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Chen SH, Lee MC, Pu C. Medication adherence in patients with type 2 diabetes after disability onset: a difference-in-differences analysis using nationwide data. BMC Med 2024; 22:102. [PMID: 38448936 PMCID: PMC10918964 DOI: 10.1186/s12916-024-03324-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 02/27/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Effectively managing the coexistence of both diabetes and disability necessitates substantial effort. Whether disability onset affects adherence to type 2 diabetes medication remains unclear. This study investigated whether disability onset reduces such adherence and whether any reduction varies by disability type. METHODS This study used the National Disability Registry and National Health Insurance Research Database from Taiwan to identify patients with type 2 diabetes who subsequently developed a disability from 2013 to 2020; these patients were matched with patients with type 2 diabetes without disability onset during the study period. Type 2 diabetes medication adherence was measured using the medication possession ratio (MPR). A difference-in-differences analysis was performed to determine the effect of disability onset on the MPR. RESULTS The difference-in-differences analysis revealed that disability onset caused a reduction of 5.76% in the 1-year MPR (P < 0.001) and 13.21% in the 2-year MPR (P < 0.001). Among all disability types, organ disabilities, multiple disabilities, rare diseases, and a persistent vegetative state exhibited the largest reductions in 2-year MPR. CONCLUSIONS Policies aimed at improving medication adherence in individuals with disabilities should consider not only the specific disability type but also the distinct challenges and barriers these patients encounter in maintaining medication adherence.
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Affiliation(s)
- Szu-Han Chen
- Department of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Miaw-Chwen Lee
- Department of Social Welfare, National Chung Cheng University, Chia-Yi, Taiwan
- Center for Innovative Research on Aging Society, National Chung Cheng University, Chiayi, Taiwan
- Advanced Institute of Manufacturing with High-tech Innovations, National Chung Cheng University, Chiayi, Taiwan
| | - Christy Pu
- Institute of Public Health, College of Medicine, National Yang Ming Chiao Tung University, 155 Li-Nong ST, Sec 2, Peitou, Taipei, Taiwan.
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Heiran A, Azarchehry SP, Dehghankhalili S, Afarid M, Shaabani S, Mirahmadizadeh A. Prevalence of diabetic retinopathy in the Eastern Mediterranean Region: a systematic review and meta-analysis. J Int Med Res 2022; 50:3000605221117134. [PMID: 36314851 PMCID: PMC9629581 DOI: 10.1177/03000605221117134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objectives Individual studies in the Eastern Mediterranean Region (EMR) have shown the high prevalence of diabetic retinopathy. We conducted a meta-analysis to yield an estimate of the prevalence of diabetic (type 1 and 2) retinopathy in the EMR. Additionally, we explored its potential modulators. Methods Two-step screening of relevant articles published from 1 January 2000 to 13 December 2019 was carried out. An estimation of summary proportions, subgroup analysis, meta-regression, and publication bias assessment were performed. Results One hundred nine articles were included in the meta-analysis, involving 280,566 patients. The prevalence of diabetic retinopathy was 31% (95% confidence interval [CI] = 28, 33). The highest and lowest diabetic retinopathy prevalence rates were observed in low human development index (HDI) countries (63.6; 95% CI = 52.4, 74.0) and very high HDI countries 22.6 (95% CI = 20.5, 24.7), respectively. Conclusions The prevalence of diabetic retinopathy is high in the EMR. Our results provide important information for diverse healthcare surveillance systems in the EMR to implement the modifiable risk factors, diabetes screening to decrease undiagnosed diabetes, early detection of retinopathy, and proper diabetes care to decrease untreated diabetes.
