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Lamaro BD, Greenfield JR, Snaith JR. Can Unmet Needs Be Addressed by Adjunctive Therapies? Findings from a Patient Perspectives Survey in Adults with Type 1 Diabetes. J Patient Exp 2024; 11:23743735241257811. [PMID: 38799027 PMCID: PMC11128168 DOI: 10.1177/23743735241257811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024] Open
Abstract
Many individuals with type 1 diabetes (T1D) do not achieve their management goals. The patient perspective on unmet needs in T1D may guide the role of adjunctive therapies, including glucagon like peptide-1 receptor agonists (GLP-1RAs). A quantitative online survey (n = 133) assessed (1) self-reported demographic and management data, (2) management priorities, satisfaction, and willingness to use adjunctive therapies and (3) conducted a risk-benefit analysis using three masked drug profiles (1.8 mg vs 0.6 mg liraglutide vs placebo). A subgroup of respondents (n = 20) participated in semi-structured interviews to extend upon survey insights. Needs were unmet by current treatment in 28% of surveyed individuals. The greatest unmet needs included (1) glycemia, (2) management-related fatigue, and (3) weight management. Most respondents (94%) indicated that they would use adjunctive therapies. The preferred administration route was daily tablets (66%) followed by weekly injections (32%). Metabolic improvements were most valued (reduction in hypoglycemia, hyperglycemia). Most respondents (94%) preferred the liraglutide risk-benefit profile (1.8 mg, then 0.6 mg) over placebo. Individuals with T1D self-report many unmet needs. While not currently approved in T1D, GLP-1RA properties align with many management priorities reported by individuals with T1D.
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Affiliation(s)
- Bella D. Lamaro
- Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Jerry R. Greenfield
- Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Diabetes and Endocrinology, St Vincent's Hospital, Sydney, New South Wales, Australia
- Diabetes and Metabolism, Garvan Institute of Medical Research, Sydney, New South Wales, Australia
| | - Jennifer R. Snaith
- Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Diabetes and Endocrinology, St Vincent's Hospital, Sydney, New South Wales, Australia
- Diabetes and Metabolism, Garvan Institute of Medical Research, Sydney, New South Wales, Australia
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2
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Messina R, Liliana I, Iommi M, Trombetta M, Roos T, Hermanns N, Di Sipio A, Fantini MP, Calvo V. Assessing attitudes towards insulin pump therapy in adults with type 1 diabetes: Italian validation of the Insulin Pump Attitudes Questionnaire (IT-IPA questionnaire). Acta Diabetol 2023; 60:687-695. [PMID: 36801976 PMCID: PMC10063466 DOI: 10.1007/s00592-023-02046-7] [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: 03/10/2022] [Accepted: 02/02/2023] [Indexed: 02/23/2023]
Abstract
AIMS The aim of the study was to adapt the German version of the insulin pump therapy (IPA) questionnaire to Italian (IT-IPA) and to evaluate its psychometric properties in adults with type 1 diabetes. METHODS We conducted a cross-sectional study, data were collected through an online survey. In addition to IT-IPA, questionnaires evaluating depression, anxiety, diabetes distress, self-efficacy, and treatment satisfaction were administered. The six factors identified in the IPA German version were assessed using confirmatory factor analysis; psychometric testing included construct validity and internal consistency. RESULTS The online survey was compiled by 182 individuals with type 1 diabetes: 45.6% continuous subcutaneous insulin infusion (CSII) users and 54.4% multiple daily insulin injection users. The six-factor model had a very good fit in our sample. The internal consistency was acceptable (Cronbach's α = 0.75; 95% IC [0.65-0.81]). Diabetes treatment satisfaction was positively correlated with a positive attitude towards CSII therapy (Spearman's rho = 0.31; p < 0.01), less Technology Dependency, higher Ease of Use, and less Impaired Body Image. Furthermore, less Technology Dependency was associated with lower diabetes distress and depressive symptoms. CONCLUSIONS The IT-IPA is a valid and reliable questionnaire evaluating attitudes towards insulin pump therapy. The questionnaire can be used for clinical practice during consultations for shared decision-making to CSII therapy.
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Affiliation(s)
- Rossella Messina
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Via San Giacomo 12, 40126, Bologna, Italy.
- Dipartimento Di Medicina, Azienda Ospedaliera-Università Di Padova, Padua, Italy.
