROCESS Consensus was achieved by group discussion during conference calls and face-to-face meetings, as well as by iterative revisions of the written document. The document was reviewed and approved by the American Diabetes Association's Professional Practice Committee in October 2012 and approved by the Executive Committee of the Board of Directors in November 2012 and was reviewed and approved by The Endocrine Society's Clinical Affairs Core Committee in October 2012 and by Council in November 2012. CONCLUSIONS The workgroup reconfirmed the previous definitions of hypoglycemia in diabetes, reviewed the implications of hypoglycemia on both short- and long-term outcomes, considered the implications of hypoglycemia on treatment outcomes, presented strategies to prevent hypoglycemia, and identified knowledge gaps that should be addressed by future research. In addition, tools for patients to report hypoglycemia at each visit and for clinicians to document counseling are provided.
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Affiliation(s)
- Elizabeth R Seaquist
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota 55455, USA.
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37
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Cooke D, O'Hara MC, Beinart N, Heller S, La Marca R, Byrne M, Mansell P, Dinneen SF, Clark M, Bond R, Speight J. Linguistic and psychometric validation of the Diabetes-Specific Quality-of-Life Scale in U.K. English for adults with type 1 diabetes. Diabetes Care 2013; 36:1117-25. [PMID: 23250797 PMCID: PMC3631848 DOI: 10.2337/dc12-0076] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Accepted: 10/29/2012] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To develop a linguistically and psychometrically validated U.K. English (U.K./Ireland) version of the Diabetes-Specific Quality-of-Life Scale (DSQOLS) for adults with type 1 diabetes. RESEARCH DESIGN AND METHODS We conducted independent forward and backward translation of the validated German DSQOLS. An iterative interview study with health professionals (n = 3) and adults with type 1 diabetes (n = 8) established linguistic validity. The DSQOLS was included in three Dose Adjustment for Normal Eating (DAFNE) studies (total N = 1,071). Exploratory factor analysis (EFA) was undertaken to examine questionnaire structure. Concurrent and discriminant validity, internal consistency, and reliability were assessed. RESULTS EFA indicated a six-factor structure for the DSQOLS (social aspects, fear of hypoglycemia, dietary restrictions, physical complaints, anxiety about the future, and daily hassles). High internal consistency reliability was found for these factors and the weighted treatment satisfaction scale (α = 0.85-0.94). All subscales were moderately, positively correlated with the Audit of Diabetes-Dependent Quality-of-Life (ADDQoL) measure, demonstrating evidence of concurrent validity. Lower DSQOLS subscale scores [indicating impaired quality of life (QoL)] were associated with the presence of diabetes-related complications. CONCLUSIONS The DSQOLS captures the impact of detailed aspects of modern type 1 diabetes management (e.g., carbohydrate counting and flexible insulin dose adjustment) that are now routine in many parts of the U.K. and Ireland. The U.K. English version of the DSQOLS offers a valuable tool for assessing the impact of treatment approaches on QoL in adults with type 1 diabetes.
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Affiliation(s)
- Debbie Cooke
- School of Health and Social Care, University of Surrey, Surrey, U.K.
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Patte C, Pleus S, Galley P, Weinert S, Haug C, Freckmann G. Feasibility of overnight closed-loop control based on hourly blood glucose measurements. J Diabetes Sci Technol 2012; 6:902-9. [PMID: 22920817 PMCID: PMC3440162 DOI: 10.1177/193229681200600422] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Safe and effective closed-loop control (artificial pancreas) is the ultimate goal of insulin delivery. In this study, we examined the performance of a closed-loop control algorithm used for the overnight time period to safely achieve a narrow target range of blood glucose (BG) concentrations prior to breakfast. The primary goal was to compare the quality of algorithm control during repeated overnight experiments. MATERIALS AND METHODS Twenty-three subjects with type 1 diabetes performed 2 overnight experiments on each of three visits at the study site, resulting in 138 overnight experiments. On the first evening, the subject's insulin therapy was applied; on the second, the insulin was delivered by an algorithm based on subcutaneous continuous glucose measurements (including meal control) until midnight. Overnight closed-loop control was applied between midnight and 6 a.m. based on hourly venous BG measurements during the first and second nights. RESULTS The number of BG values within the target range (90-150 mg/dl) increased from 52.9% (219 out of 414 measurements) during the first nights to 72.2% (299 out of 414 measurements) during the second nights (p < .001, χ²-test). The occurrence of hypoglycemia interventions was reduced from 14 oral glucose interventions, the latest occurring at 2:36 a.m. during the first nights, to 1 intervention occurring at 1:02 a.m. during the second nights (p < .001, χ²-test). CONCLUSIONS Overnight controller performance improved when optimized initial control was given; this was suggested by the better metabolic control during the second night. Adequate controller run-in time seems to be important for achieving good overnight control. In addition, the findings demonstrate that hourly BG data are sufficient for the closed-loop control algorithm tested to achieve appropriate glycemic control.