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Affiliation(s)
- Alireza Heiran
- Non-communicable Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran,Alireza Mirahmadizadeh, Non-communicable Diseases Research Center, Shiraz University of Medical Sciences, Zand Blvd, Shiraz, Iran. PO: 7193635899.
| | - Seyede Pegah Azarchehry
- Department of Biochemistry, Faculty of Biological Sciences, Tarbiat Modares University, Tehran, Iran
| | | | - Mehrdad Afarid
- Poostchi Ophthalmology Research Center, Department of Ophthalmology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sonia Shaabani
- Alzahra Cardiovascular Charitable Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Alireza Mirahmadizadeh
- Non-communicable Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Kim CR, Cho YC, Lee SH, Han JH, Kim MJ, Ji HB, Kim S, Min CH, Shin BH, Lee C, Cho YM, Choy YB. Implantable device actuated by manual button clicks for noninvasive self-drug administration. Bioeng Transl Med 2022; 8:e10320. [PMID: 36684080 PMCID: PMC9842066 DOI: 10.1002/btm2.10320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 03/10/2022] [Accepted: 03/11/2022] [Indexed: 02/01/2023] Open
Abstract
Self-injectable therapy has several advantages in the treatment of metabolic disorders. However, frequent injections with needles impair patient compliance and medication adherence. Therefore, we develop a fully implantable device capable of on-demand administration of self-injection drugs via noninvasive manual button clicks on the outer skin. The device is designed to infuse the drug only at the moment of click actuation, which allows for an accurate and reproducible drug infusion, and also prevents unwanted drug leakage. Using a mechanical means of drug infusion, this implantable device does not contain any electronic compartments or batteries, making it compact, and semi-permanent. When tested in animals, the device can achieve subcutaneous injection-like pharmacokinetic and pharmacodynamic effects for self-injection drugs such as exenatide, insulin, and glucagon.
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Affiliation(s)
- Cho Rim Kim
- Interdisciplinary Program in Bioengineering, College of EngineeringSeoul National UniversitySeoulSouth Korea
| | - Yong Chan Cho
- Interdisciplinary Program in Bioengineering, College of EngineeringSeoul National UniversitySeoulSouth Korea
| | - Seung Ho Lee
- Institute of Medical and Biological Engineering, Medical Research CenterSeoul National UniversitySeoulSouth Korea
| | - Jae Hoon Han
- Interdisciplinary Program in Bioengineering, College of EngineeringSeoul National UniversitySeoulSouth Korea
| | - Min Ji Kim
- Interdisciplinary Program in Bioengineering, College of EngineeringSeoul National UniversitySeoulSouth Korea
| | - Han Bi Ji
- Interdisciplinary Program in Bioengineering, College of EngineeringSeoul National UniversitySeoulSouth Korea
| | - Se‐Na Kim
- Institute of Medical and Biological Engineering, Medical Research CenterSeoul National UniversitySeoulSouth Korea
| | - Chang Hee Min
- Institute of Medical and Biological Engineering, Medical Research CenterSeoul National UniversitySeoulSouth Korea
| | - Byung Ho Shin
- Department of Biomedical EngineeringSeoul National University College of MedicineSeoulSouth Korea
| | - Cheol Lee
- Department of PathologySeoul National University College of MedicineSeoulSouth Korea
| | - Young Min Cho
- Department of Internal MedicineSeoul National University College of MedicineSeoulSouth Korea,Department of Translational Medicine, College of MedicineSeoul National UniversitySeoulSouth Korea
| | - Young Bin Choy
- Interdisciplinary Program in Bioengineering, College of EngineeringSeoul National UniversitySeoulSouth Korea,Institute of Medical and Biological Engineering, Medical Research CenterSeoul National UniversitySeoulSouth Korea,Department of Biomedical EngineeringSeoul National University College of MedicineSeoulSouth Korea
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A valid self-help tool to measure the role of spousal support in the care of persons with diabetes mellitus. Int J Diabetes Dev Ctries 2021. [DOI: 10.1007/s13410-021-01001-y] [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: 11/28/2022] Open
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Piyasena MMPN, Zuurmond M, Yip JLY, Murthy GVS. Process of adaptation, development and assessment of acceptability of a health educational intervention to improve referral uptake by people with diabetes in Sri Lanka. BMC Public Health 2019; 19:614. [PMID: 31113393 PMCID: PMC6528317 DOI: 10.1186/s12889-019-6880-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 04/22/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND One major barrier to uptake of diabetic retinopathy (DR) services is lack of knowledge and awareness of DR among the people with diabetes (PwDM). Targeted health education (HE) can be a key element in improving the uptake of eye care services. Such interventions are lacking in Sri Lanka. METHODS A local context specific HE intervention (HEI) was developed by adopting available resources and incorporating views from