| | - Indelicato Liliana
- University of Verona, Verona, Italy
- Dipartimento Di Medicina, Azienda Ospedaliera-Università Di Padova, Padua, Italy
| | - Marica Iommi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Via San Giacomo 12, 40126, Bologna, Italy
- Dipartimento Di Medicina, Azienda Ospedaliera-Università Di Padova, Padua, Italy
| | - Maddalena Trombetta
- University of Verona, Verona, Italy
- Dipartimento Di Medicina, Azienda Ospedaliera-Università Di Padova, Padua, Italy
| | - Timm Roos
- Dipartimento Di Medicina, Azienda Ospedaliera-Università Di Padova, Padua, Italy
- Research Institute of the Diabetes Academy Mergentheim (FIDAM), Bad Mergentheim, Germany
| | - Norbert Hermanns
- Dipartimento Di Medicina, Azienda Ospedaliera-Università Di Padova, Padua, Italy
- Research Institute of the Diabetes Academy Mergentheim (FIDAM), Bad Mergentheim, Germany
| | - Annamaria Di Sipio
- Dipartimento Di Medicina, Azienda Ospedaliera-Università Di Padova, Padua, Italy
- Department of Philosophy, Sociology, Pedagogy, and Applied Psychology, University of Padova, Padua, Italy
| | - Maria Pia Fantini
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Via San Giacomo 12, 40126, Bologna, Italy
- Dipartimento Di Medicina, Azienda Ospedaliera-Università Di Padova, Padua, Italy
| | - Vincenzo Calvo
- Dipartimento Di Medicina, Azienda Ospedaliera-Università Di Padova, Padua, Italy
- Department of Philosophy, Sociology, Pedagogy, and Applied Psychology, University of Padova, Padua, Italy
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3
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Hoffmann A, Plotkina D, Roger P, D’Hondt C. Superstitious beliefs, locus of control, and feeling at risk in the face of Covid-19. PERSONALITY AND INDIVIDUAL DIFFERENCES 2022; 196:111718. [PMID: 35573936 PMCID: PMC9085462 DOI: 10.1016/j.paid.2022.111718] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 05/05/2022] [Accepted: 05/06/2022] [Indexed: 12/31/2022]
Abstract
Unprecedented uncertainty during the Covid-19 pandemic stimulated anxiety among individuals, while the associated health restrictions contributed to a feeling of loss of control. Prior research suggests that, in times of crisis, some individuals rely on superstitious beliefs as a coping mechanism, but it remains unclear whether superstition is positively or negatively associated with fear of Covid-19 during the pandemic, and the role that individuals' locus of control plays in this regard. In two studies conducted among individuals in Belgium and the U.S., we therefore examined the relationship between superstitious beliefs, locus of control, and feeling at risk of Covid-19. Across both countries, we found that superstition is positively, and internal locus of control negatively, related with feeling at risk of Covid-19. Moreover, in Belgium, the effect of superstition was less pronounced for individuals with a higher level of internal locus of control. The absence of an interaction effect between superstition and locus of control in the U.S. could be explained by this country's higher level of superstitious beliefs and lower level of internal locus of control combined with a stronger feeling of being at risk of Covid-19 or cultural differences such as Belgium's higher uncertainty avoidance compared to the U.S.
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Franceschi R, Canale M, Piras EM, Galvagni L, Vivori C, Cauvin V, Soffiati M, Maines E. Influence of Parental Health Locus of Control on Behavior, Self-Management and Metabolic Control, in Pediatric Patients with Type 1 Diabetes. J Pers Med 2022; 12:jpm12101590. [PMID: 36294729 PMCID: PMC9604908 DOI: 10.3390/jpm12101590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/19/2022] [Accepted: 09/23/2022] [Indexed: 11/23/2022] Open
Abstract
Background: Precision medicine in type 1 diabetes (T1D) treatment considers context and environmental data to subclassify patients. Parental Health Locus of Control PHLOC) could influence behavior, self-management, and metabolic control of children with T1D. Methods: No. 135 pediatric patients with T1D (No. 57 with HbA1c ≤ 7.0%, “optimal” group, and No. 78 with >7.0%, “sub-optimal” group) were enrolled in the study. History, anthropometric and diabetes management data were collected, as well as caregiver’s data about socioeconomic status (SES). The PHLOC scale questionnaire and a semi-structured interview were administered. Results: Access to technology was lower in the “sub-optimal” group and, in particular, in the ethnic minority subgroup, only 8% used them. In the “sub-optimal” group ethnic minority status was higher (24%), the caregiver had a lower SES and showed lower internal HLOC. Conclusions: New care models have to be implemented to ensure equity in diabetes care and precision treatment, particularly for ethnic minority groups, because SES and external PHLOC are still an important barrier to “optimal” diabetes control. In the “sub-optimal” group, we have to implement strategies aimed at increasing self-efficacy, while in the “optimal” one, a personalised approach should be considered to facilitate the shifting of responsibilities within the family, avoiding psychological distress.
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Affiliation(s)
- Roberto Franceschi
- Pediatric Diabetology Unit, Pediatric Department, Santa Chiara Hospital of Trento, 38122 Trento, Italy
- Correspondence: ; Tel.: +39-0461-903538
| | - Marta Canale
- Pediatric Diabetology Unit, Pediatric Department, Santa Chiara Hospital of Trento, 38122 Trento, Italy
| | - Enrico Maria Piras
- Center for Information and Communication Technology, eHealth Unit, Fondazione “Bruno Kessler”, 38123 Trento, Italy
| | - Lucia Galvagni
- Center for Religious Studies, Bruno Kessler Foundation, 38123 Trento, Italy
| | - Cinzia Vivori
- Hygiene and Public Prevention Department, Azienda Provinciale per i Servizi Sanitari, 38100 Trento, Italy
| | - Vittoria Cauvin
- Pediatric Diabetology Unit, Pediatric Department, Santa Chiara Hospital of Trento, 38122 Trento, Italy
| | - Massimo Soffiati
- Pediatric Diabetology Unit, Pediatric Department, Santa Chiara Hospital of Trento, 38122 Trento, Italy
| | - Evelina Maines
- Pediatric Diabetology Unit, Pediatric Department, Santa Chiara Hospital of Trento, 38122 Trento, Italy
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5
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Tanenbaum ML, Commissariat PV. Barriers and Facilitators to Diabetes Device Adoption for People with Type 1 Diabetes. Curr Diab Rep 2022; 22:291-299. [PMID: 35522355 PMCID: PMC9189072 DOI: 10.1007/s11892-022-01469-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/14/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW Diabetes technology (insulin pumps, continuous glucose monitoring, automated insulin delivery systems) has advanced significantly and provides benefits to the user. This article reviews the current barriers to diabetes device adoption and sustained use, and outlines the known and potential facilitators for increasing and sustaining device adoption. RECENT FINDINGS Barriers to diabetes device adoption continue to exist at the system-, provider-, and individual-level. Known facilitators to promote sustained adoption include consistent insurance coverage, support for providers and clinics, structured education and support for technology users, and device user access to support as needed (e.g., through online resources). Systemic barriers to diabetes device adoption persist while growing evidence demonstrates the increasing benefits of newest devices and systems. There are ongoing efforts to develop evidence-based structured education programs to support device adoption and sustained use.