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Affiliation(s)
- Caroline Patte
- Roche Diabetes Care, Roche Diagnostics, Mannheim, Germany
| | - Stefan Pleus
- Institut für Diabetes-Technologie GmbH, Ulm, Germany
| | - Paul Galley
- Roche Diagnostics Operations Inc., Roche Diagnostics, Indianapolis, Indiana
| | - Stefan Weinert
- Roche Diagnostics Operations Inc., Roche Diagnostics, Indianapolis, Indiana
| | - Cornelia Haug
- Institut für Diabetes-Technologie GmbH, Ulm, Germany
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Affiliation(s)
- John C Pickup
- Diabetes Research Group, Division of Diabetes and Nutritional Sciences, King's College London School of Medicine and Guy's Hospital, London, United Kingdom.
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Switzer SM, Moser EG, Rockler BE, Garg SK. Intensive insulin therapy in patients with type 1 diabetes mellitus. Endocrinol Metab Clin North Am 2012; 41:89-104. [PMID: 22575408 DOI: 10.1016/j.ecl.2011.12.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
There has been a significant increase in the prevalence of type 1 diabetes mellitus and type 2 diabetes mellitus in the past decade. The International Diabetes Foundation reported that there will be more than a half-billion people with diabetes by 2030, largely in emerging economies. Improved glucose control reduces microvascular and macrovascular complications and can be accomplished with intensive diabetes management. Continuous glucose monitors allow further improvement. The best way to emulate normal physiology is the development of an artificial pancreas. Early versions of closed-loop technology may be available in the United States in the next 3 to 5 years.
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Affiliation(s)
- Sean M Switzer
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, 1775 Aurora Court, A140, Aurora, CO 80045, USA
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Abstract
Continuous subcutaneous insulin infusion (CSII, or insulin pump therapy) reduces HbA1c levels and hypoglycaemia in patients with type 1 diabetes mellitus (T1DM) compared with multiple daily insulin injections (MDI). The greatest reduction in HbA(1c) levels with CSII occurs in patients with the worst glycaemic control; therefore, the most appropriate and cost-effective use of CSII in adults with T1DM is in those who have continued, elevated HbA(1c) levels or disabling hypoglycaemic episodes with MDI (including the use of long-acting insulin analogues and structured patient education). The disadvantages of CSII include higher costs than MDI and the risk of ketosis in the event of pump failure. In children with T1DM, CSII may be used when MDI is considered impractical or inappropriate. Pumps are not generally recommended for patients with type 2 diabetes mellitus but may improve control in some subgroups. A new generation of smaller insulin infusion pumps with an integrated cannula, called patch pumps, could improve uptake of CSII in general. The important clinical question is not whether CSII is more efficacious than MDI in general adult T1DM, but whether CSII further improves glycaemic control when this control continues to be poor with MDI, and evidence exists that in most cases it does.
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Affiliation(s)
- John C Pickup
- Diabetes Research Group, King's College London School of Medicine, Guy's Hospital, London SE1 1UL, UK.