PwDM and key stakeholders. Four sessions of participatory workshops with PwDM (20 Sinhala and 13 Tamil speaking) and two stage 12 stakeholder interviews were conducted to both develop and pre-test the material. The products were a video and a leaflet, delivered at a medical clinic to a sample of 45 PwDM identified as having DR. Semi-structured interviews were conducted after 4 weeks, to evaluate the acceptability and comprehension of the HEI. Additionally, nine interviews were conducted with clinical providers to explore process issues related to delivery of the HEI. Data analysis was conducted using thematic analysis. RESULTS The lack of knowledge and awareness on DR, and of the importance of regular DR screening and follow up, combined with poor information on referral pathways were key elements identified from the workshops with PwDM. The stakeholders prioritised the importance of using simple language, and the need for emphasis on improving understanding about the asymptomatic phase of DR. The overall acceptability of the HEI material was satisfactory, although there was some difficulty with interpretation of medical images. Overall, although PwDM liked the ideas of the video, the leaflet was seen as a more practical option, given the busy clinic environment. The key issue was both formats required interaction with the provider, in order to support understanding of the messages. CONCLUSIONS The process of adapting HE material is not simply translation into the appropriate language. Instead, a tailored approach in a country, context and particular health services setting is needed. This study illustrates the value of using a participatory approach and involving PwDM and stakeholders in the adaptation and pilot testing of a HEI to improve uptake of screening for DR in the context of Sri Lanka.
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Affiliation(s)
- M. M. P. N. Piyasena
- Vitreo-retina unit, National Eye Hospital, Colombo 10, Sri Lanka
- Clinical Research Department, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Maria Zuurmond
- International Centre for Evidence in Disability, Clinical Research Department, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Jennifer L. Y. Yip
- Clinical Research Department, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - G. V. S. Murthy
- Clinical Research Department, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
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Piyasena MMPN, Murthy GVS, Yip JLY, Gilbert C, Zuurmond M, Peto T, Gordon I, Hewage S, Kamalakannan S. Systematic review on barriers and enablers for access to diabetic retinopathy screening services in different income settings. PLoS One 2019; 14:e0198979. [PMID: 31013274 PMCID: PMC6478270 DOI: 10.1371/journal.pone.0198979] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 04/03/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Diabetic retinopathy (DR) can lead to visual impairment and blindness if not detected and treated in time. Knowing the barriers/enablers in advance in contrasting different country income settings may accelerate development of a successful DR screening (DRS) program. This would be especially applicable in the low-income settings with the rising prevalence of DR. OBJECTIVES The aim of this systematic review is to identify and contrast the barriers/enablers to DRS for different contexts using both consumers i.e., people with diabetes (PwDM) and provider perspectives and system level factors in different country income settings. METHODS We searched MEDLINE, Embase, CENTRAL in the Cochrane Library from the databases start date to December 2018. We included the studies reported on barriers and enablers to access DRS services based at health care facilities. We categorised and synthesized themes related to the consumers (individuals), providers and the health systems (environment) as main dimensions according to the constructs of social cognitive theory, supported by the quantitative measures i.e., odds ratios as reported by each of the study authors. MAIN RESULTS We included 77 studies primarily describing the barriers and enablers. Most of the studies were from high income settings (72.7%, 56/77) and cross sectional in design (76.6%, 59/77). From the perspectives of consumers, lack of knowledge, attitude, awareness and motivation were identified as major barriers. The enablers were fear of blindness, proximity of screening facility, experiences of vision loss and being concerned of eye complications. In providers' perspectives, lack of skilled human resources, training programs, infrastructure of retinal imaging and cost of services were the main barriers. Higher odds of uptake of DRS services was observed when PwDM were provided health education (odds ratio (OR) 4.3) and having knowledge on DR (OR range 1.3-19.7). CONCLUSION Knowing the barriers to access DRS is a pre-requisite in development of a successful screening program. The awareness, knowledge and attitude of the consumers, availability of skilled human resources and infrastructure emerged as the major barriers to access to DRS in any income setting.