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Affiliation(s)
- Molly L Tanenbaum
- Department of Pediatrics, Division of Endocrinology and Diabetes, Stanford University School of Medicine, Stanford, CA, USA.
| | - Persis V Commissariat
- Pediatric, Adolescent and Young Adult Section, Joslin Diabetes Center, Boston, MA, USA
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6
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Wilmot EG, Close KL, Jurišić-Eržen D, Bruttomesso D, Ampudia-Blasco FJ, Bosnyak Z, Roborel de Climens A, Bigot G, Peters AL, Renard E, Berard L, Calliari LE, Seufert J. Patient-reported outcomes in adults with type 1 diabetes in global real-world clinical practice: The SAGE study. Diabetes Obes Metab 2021; 23:1892-1901. [PMID: 33914401 DOI: 10.1111/dom.14416] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 04/14/2021] [Accepted: 04/26/2021] [Indexed: 12/22/2022]
Abstract
AIMS To conduct a secondary analysis of the SAGE study to evaluate the association between glycaemic control and patient-reported outcomes (PROs), in adults with type 1 diabetes (T1DM) across different age groups and regions. MATERIALS AND METHODS SAGE was a multinational, cross-sectional, observational study in adults with T1DM. Data were collected at a single visit, analysed according to predefined age groups (26-44, 45-64, and ≥65 years), and reported across different regions. PRO questionnaires were applied to assess hypoglycaemia fear (Hypoglycemia Fear Survey-II), diabetes-related distress (Problem Areas In Diabetes questionnaire), insulin treatment satisfaction (Insulin Treatment Satisfaction Questionnaire), and diabetes-specific quality of life (QoL; Audit of Diabetes-Dependent Quality of Life). Multivariable analysis was performed to evaluate the relationship between glycated haemoglobin (HbA1c) target achievement (<7% and individualised targets) with PRO scores. RESULTS The PRO scores showed relatively low levels of diabetes-related emotional distress and fear of hypoglycaemia, moderate to high treatment satisfaction, and low diabetes-related impact on QoL. Results were generally comparable across age groups with some regional variability. Achievement of the HbA1c <7% target was associated with less worry about hypoglycaemia, lower diabetes-related emotional distress, higher insulin treatment satisfaction, and higher QoL. Achievement of individualised HbA1c targets was associated with lower diabetes-related emotional distress and higher insulin treatment satisfaction. CONCLUSIONS Better glycaemic control was most closely associated with low emotional distress due to diabetes and high patient-reported insulin treatment satisfaction.
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Affiliation(s)
- Emma G Wilmot
- Diabetes Department, Royal Derby Hospital, Derby, UK
- University of Nottingham, Nottingham, UK
| | - Kelly L Close
- The diaTribe Foundation, San Francisco, California, USA
| | | | | | | | | | | | | | - Anne L Peters
- Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Eric Renard
- Department of Endocrinology, Diabetes, Nutrition, Montpellier University Hospital; INSERM Clinical Investigation Centre 1411; Institute of Functional Genomics, CNRS, INSERM, University of Montpellier, Montpellier, France
| | - Lori Berard
- Nurse Consultant, Winnipeg, Manitoba, Canada
| | | | - Jochen Seufert
- Medical Faculty, University Hospital of Freiburg, Freiburg, Germany
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7
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Messer LH, Campbell K, Pyle L, Forlenza GP. Basal-IQ technology in the real world: satisfaction and reduction of diabetes burden in individuals with type 1 diabetes. Diabet Med 2021; 38:e14381. [PMID: 32767401 DOI: 10.1111/dme.14381] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 07/08/2020] [Accepted: 07/28/2020] [Indexed: 12/21/2022]
Abstract
AIM To describe person-reported outcomes of the Basal-IQ predictive low-glucose-suspend system (Tandem Diabetes Care, San Diego, CA, USA) in real-world use. METHODS Adults with type 1 diabetes/caregivers of minors with type 1 diabetes completed the Diabetes Impact and Device Satisfaction questionnaire (11 items scored on 10-point Likert scales) prior to Basal-IQ system initiation, and at 2, 4 and 6 months post-initiation. Analysis was stratified by previous insulin treatment method. Beta mixed models were used to measure change in device satisfaction (e.g. trust, ease of use) and diabetes impact (e.g. hypoglycaemia fear, poor sleep) scores between time points, adjusting for baseline covariates. RESULTS A total of 967 adults and caregivers [54% women, mean (sd) age 36 (17) years, 57% Tandem pump users, 27% non-Tandem pump users, 17% multiple daily injection users] completed surveys. Device satisfaction significantly increased from baseline to 2 months in all groups (P<0.001 multiple daily injection and non-Tandem pump users; P=0.048 Tandem pump users), and was sustained from 2 to 6 months in all groups. Diabetes impact decreased significantly from baseline to 2 months in all groups (P<0.001 for all), was sustained from 2 to 6 months in multiple daily injection and Tandem pump users, and increased slightly at 4 months/decreased at 6 months in non-Tandem users. CONCLUSION The Basal-IQ system increased device satisfaction and reduced diabetes impact in all users in the first 2 months of use, and satisfaction was sustained over 6 months, with small fluctuations.