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External insulin pump treatment in the day-to-day management of diabetes: benefits and future prospectives. DIABETES & METABOLISM 2011; 37 Suppl 4:S40-7. [DOI: 10.1016/s1262-3636(11)70964-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Garmo A, Garmo H, Ärnlöv J, Leksell J. Long-term treatment effects of insulin pump therapy. PRACTICAL DIABETES 2011. [DOI: 10.1002/pdi.1618] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Kordonouri O, Hartmann R, Danne T. Treatment of type 1 diabetes in children and adolescents using modern insulin pumps. Diabetes Res Clin Pract 2011; 93 Suppl 1:S118-24. [PMID: 21864743 DOI: 10.1016/s0168-8227(11)70027-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
In the last decades, we are experiencing an increasing use of insulin pumps for the treatment of type 1 diabetes in children and adolescents. The most frequent reasons for switching from insulin injection schemes to pump therapy are frequent and/or severe hypoglycaemia, dawn phenomenon, poor glycaemic control, wish for more flexibility in daily life, and needle phobia. In toddlers and preschoolers, pumps are frequently introduced from the onset of type 1 diabetes. Pumps offer the possibility of adjusting basal insulin rates individually on an age-depended manner as well as of optimizing meal-related insulin requirements according to the meal composition by using three different kinds of boluses. Structured and intensive education of patients and their families on basics and specific requirements of insulin pump therapy is essential in order to get them familiar with the devices and their features. There is increasing evidence both from multicentre cross-sectional studies as well as from meta-analyses of randomized clinical trials in paediatric populations showing that patients with pump therapy can achieve a more favourable metabolic control accompanied with less hypoglycaemic events than those with multiple daily injections.
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Affiliation(s)
- Olga Kordonouri
- Bult Diabetes Centre for Children and Adolescents, Kinderkrankenhaus auf der Bult, Hannover, Germany.
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Nixon R, Pickup JC. Fear of hypoglycemia in type 1 diabetes managed by continuous subcutaneous insulin infusion: is it associated with poor glycemic control? Diabetes Technol Ther 2011; 13:93-8. [PMID: 21284474 DOI: 10.1089/dia.2010.0192] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND We surveyed the extent of fear of hypoglycemia in people with type 1 diabetes treated by continuous subcutaneous insulin infusion (CSII) and tested the hypothesis that suboptimal glycemic control during CSII is related to fear of hypoglycemia. METHODS We audited nonpregnant type 1 diabetes patients attending an Insulin Pump Clinic with at least 6 months' duration of CSII. In 104 eligible subjects, fear of hypoglycemia was assessed by questionnaire; 75 responded. RESULTS The median duration of CSII was 5 years (range, 1-29 years). Poor glycemic control (hemoglobin A1c [HbA1c] ≥ 8.5%; mean ± SD, 9.1 ± 1.0%) was present in 27%, and this group had more men than a good-control group with HbA1c < 7.0% (43% vs. 11%). Substantial fear of hypoglycemia (score > 50%) occurred in 27% of subjects, but fear of hypoglycemia was not correlated with HbA1c. The only significant correlates of fear of hypoglycemia were accumulated episodes of severe hypoglycemia (r = 0.48, P < 0.001) and rate of hypoglycemia on CSII (r = 0.48, P < 0.001). The HbA1c on CSII was correlated with multiple daily injection (MDI) HbA1c (r = 0.66, P < 0.001) and the change in HbA1c (r = 0.63, P < 0.001). CONCLUSIONS Fear of hypoglycemia is not correlated with, and is unlikely to be a major determinant of, HbA1c on CSII. Other factors (such as HbA1c on MDI and adherence to insulin pump procedures) are likely to be more important. Nevertheless, substantial fear of hypoglycemia is present in many CSII-treated people and may adversely affect quality of life and psychological well-being.