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Affiliation(s)
- Mapa Mudiyanselage Prabhath Nishantha Piyasena
- Clinical Research Department, Department of Infectious and Tropical Diseases, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Gudlavalleti Venkata S. Murthy
- Clinical Research Department, Department of Infectious and Tropical Diseases, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jennifer L. Y. Yip
- Clinical Research Department, Department of Infectious and Tropical Diseases, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Clare Gilbert
- Clinical Research Department, Department of Infectious and Tropical Diseases, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Maria Zuurmond
- Clinical Research Department, Department of Infectious and Tropical Diseases, International Centre for Evidence in Disability, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Tunde Peto
- Centre for Public Health, Faculty of Medicine, Health and Life Sciences, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University, Belfast, Northern Ireland
| | - Iris Gordon
- Clinical Research Department, Department of Infectious and Tropical Diseases, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Suwin Hewage
- Retina Unit, Department of Vitreo-retina, National Eye Hospital, Colombo, Sri Lanka
| | - Sureshkumar Kamalakannan
- Department of Eye Health and Disability, Indian Institute of Public Health, Public Health Foundation of India, Hyderabad, Telangana, India
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Piyasena MMPN, Yip JLY, MacLeod D, Kim M, Gudlavalleti VSM. Diagnostic test accuracy of diabetic retinopathy screening by physician graders using a hand-held non-mydriatic retinal camera at a tertiary level medical clinic. BMC Ophthalmol 2019; 19:89. [PMID: 30961576 PMCID: PMC6454614 DOI: 10.1186/s12886-019-1092-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 03/26/2019] [Indexed: 11/10/2022] Open
Abstract
Background The evidence on diagnostic test accuracy (DTA) of diabetic retinopathy (DR) screening utilising photographic studies by non-ophthalmologist personnel in low and middle-income country (LMIC) settings is scarce. We aimed to assess DTA of DR screening using a nonmydriatic hand-held digital camera by trained general physicians in a non-ophthalmic setting. Methods This study is a validation of a screening intervention. We selected 700 people with diabetes (PwDM) > 18 years of age, not previously screened or treated for DR, presenting at a tertiary medical clinic in Sri Lanka. Two-field retinal imaging was used to capture fundus images before and after pupil dilatation, using a hand-held non-mydriatic (Visuscout 100®-Germany) digital retinal camera. The images were captured and graded by two trained, masked independent physician graders. The DTA of different levels of DR was assessed comparing physician’s grading with a retinologist’s clinical examination by mydriatic bio-microscopy, according to a locally adopted guideline. Results Seven hundred eligible PwDM were screened by physician graders. The mean age of participants was 60.8 years (SD ±10.08) and mean duration of DM was 9.9 years (SD ±8.09). Ungradable image proportion in non-mydriatic imaging was 43.4% (either eye-31.3%, both eyes 12.1%). This decreased to 12.8% (either eye-11.6%, both eyes-1.2%) following pupil dilatation. In comparison to detection of any level of DR, a referable level DR (moderate non-proliferative DR and levels above) showed a higher level of DTA. The sensitivity of the defined referable DR was 88.7% (95% CI 81.7–93.8%) for grader 1 (positive predictive value [PPV] 59.1%) and 92.5% (95% CI 86.4–96.5%) for grader 2 (PPV 68%), using mydriatic imaging, after including ungradable images as screen positives. The specificity was 94.9% (95% CI 93.6–96.0%) for grader 1 (negative predictive value [NPV] 99%) and 96.4% (95% CI 95.3–97.3%) for grader 2 (NPV 99.4%). Conclusions The Physicians grading of images from a digital hand-held non-mydriatic camera at a medical clinic, with dilatation of pupil of those who have ungradable images, provides a valid modality to identify referable level of DR. This could be a feasible alternative modality to the existing opportunistic screening to improve the access and coverage. Trial registration Current Controlled Trials ISRCTN47559703. Date of Registration 18th March 2019, Retrospectively registered. Electronic supplementary material The online version of this article (10.1186/s12886-019-1092-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Jennifer L Y Yip