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Affiliation(s)
- L H Messer
- Barbara Davis Center, University of Colorado Anschutz, Aurora, CO, USA
| | - K Campbell
- Barbara Davis Center, University of Colorado Anschutz, Aurora, CO, USA
| | - L Pyle
- Barbara Davis Center, University of Colorado Anschutz, Aurora, CO, USA
| | - G P Forlenza
- Barbara Davis Center, University of Colorado Anschutz, Aurora, CO, USA
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8
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Vieira RVDA, Kowacs F, Londero RG, Barea LM, Grassi V, Rodrigues LEB, Santos EP, Gomes WB, Gauer G. Who is in charge when I have a headache? Brazilian version of the Headache-Specific Locus of Control Scale. ARQUIVOS DE NEURO-PSIQUIATRIA 2021; 79:222-228. [PMID: 33886796 DOI: 10.1590/0004-282x-anp-2019-0439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/22/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Headache-Specific Locus of Control (LOC) refers to individuals' beliefs about their control over the onset, course and consequences of headaches. LOC beliefs have been associated with depression, coping strategies, headache-related disability and treatment outcomes. OBJECTIVE To test the cross-cultural adaptation and psychometric properties of a Brazilian version of the Headache-Specific Locus of Control Scale (HSLC). METHODS One hundred and thirty-four migraine outpatients completed the HSLC and provided measurements of psychopathological symptoms, pain catastrophizing, depression, anxiety, quality of life and headache-related disability. RESULTS The three-factor structure of the HSLC (LOC-P, LOC-C and LOC-I) was confirmed in the Brazilian sample. The instrument showed good internal consistency, with Cronbach's α of 0.77 for total HSLC and 0.70, 0.83 and 0.87, for LOC-P, LOC-C and LOC-I, respectively. LOC-C correlated with headache frequency and headache intensity. Along with headache intensity, depression and pain catastrophizing, LOC-I accounted for 45% of the variance (adjusted R2=0.45; F=12.97; p<0.01) in headache-related disability. CONCLUSIONS The Brazilian version of the HSLC is a valid and reliable measure of headache-specific LOC beliefs. It is important to consider the balance between the three LOCs for each individual, instead of interpreting them separately.
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Affiliation(s)
- Rebeca Veras de Andrade Vieira
- Universidade do Vale do Rio dos Sinos, São Leopoldo RS, Brazil.,Universidade Federal do Rio Grande do Sul, Porto Alegre RS, Brazil
| | - Fernando Kowacs
- Hospital Moinhos de Vento, Porto Alegre RS, Brazil.,Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre RS, Brazil
| | - Renata Gomes Londero
- Hospital Moinhos de Vento, Porto Alegre RS, Brazil.,Hospital de Clínicas de Porto Alegre, Serviço de Neurologia, Porto Alegre, RS, Brazil
| | - Liselotte Menke Barea
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre RS, Brazil.,Santa Casa de Misericórdia de Porto Alegre, Porto Alegre RS, Brazil
| | - Vanise Grassi
- Santa Casa de Misericórdia de Porto Alegre, Porto Alegre RS, Brazil
| | | | | | | | - Gustavo Gauer
- Universidade Federal do Rio Grande do Sul, Porto Alegre RS, Brazil
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9
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Chatwin H, Broadley M, Speight J, Cantrell A, Sutton A, Heller S, de Galan B, Hendrieckx C, Pouwer F. The impact of hypoglycaemia on quality of life outcomes among adults with type 1 diabetes: A systematic review. Diabetes Res Clin Pract 2021; 174:108752. [PMID: 33722700 DOI: 10.1016/j.diabres.2021.108752] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 02/15/2021] [Accepted: 03/05/2021] [Indexed: 01/20/2023]
Abstract
Hypoglycaemia is a common barrier to optimal glycaemic management and often feared among adults with type 1 diabetes. The aim of this systematic review was to summarize current evidence regarding the impact of hypoglycaemia on quality of life (QoL) and related outcomes. Electronic searches of MEDLINE, PsycINFO, CINAHL, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials were conducted. Peer-reviewed empirical studies investigating the relationship between hypoglycaemia and QoL were eligible for inclusion. Thirty studies met the inclusion criteria. Extracted data was summarized in a narrative synthesis according to Synthesis Without Meta-Analysis guidelines. None of the studies examined the impact of hypoglycaemia on general QoL. There was no association between hypoglycaemia and diabetes-specific QoL in four of the 30 studies. Severe hypoglycaemia was associated with greater fear of hypoglycaemia and diabetes distress, and lower general emotional well-being, but not with depression, anxiety, or health status. Self-treated hypoglycaemia was associated with greater fear of hypoglycaemia. With the exception of fear of hypoglycaemia, this review shows mixed associations between hypoglycaemia and psychological outcomes. Further research is needed to investigate the impact of hypoglycaemia on other domains of QoL.