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Affiliation(s)
- Rodanthe Nixon
- Diabetes Research Group, King's College London School of Medicine, Guy's Hospital, London, UK
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Zisser H, Wagner R, Pleus S, Haug C, Jendrike N, Parkin C, Schweitzer M, Freckmann G. Clinical performance of three bolus calculators in subjects with type 1 diabetes mellitus: a head-to-head-to-head comparison. Diabetes Technol Ther 2010; 12:955-61. [PMID: 21128842 DOI: 10.1089/dia.2010.0064] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Insulin pump systems now provide automated bolus calculators (ABCs) that electronically calculate insulin boluses to address carbohydrate intake and out-of-range blood glucose (bG) levels. We compared the efficacy of three ABCs (Accu-Chek(®) Combo [Roche Insulin Delivery Systems (IDS), Inc., Fishers, IN, a member of the Roche Group], Animas(®) 2020 [Animas Corp., West Chester, PA, a Johnson and Johnson company], and MiniMed Paradigm Bolus Wizard(®) [Medtronic MiniMed, Northridge, CA]) to safely reduce postprandial hyperglycemia in type 1 diabetes mellitus (T1DM). METHODS T1DM subjects (n = 24) were recruited at a single center for a prospective, triple crossover study. ABCs with the programmed target range (80-140 mg/dL) were used in random order. Postprandial hyperglycemia was induced by reducing the calculated bolus by 25%. Two hours after test meals, the ABCs were allowed to determine whether a correction bolus was needed. Differences between 6-h bG values after test meals that achieved 2-h postprandial hyperglycemia and the mean of the target range (110 mg/dL) were determined. RESULTS The mean difference between 6-h bG levels following test meals and the 110 mg/dL bG target with the MiniMed device (47.4 ± 31.8 mg/dL) was significantly higher than the Animas (17.3 ± 30.9 mg/dL) and Roche IDS (18.8 ± 33.8 mg/dL) devices (P = 0.0022 and P = 0.0049, respectively). The number of meals with 2-h postprandial hyperglycemia and bG levels at 2 h was similar. Roche IDS and Animas devices recommended correction boluses significantly (P = 0.0001 and P = 0.0002, respectively) more frequently than the MiniMed device. ABC use was not associated with severe hypoglycemia. There was no significant difference in the rate of mild hypoglycemia (bG <60 mg/dL not requiring assistance) among the three groups (Roche IDS and Animas, n = 2; MiniMed, n = 0). CONCLUSIONS In this study, the Roche IDS and Animas devices were more efficacious in controlling postprandial hyperglycemia than the MiniMed device. This may be due, in part, to differences in ABC setup protocols and algorithms. Use of ABCs can assist in controlling postprandial glycemia without significant hypoglycemia.
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Affiliation(s)
- Howard Zisser
- Sansum Diabetes Research Institute, Santa Barbara, CA, USA
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Abstract
Undetected nocturnal hypoglycaemia frequently occurs in patients with diabetes, having a negative influence on well-being, counterregulation against and awareness of subsequent hypoglycaemia, and even causing sudden death in some cases most likely by inducing cardiac arrhythmia. Sleep markedly weakens the neuroendocrine defence mechanism against hypoglycaemia by shifting the glycaemic threshold for counterregulatory activation to lower levels. While hypoglycaemia triggers awakening in healthy subjects, patients with type 1 diabetes frequently fail to awake in the presence of low plasma glucose levels. Little is known about the frequency of and responses to nocturnal hypoglycaemia in patients with type 2 diabetes. Unfortunately, effective strategies to prevent or even safely detect nocturnal hypoglycaemia are still lacking. Taken together, hypoglycaemia occurring during sleep presents a major, often neglected problem in the management of diabetic patients. Different aspects of this phenomenon such as responses to and consequences of nocturnal hypoglycaemia as well as strategies for its prevention are highlighted in this review.
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Affiliation(s)
- Kamila Jauch-Chara
- Department of Psychiatry and Psychotherapy, University of Luebeck, Ratzeburger Allee 160, 23638 Luebeck, Germany
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Bragd J, von Döbeln A, Lins PE, Adamson U, Bergström J, Oskarsson P. Basal insulin substitution with glargine or continuous subcutaneous insulin infusion in adult type 1 diabetes patients-a randomized controlled trial. Diabetes Technol Ther 2010; 12:689-93. [PMID: 20687863 DOI: 10.1089/dia.2010.0062] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND It is generally held that basal insulin substitution with continuous subcutaneous insulin infusion (CSII) provides less variable glucose levels than with long-acting insulin analogs, e.g., glargine, in patients with type 1 diabetes, although this has not been convincingly demonstrated by continuous glucose monitoring. METHODS To compare glucose control assessed by a continuous glucose monitoring system (CGMS) during basal insulin substitution with glargine versus CSII, we conducted a non-blinded, randomized, crossover trial in 15 type 1 diabetes patients experienced with CSII. All subjects were randomly assigned to receive either a morning dose of insulin glargine, comprising their average 24-h basal insulin requirement, minus 2.4 U, which was delivered by the pump, or to continue as before for 4 weeks followed by a 1-week washout period and a crossover. All mealtime doses of insulin were given by the pump as before. CGMS data were blinded until the end of the study. RESULTS The mean blood glucose was lower in the non-glargine arm according to self-monitoring of plasma glucose (9.2 vs. 10.6 mmol/L; P = 0.010) and CGMS (9.1 vs. 10.3 mmol/L; P = 0.002), and hemoglobin A1c was 6.5% without glargine versus 6.8% with (P = 0.018). There were no significant differences in glucose variability measured as SD of plasma glucose (SDPG) or mean amplitude of glycemic excursions (MAGE), although significantly longer periods of glucose values spent within the target of 4.5-10.0 mmol/L were demonstrated in the non-glargine arm using CGMS (P = 0.034). More episodes below 3.5 mmol/L were seen during the CSII period (P = 0.053). CONCLUSIONS CSII provided improved glucose control compared to glargine with a lower mean plasma glucose and longer periods of glucose values within target on a somewhat lower insulin dose. There was a tendency with more episodes below 3.5 mmol/L during CSII. No difference with respect to glucose variability was found when calculated as SDPG or MAGE.