- Public Health Ophthalmology, International Centre for Eye Health, Clinical Research Department, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - David MacLeod
- Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Min Kim
- Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Venkata S Murthy Gudlavalleti
- Public Health for Eye Care and Disability, International Centre for Eye Health, Clinical Research Department, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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Piyasena MMPN, Gudlavalleti VSM, Gilbert C, Yip JL, Peto T, MacLeod D, Fonseka C, Kulatunga A, Bandutilake B, Dhanapala M, Pathirana L, Dissanayake H. Development and Validation of a Diabetic Retinopathy Screening Modality Using a Hand-Held Nonmydriatic Digital Retinal Camera by Physician Graders at a Tertiary-Level Medical Clinic: Protocol for a Validation Study. JMIR Res Protoc 2018; 7:e10900. [PMID: 30530458 PMCID: PMC6305894 DOI: 10.2196/10900] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 07/05/2018] [Accepted: 09/13/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Visual impairment and blindness from diabetic retinopathy (DR), which can be reduced by early screening and treatment, is an emerging public health concern in low-income and middle-income countries (LMICs) owing to the increasing prevalence of diabetes mellitus (DM). However, no systematic screening exists in most LMIC settings. The Western province of Sri Lanka has the highest prevalence of DM (18.6%) in the country. A situational analysis identified a marked gap in DR screening (DRS) and treatment services uptake in this region; only opportunistic screening is practiced currently. OBJECTIVE The aim of this protocol is to describe the methods of development and validation of a DRS intervention using a hand-held nonmydriatic digital camera by physician graders in a non-ophthalmological setting at a tertiary-level medical clinic to propose a valid and feasible modality to improve uptake. METHODS DRS modality was developed after assessing barriers and identifying the most appropriate personnel, methods, and location for screening services, following formative research work. The validation will be conducted in a public sector tertiary care center in the Western province of Sri Lanka. The selected physicians will be trained on capturing and grading images according to a valid locally adopted protocol. Two physicians rated high on training will screen a sample of 506 people with DM at a medical clinic. They will use nonmydriatic and mydriatic 2-field imaging strategy. The validity of the proposed screening procedure will be assessed and compared with the mydriatic indirect biomicroscopic examination by a senior retinologist. RESULTS The validity of screening by physician graders will be analyzed and the sensitivity, specificity, and predictive values (with 95% CIs) calculated by the dilation status and for each grader. The diagnostic accuracy at each level of severity of DR will be assessed to define the most appropriate referable criteria. Data is currently being collected. CONCLUSIONS The outcome of this study will be useful for the detection of a defined level of DR at non-ophthalmological setting to filter the people with DM before referral to an eye clinic. This will be helpful to improve the uptake and identify risk groups in advance to prevent sight-threatening DR. Furthermore, evidence from this study will be useful for the implementation of a DRS program in this region and in similar communities. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/10900.