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Affiliation(s)
- Hannah Chatwin
- Department of Psychology, University of Southern Denmark, Odense, Denmark.
| | - Melanie Broadley
- Department of Psychology, University of Southern Denmark, Odense, Denmark
| | - Jane Speight
- Department of Psychology, University of Southern Denmark, Odense, Denmark; School of Psychology, Deakin University, Geelong, Australia; The Australian Centre for Behavioural Research in Diabetes, Melbourne, Australia
| | - Anna Cantrell
- Information Resources Group, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, United Kingdom
| | - Anthea Sutton
- Information Resources Group, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, United Kingdom
| | - Simon Heller
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, United Kingdom
| | - Bastiaan de Galan
- Department of Internal Medicine, Maastricht University Medical Center, Maastricht, Netherlands; Radboud University Medical Center, Nijmegen, Netherlands
| | - Christel Hendrieckx
- School of Psychology, Deakin University, Geelong, Australia; The Australian Centre for Behavioural Research in Diabetes, Melbourne, Australia
| | - Frans Pouwer
- Department of Psychology, University of Southern Denmark, Odense, Denmark; School of Psychology, Deakin University, Geelong, Australia; Steno Diabetes Center Odense, Odense, Denmark
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10
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Topaloğlu US, Topaloğlu HK, Kızıltepe M, Kılıç M, Bahçebaşı S, Ata S, Yıldız Ş, Şimşek Y. Fear of hypoglycemia in adults with diabetes mellitus switching to treatment with IDegAsp co-formulation to examine real-world setting: an observational study (The HATICE study). Drug Metab Pers Ther 2020; 0:dmdi-2020-0166. [PMID: 33780195 DOI: 10.1515/dmdi-2020-0166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 12/06/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To evaluate the clinical results of insulin degludec/aspart (IDEgAsp) therapy and its effect on the fear of hypoglycemia. METHODS A prospective observational study has been conducted through surveys of 36 patients using insulin because of type 2 diabetes mellitus who initiated treatment with IDegAsp switching from other insulins. Patients, 18-75 years old, were recruited to the study, consecutively. Participants' age, gender, height, weight, body mass index (BMI), daily insulin dose, glycated hemoglobin (HbA1c), hypoglycemia rate, hypoglycemia fear survey (HFS) were recorded at the beginning of the study. By the end of 12th month, data was re-measured and compared with each other. RESULTS HbA1c was declined by mean of -1.59% (95% CI -1.06 to -2.12, p<0.001). There was also a significant decrease in mean, daily insulin dose, weight and BMI values of patients via IDegAsp. While there was an increase in the amount of dipeptidyl peptidase 4-inhibitors (DPP4-i) and sodium-glucose co-transporter 2-inhibitors (SGLT2-i), there was a decrease in daily injection frequency. There was also a significant decrease in the median values of monthly hypoglycemia rate (from 2.0 to 1.0, p<0.001) and the entire HFS scores (HFS-T: from 1.09 to 0.73, p<0.001; HFS-B: from 0.83 to 0.60, p<0.001; HFS-W: from 1.33 to 0.88, p<0.001). There was a strong positive correlation between ΔHFS-B and daily injection frequency (Rho: 0.398; P: 0.016). CONCLUSIONS IDegAsp co-formulation, combined with DPP4-i and/or SGLT2-i, can provide usefulness in terms of rates of hypoglycemia, reduced HbA1c, less injection administration, and decreased the fear of hypoglycemia in diabetics.
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Affiliation(s)
| | | | - Melih Kızıltepe
- Department of Internal Medicine, Kayseri City Hospital, Kayseri, Turkey
| | - Mesut Kılıç
- Department of Internal Medicine, Kayseri City Hospital, Kayseri, Turkey
| | - Sami Bahçebaşı
- Department of Internal Medicine, Kayseri City Hospital, Kayseri, Turkey
| | - Sibel Ata
- Department of Internal Medicine, Kayseri City Hospital, Kayseri, Turkey
| | - Şeyma Yıldız
- Department of Internal Medicine, Kayseri City Hospital, Kayseri, Turkey
| | - Yasin Şimşek
- Department of Endocrinology, Kayseri City Hospital, Kayseri, Turkey
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11
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Abdoli S, Hessler D, Smither B, Miller-Bains K, Burr EM, Stuckey HL. New insights into diabetes burnout and its distinction from diabetes distress and depressive symptoms: A qualitative study. Diabetes Res Clin Pract 2020; 169:108446. [PMID: 32946853 DOI: 10.1016/j.diabres.2020.108446] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 08/25/2020] [Accepted: 09/10/2020] [Indexed: 10/23/2022]
Abstract
AIMS This study aimed to corroborate the main hypotetized dimensions of diabetes burnout, and its distinction from diabetes distress and depressive symptoms among adults with type 1 diabetes (T1D). METHODS A qualitative descriptive study was employed to collect data from 31 eligible participants using semi-structured individual phone interviews. Participants were recruited through purposive sampling among a larger sample of adults with T1D in a previous study. Data was analyzed using qualitative content analysis including immersion, reduction, and interpretation. RESULTS Exhaustion and detachment were frequent manifestations of diabetes burnout that often accompanied by instances during which participants experienced a loss of control over diabetes. Whereas individuals' support systems could either help or hinder diabetes burnout. Participants saw burnout as separate but closely related to distress and depressive symptoms, with some suggesting correlations among burnout, distress, and depressive symptoms, while others expressed that distress caused their burnout and depressive symptoms. CONCLUSIONS Diabetes burnout reflects a significant yet unexplored concept which might explain the complexities of suboptimal self-management and poor diabetes outcomes. Emerging evidence suggesting diabetes burnout as a distinct concept calls for more studies to mitigate diabetes burnout as an obstacle to optimal diabetes care.