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Affiliation(s)
- Joakim Bragd
- Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden.
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Giménez M, Lara M, Conget I. Sustained efficacy of continuous subcutaneous insulin infusion in type 1 diabetes subjects with recurrent non-severe and severe hypoglycemia and hypoglycemia unawareness: a pilot study. Diabetes Technol Ther 2010; 12:517-21. [PMID: 20597825 DOI: 10.1089/dia.2010.0028] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND This study evaluated the effect of CSII on hypoglycemia awareness and on glucose profile in type 1 diabetes (T1D) subjects with repeated non-severe or severe hypoglycemia (NS or SH, respectively). METHODS We included subjects (1) older than 18 years, (2) with T1D duration of >5 years, (3) on multiple doses of insulin, and (4) without micro- or macrovascular complications and more than four NS events per week (in the last 8 weeks) and more than two SH events (in the last 2 years). NS/SH episodes and hypoglycemia awareness were evaluated. A 72-h continuous glucose monitoring (CGM) was performed before continuous subcutaneous insulin infusion (CSII). A hypoglycemia-induced test was used to evaluate each patient's symptoms in euglycemia/hypoglycemia. Quality of life (QoL) was also evaluated. After 6, 12, and 24 months, all the subjects were reevaluated. RESULTS Twenty subjects were included (34.0 +/- 7.5 years old, 12 women, A1c 6.7 +/- 1.1%, 16.2 +/- 6.6 years of diabetes' duration). At baseline, 19 out of 20 subjects displayed hypoglycemia unawareness, which diminished significantly during the follow-up (3 out of 20). NH episodes per week diminished from 5.40 +/- 2.09 at baseline to 2.75 +/- 1.74 at the end of the follow-up (P < 0.001). SH episodes fell from 1.25 +/- 0.44 per subject-year to 0.05 +/- 0.22 after 24 months (P < 0.001). Hemoglobin A1c remained unaltered. With CGM, the percentage of values within 70-180 mg/dL increased (53.2 +/- 11.0% to 60.3 +/- 17.1%, P = 0.13), and the percentage of values <70 mg/dL decreased (13.7 +/- 9.4% to 9.1 +/- 5.2%, P = 0.07), after 24 months. Mean amplitude of glycemic excursions diminished after 24 months of CSII (136 +/- 28 mg/dL to 115 +/- 19 mg/dL; P < 0.02). An improvement in all the aspects of QoL was observed. The basal alteration in symptom response to an induced hypoglycemia improved after 24 months of initiating CSII leading to a response indistiguishable from that observed in a control group of subjects with T1D without repeated NH and SH. CONCLUSIONS CSII prevents hypoglycemic episodes, improves hypoglycemia awareness, and ameliorates glycemic profile in T1D subjects with repeated NS/SH. Its use is also associated with an improvement in diabetes QoL.
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Affiliation(s)
- Marga Giménez
- Institute of Biomedical Investigations August Pi i Sunyer, Barcelona, Spain
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Abstract
In recent years continuous subcutaneous insulin infusion pumps have become widely adopted in many parts of the world in the treatment of type 1 diabetes in adults. A comprehensive summary of all aspects of pump therapy is beyond the scope of this article, and in this review we will focus on several practical issues that in our experience are of clinical importance in the care of patients using insulin pumps. These include: benefits and risks of pump therapy, including the use of pumps to limit hypoglycemia; individual patient considerations in choosing between pump therapy and multiple daily injections; common pump-specific etiologies of erratic glucose control, including routine clinical practices that can assist with the detection of these problems; and the use of different pump bolus types for prandial insulin coverage.
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Affiliation(s)
- Greeshma Shetty
- Section of Adult Diabetes, Joslin Diabetes Center, One Joslin Place, Boston, MA 02215, USA
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