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Affiliation(s)
| | - Venkata S Murthy Gudlavalleti
- Clinical Research Department, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Clare Gilbert
- Clinical Research Department, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jennifer Ly Yip
- Clinical Research Department, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Tunde Peto
- School of Medicine, Dentistry and Bio-medical Science, Queen's University, Belfast, Ireland
| | - David MacLeod
- Clinical Research Department, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Charith Fonseka
- Vitreo-retina Unit, National Eye Hospital, Colombo, Sri Lanka
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Lin S, Ramulu P, Lamoureux EL, Sabanayagam C. Addressing risk factors, screening, and preventative treatment for diabetic retinopathy in developing countries: a review. Clin Exp Ophthalmol 2016; 44:300-20. [DOI: 10.1111/ceo.12745] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 01/26/2016] [Accepted: 03/08/2016] [Indexed: 01/24/2023]
Affiliation(s)
| | | | - Ecosse L Lamoureux
- Singapore Eye Research Institute; Singapore
- Office of Clinical Sciences; Duke-NUS Medical School; Singapore
| | - Charumathi Sabanayagam
- Singapore Eye Research Institute; Singapore
- Office of Clinical Sciences; Duke-NUS Medical School; Singapore
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Kovatchev BP. Diabetes technology: markers, monitoring, assessment, and control of blood glucose fluctuations in diabetes. SCIENTIFICA 2012; 2012:283821. [PMID: 24278682 PMCID: PMC3820631 DOI: 10.6064/2012/283821] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Accepted: 10/02/2012] [Indexed: 06/02/2023]
Abstract
People with diabetes face a life-long optimization problem: to maintain strict glycemic control without increasing their risk for hypoglycemia. Since the discovery of insulin in 1921, the external regulation of diabetes by engineering means has became a hallmark of this optimization. Diabetes technology has progressed remarkably over the past 50 years-a progress that includes the development of markers for diabetes control, sophisticated monitoring techniques, mathematical models, assessment procedures, and control algorithms. Continuous glucose monitoring (CGM) was introduced in 1999 and has evolved from means for retroactive review of blood glucose profiles to versatile reliable devices, which monitor the course of glucose fluctuations in real time and provide interactive feedback to the patient. Technology integrating CGM with insulin pumps is now available, opening the field for automated closed-loop control, known as the artificial pancreas. Following a number of in-clinic trials, the quest for a wearable ambulatory artificial pancreas is under way, with a first prototype tested in outpatient setting during the past year. This paper discusses key milestones of diabetes technology development, focusing on the progress in the past 10 years and on the artificial pancreas-still not a cure, but arguably the most promising treatment of diabetes to date.
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Affiliation(s)
- Boris P. Kovatchev
- Department of Psychiatry and Neurobehavioral Sciences, Department of Systems and Information Engineering, Center for Diabetes Technology, and University of Virginia Health System, University of Virginia, P.O. Box 400888, Charlottesville, VA 22908, USA
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Abstract
Closed-loop (CL) therapy systems should be safe, efficacious, and easily manageable for type 1 diabetes mellitus patient use. For the first two clinical requirements, noninferiority and superiority criteria must be determined based on current conventional and intensive therapy outcomes. Current frequencies of hypoglycemia and diabetic ketoacidosis are reviewed and safety expectations for CL therapy systems are proposed. Glycosylated hemoglobin levels lower than current American Diabetes Association recommendations for different age groups are proposed as superiority criteria. Measures of glycemic variability are described and the recording of blood glucose levels as percentages within, above, and below a target range are suggested as reasonable alternatives to sophisticated statistical analyses. It is also suggested that Diabetes Quality of Life and Fear of Hypoglycemia surveys should be used to track psychobehavioral outcomes. Manageability requirements for safe and effective clinical management of CL systems are worth being underscored. The weakest part of the infusion system remains the catheter, which is exposed to variable and under-delivery incidents. Detection methods are needed to warn both the system and the patient about altered insulin delivery, including internal pressure and flow alarms. Glucose monitor sensor accuracy is another requirement; it includes the definition of conditions that lead to capillary glucose measurement, eventually followed by sensor recalibration or replacement. The crucial clinical requirement will be a thorough definition of the situations when the patient needs to move from CL to manual management of insulin delivery, or inversely can switch back to CL after a requested interruption. Instructions about these actions will constitute a major part of the education process of the patients before using CL systems and contribute to the manageability of these systems.
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Affiliation(s)
- William L Clarke
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Virginia Health Sciences Center, Charlottesville, Virginia 22908, USA.