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Affiliation(s)
- Samereh Abdoli
- College of Nursing, University of Tennessee, 1200 Volunteer Blvd Rm 155, Knoxville, TN 37996, USA.
| | - Danielle Hessler
- Department of Family and Community Medicine, University of California, 500 Parnassus Avenue, San Francisco, CA 94117, USA.
| | - Betsy Smither
- Health, Energy, and the Environment, Oak Ridge Associated Universities, P.O. Box 117, MS-##, Oak Ridge, 37831, Oak Ridge, TN 37831, USA.
| | | | - Erin M Burr
- Assessment and Evaluation, Oak Ridge Associated Universities, Oak Ridge, TN 37831, USA.
| | - Heather L Stuckey
- Pennsylvania State University Hershey College of Medicine, 500 University Drive, H034, Hershey, PA 17033, USA.
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12
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Schmidt S, Andersen Nexø M, Norgaard O, Willaing I, Pedersen-Bjergaard U, Skinner TC, Nørgaard K. Psychosocial factors associated with HbA 1c in adults with insulin pump-treated type 1 diabetes: a systematic review. Diabet Med 2020; 37:1454-1462. [PMID: 32579748 DOI: 10.1111/dme.14347] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 05/16/2020] [Accepted: 06/18/2020] [Indexed: 01/31/2023]
Abstract
AIMS To identify currently available studies on the association between psychosocial factors and HbA1c in adults with insulin pump-treated type 1 diabetes, by performing a systematic review of the literature. METHODS MEDLINE, Embase, CINAHL and PsycINFO were searched for original studies on the association between psychosocial factors and HbA1c in ≥ 50 adult, non-pregnant, insulin pump users with type 1 diabetes. RESULTS The search resulted in 1777 unique records, of which eight were eligible for inclusion. All identified studies were observational, with sample sizes ranging from 51 to 214. Seven different psychosocial factors were investigated in the eight studies. Study analysis suggested that HbA1c may be associated with diabetes numeracy and quality of life. There were no indications of associations between HbA1c and fear of hypoglycaemia or self-efficacy. Results regarding associations between HbA1c and coping style, diabetes distress and locus of control were inconsistent. CONCLUSIONS This systematic review summarizes the currently limited information on the association between psychosocial factors and HbA1c during insulin pump therapy. The evidence base of the included studies was weak, and this review highlights the need for more research in these areas, with improved methodological and theoretical frameworks, including exploration of a broader spectrum of psychosocial variables and their potential association with HbA1c and other metabolic outcomes. (PROSPERO International prospective register of systematic reviews registration no: CRD42020145705).
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Affiliation(s)
- S Schmidt
- Steno Diabetes Centre Copenhagen, Gentofte, Denmark
| | | | - O Norgaard
- Steno Diabetes Centre Copenhagen, Gentofte, Denmark
| | - I Willaing
- Steno Diabetes Centre Copenhagen, Gentofte, Denmark
| | - U Pedersen-Bjergaard
- Nordsjaellands Hospital, Hillerød, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - T C Skinner
- Institute of Psychology, University of Copenhagen, Copenhagen, Denmark
- La Trobe Rural Health School, La Trobe University, Bendigo, Australia
| | - K Nørgaard
- Steno Diabetes Centre Copenhagen, Gentofte, Denmark
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13
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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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14
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Cipponeri E, Blini C, Lamera C, De Mori V, Veronesi G, Bossi AC. Insulin Management for Type 1 Diabetic Patients During Social Alcohol Consumption: The SPRITZ Study. Curr Diabetes Rev 2020; 16:619-627. [PMID: 32552634 DOI: 10.2174/1573399815666190507121332] [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: 11/08/2018] [Revised: 04/20/2019] [Accepted: 04/23/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND There is no data available on the best insulin treatment to counteract the effects of glucose excursions due to a moderate alcohol intake associated with portions of slight fat and protein-containing food, as often the case during social happenings or "happy hours". INTRODUCTION This study analyzes the glycemic control and quality of life in 8 adult type 1 diabetic (T1D) patients on insulin-pump therapy which were invited to consume a traditional Italian aperitif ("Spritz" and chips). METHODS Patients consumed Spritz aperitif twice: using their habitual bolus, based on carbohydrates (CHO) counting (V1), or with a personalized, advanced bolus (V2) calculated from insulin/Kcal derived from Fats and Proteins (FPU). Post-prandial glucose was continuously monitored; glucose incremental areas (iAUC), glucose peak and time to peak, and estimated change from V1 to V2 from repeated- measures models were computed. Each patient fulfilled validated questionnaires on quality of life, knowledge about diabetes and CHO counting. RESULTS After the educational program, a reduced iAUC (0-80 min: -306, p=ns; 40-80 min: -400, p=0.07) due to greater (p=0.03) and prolonged double-wave insulin boluses was observed. Blood glucose peak and time to peak were also reduced. Moreover, improvements in the psycho-affective dimension, as well as in the alimentary knowledge were detected. CONCLUSION Therefore, a personalized educational program on CHO + FPU counting together with insulin bolus management can improve glycemic control during social consumption of alcohol, with positive reflections on the psycho-affective dimension. Further studies are mandatory to confirm such preliminary results.
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Affiliation(s)
- Elisa Cipponeri
- Endocrine Unit, Diabetes Regional Centre, ASST Bergamo Ovest, Treviglio (Bg), Italy
| | - Cesare Blini
- Endocrine Unit, Diabetes Regional Centre, ASST Bergamo Ovest, Treviglio (Bg), Italy
| | - Christian Lamera
- Endocrine Unit, Diabetes Regional Centre, ASST Bergamo Ovest, Treviglio (Bg), Italy
| | - Valentina De Mori
- Endocrine Unit, Diabetes Regional Centre, ASST Bergamo Ovest, Treviglio (Bg), Italy
| | - Giovanni Veronesi
- Research Centre EPIMED - Epidemiology and Preventive Medicine, Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Antonio Carlo Bossi
- Endocrine Unit, Diabetes Regional Centre, ASST Bergamo Ovest, Treviglio (Bg), Italy
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15
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Bisio A, Gamarra E, Broglio F, Grassi G. Coping strategies in people with type 1 diabetes on insulin pump treatment. MINERVA ENDOCRINOL 2020; 44:336-343. [DOI: 10.23736/s0391-1977.19.03024-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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16
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Abstract
There continues to be uncertainty about the effectiveness in Type 1 diabetes of insulin pump therapy (continuous subcutaneous insulin infusion, CSII) vs. multiple daily insulin injections (MDI). This narrative review discusses the reasons for this uncertainty, summarizes the current evidence base for CSII and suggests some future research needs. There are difficulties in interpreting trials of CSII because effectiveness varies widely due to factors such as differing baseline control, suboptimal use of best CSII practices, and psychological factors, for example, high external locus of control, non-adherence and lack of motivation. Many summary meta-analyses are also misleading because of poor trial selection (e.g. short duration, obsolete pumps, low baseline rate of hypoglycaemia) and reliance on mean effect size for decision-making. Both MDI and CSII can achieve strict glycaemic control without hypoglycaemia in some people with Type 1 diabetes, especially those who are motivated and have undergone structured diabetes education, and with high levels of ongoing input from healthcare professionals. CSII is particularly effective in those people with Type 1 diabetes who have not achieved target HbA1c levels without disabling hypoglycaemia using best attempts with MDI, and here there can be valuable and substantial improvement. Insulin pumps are safe, effective and accepted when used in newly diagnosed diabetes, particularly in children, where MDI may not be practicable. Future research needs include more studies on mortality associated with insulin pumps where registry data have suggested lower rates vs. MDI; and psychological strategies to improve non-adherence and suboptimal glycaemic outcomes on CSII.
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Affiliation(s)
- J C Pickup
- Department of Diabetes, King's College London, Guy's Hospital, London, UK
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17
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Oita M, Miyoshi H, Ono K, Nakamura A, Cho KY, Nomoto H, Yamamoto K, Omori K, Manda N, Kurihara Y, Aoki S, Atsumi T. Satisfaction and efficacy of switching from daily dipeptidyl peptidase-4 inhibitors to weekly trelagliptin in patients with type 2 diabetes-Randomized controlled study. Endocr J 2018; 65:141-150. [PMID: 29093280 DOI: 10.1507/endocrj.ej17-0303] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
We compared treatment satisfaction between daily dipeptidyl peptidase-4 (DPP-4) inhibitors and a weekly DPP-4 inhibitor in patients with type 2 diabetes. The study was a 12-week, open-label, randomized, multicenter, controlled trial. Participants were Japanese patients with type 2 diabetes who had received daily DPP-4 inhibitors for more than 3 months. Patients were randomly assigned to a treatment cohort: (1) a group that continued taking daily DPP-4 inhibitors (daily group); or (2) a group that switched from daily DPP-4 inhibitors to a weekly DPP-4 inhibitor, trelagliptin (weekly group). The primary outcome was the change in treatment satisfaction levels from baseline to 12 weeks between the two groups, according to Diabetes Treatment Satisfaction Questionnaire (DTSQ) and Diabetes Therapy-Related Quality of Life (DTR-QOL) questionnaire scores. The changes in glycemic control and body weight were also assessed. Of 49 patients initially enrolled in the study, 47 completed the study. The change in DTSQ scores in the weekly group was not significantly different from that in the daily group. However, the improvements in total score and subscale domains 1 and 2 in the DTR-QOL analysis, which relate to burden on social/daily activities and anxiety/dissatisfaction with treatment, were significantly greater in the weekly group than the daily group (p = 0.048, 0.013 and 0.045, respectively). Mean changes in glycated hemoglobin levels and body weight were comparable between the groups. Switching from daily DPP-4 inhibitors to a weekly DPP-4 inhibitor, trelagliptin, could partially improve treatment satisfaction levels in patients with type 2 diabetes without affecting glycemic control.