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Whitelaw BC, Choudhary P, Hopkins D. Evaluating rate of change as an index of glycemic variability, using continuous glucose monitoring data. Diabetes Technol Ther 2011; 13:631-6. [PMID: 21563920 DOI: 10.1089/dia.2010.0215] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND There is no consensus as to the best method to assess glycemic variability from continuous glucose monitoring (CGM) data. Rate of change has been suggested as a preferred method of assessing glycemic variability, but this assertion has not been validated. METHODS Forty-eight hours of CGM data were analyzed from 22 subjects (seven controls and 15 with type 1 diabetes) purposively sampled to reflect a range of glycemic variability. SD, mean amplitude of glycemic excursion, continuous overall net glycemic action, SD of rate of change (SDRC), and average absolute rate of change (AARC) were calculated and correlated with a clinical assessment of variability. SDRC and AARC were recalculated following a data smoothing process involving aggregation. RESULTS SDRC calculated from non-aggregated glucose readings gives a weaker correlation (r = 0.66) with the clinical assessment of variability than the correlations obtained by other indices (r = 0.90-0.96). Following a process of data aggregation, to exclude clinically insignificant fluctuations of blood glucose, we demonstrated that 60 min was the optimal aggregation period. The correlation between clinical assessment of variability and SDRC, 60-min aggregated, is 0.93, which is comparable to correlations shown by other established indices. Similar results are obtained for AARC. CONCLUSIONS Rate of change calculated after appropriate data aggregation is a valid index of glycemic variability. Optimal data aggregation is achieved by aggregating into 1-h blocks.
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Affiliation(s)
- Benjamin C Whitelaw
- Department of Diabetic Medicine, Kings College Hospital, NHS Foundation Trust, London, United Kingdom
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Halperin F, Patti ME, Skow M, Bajwa M, Goldfine AB. Continuous glucose monitoring for evaluation of glycemic excursions after gastric bypass. J Obes 2011; 2011:869536. [PMID: 21331295 PMCID: PMC3038694 DOI: 10.1155/2011/869536] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2010] [Accepted: 01/13/2011] [Indexed: 01/06/2023] Open
Abstract
Background. Hyperinsulinemic hypoglycemia with neuroglycopenia is a rare complication of Roux-en-Y gastric bypass (RYGB). We hypothesized that continuous glucose monitoring (CGM) would be useful to characterize glycemic variability after RYGB. Methods. CGM and mixed meal tolerance testing (MMTT) were performed on sixteen post-RYGB subjects, ten with a history of neuroglycopenia on medical treatment and six asymptomatic controls. Results. 9 of 10 subjects with neuroglycopenia developed hypoglycemia defined by glucose <70 mg/dL on CGM, and 3 of 9 on MMTT. In asymptomatic subjects, 3 of 6 had asymptomatic hypoglycemia during CGM, and 3 of 5 on MMTT. Therefore, the sensitivity and specificity to detect clinically significant hypoglycemia was 90% and 50% for CGM and 33% and 40% for MMTT. Conclusions. Asymptomatic hypoglycemia after RYGB is more frequent than commonly recognized. For clinicians evaluating patients for postbypass neuroglycopenia, CGM may be a valuable diagnostic tool.
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Affiliation(s)
- Florencia Halperin
- Brigham and Women's Hospital, Boston 02115, MA, USA
- Joslin Diabetes Center, Boston, MA 02215, USA
- Harvard Medical School, Boston 02115, MA, USA
| | - Mary Elizabeth Patti
- Joslin Diabetes Center, Boston, MA 02215, USA
- Harvard Medical School, Boston 02115, MA, USA
| | - Megan Skow
- Joslin Diabetes Center, Boston, MA 02215, USA
| | | | - Allison B. Goldfine
- Brigham and Women's Hospital, Boston 02115, MA, USA
- Joslin Diabetes Center, Boston, MA 02215, USA
- Harvard Medical School, Boston 02115, MA, USA
- *Allison B. Goldfine:
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