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Affiliation(s)
- Mayuko Oita
- Division of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University Hospital, North 15, West 7, Kita-ku, Sapporo 060-8638, Japan
| | - Hideaki Miyoshi
- Division of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University Hospital, North 15, West 7, Kita-ku, Sapporo 060-8638, Japan
| | - Kota Ono
- Clinical Research and Medical Innovation Center, Hokkaido University Hospital, North 15, West 7, Kita-ku, Sapporo 060-8638, Japan
| | - Akinobu Nakamura
- Division of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University Hospital, North 15, West 7, Kita-ku, Sapporo 060-8638, Japan
| | - Kyu Yong Cho
- Division of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University Hospital, North 15, West 7, Kita-ku, Sapporo 060-8638, Japan
- Clinical Research and Medical Innovation Center, Hokkaido University Hospital, North 15, West 7, Kita-ku, Sapporo 060-8638, Japan
| | - Hiroshi Nomoto
- Division of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University Hospital, North 15, West 7, Kita-ku, Sapporo 060-8638, Japan
| | - Kohei Yamamoto
- Division of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University Hospital, North 15, West 7, Kita-ku, Sapporo 060-8638, Japan
| | - Kazuno Omori
- Division of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University Hospital, North 15, West 7, Kita-ku, Sapporo 060-8638, Japan
| | - Naoki Manda
- Manda Memorial Hospital, South 2, West 1, Chuo-ku, Sapporo 060-0062, Japan
| | - Yoshio Kurihara
- Kurihara Clinic, Athubethuchuo 3-5, Atsubetsu-ku, Sapporo 004-0053, Japan
| | - Shin Aoki
- Aoki Clinic, Nango dori 1, North 1-1, Shiroishi-ku, Sapporo 003-0023, Japan
| | - Tatsuya Atsumi
- Division of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University Hospital, North 15, West 7, Kita-ku, Sapporo 060-8638, Japan
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18
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Ferrari M, Dal Cin M, Steele M. Self-compassion is associated with optimum self-care behaviour, medical outcomes and psychological well-being in a cross-sectional sample of adults with diabetes. Diabet Med 2017; 34:1546-1553. [PMID: 28799282 DOI: 10.1111/dme.13451] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/08/2017] [Indexed: 11/30/2022]
Abstract
AIM To investigate the role of self-compassion in diabetes outcomes. Self-compassion is a construct which may be relevant to chronic conditions, given its focus on compassion toward oneself, especially in times of difficulty. METHODS In this cross-sectional study we collected data online from 310 adults diagnosed with diabetes. The questionnaire measured three primary outcomes: self-management behaviours; HbA1c levels and psychological well-being. Potential predictors were also assessed, including self-compassion, locus of control, social support and demographics. RESULTS Multiple regression analyses showed that self-compassion had the most consistent association with better outcomes, including all forms of self-management behaviour, HbA1c levels and psychological well-being. Self-compassion was independently associated with 55.1% of the variance in well-being. Internal locus of control was also significantly associated with better well-being and HbA1c outcomes. Chance and external locus of control and social support were generally associated with poorer outcomes. CONCLUSIONS Higher levels of self-compassion are typically associated with improved self-management behaviour, medical outcomes and psychological well-being in adults with diabetes mellitus. The present findings suggest that self-compassion may be a parsimonious and suitable intervention target. Future interventions and consultations with medical professionals may benefit from fostering self-compassion in adults with diabetes mellitus.
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Affiliation(s)
- M Ferrari
- School of Psychology, Australian Catholic University, Strathfield, New South Wales, Australia
- School of Psychology, University of Sydney, Sydney, New South Wales, Australia
| | - M Dal Cin
- School of Psychology, Australian Catholic University, Strathfield, New South Wales, Australia
| | - M Steele
- School of Allied Health, Australian Catholic University, Brisbane, Queensland, Australia
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Miazgowski T, Bikowska M, Ogonowski J, Taszarek A. The Impact of Health Locus of Control and Anxiety on Self-Monitored Blood Glucose Concentration in Women with Gestational Diabetes Mellitus. J Womens Health (Larchmt) 2017; 27:209-215. [PMID: 28829663 DOI: 10.1089/jwh.2017.6366] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The purpose of this study was to evaluate the associations between health locus of control (HLC), anxiety, and glycemic control from the time of diagnosis of gestational diabetes (GDM) to the end of pregnancy. METHODS The study group comprised 165 women with GDM. Baseline HLC (∼27 weeks of gestation) was assessed by the Multidimensional HLC Scale. The level of anxiety was measured at baseline and follow-up (37 weeks of gestation) by the State-Trait Anxiety Inventory. Using questionnaires, we collected information about the level of fear related to measuring blood glucose several times per day, dietary regimen, and insulin therapy, as well as fear for the baby and its health, patient's own health, and having diabetes in the next pregnancy. Glycemic control was evaluated by self-monitored fasting and postprandial blood glucose levels. RESULTS Baseline state anxiety was significantly higher than trait anxiety. From baseline to follow-up, the state anxiety and percentage of women with increased fear for their infant's health, diabetic diet, self-monitoring of blood glucose, and insulin injection significantly decreased. In comparison to women with blood glucose in the low tertile, those with blood glucose in the high tertile had significantly higher scores in the chance HLC subscale and a similar level of state anxiety. Blood glucose was positively correlated with the chance HLC score. CONCLUSIONS Chance HLC beliefs seem to be associated with poorer glycemic outcomes in women with GDM. Our results suggest the need for further efforts to reduce the GDM-associated state anxiety.
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Affiliation(s)
- Tomasz Miazgowski
- 1 Department of Hypertension and Internal Medicine, Pomeranian Medical University , Szczecin, Poland
| | - Magdalena Bikowska
- 2 Department of Long-Term Care, Pomeranian Medical University , Szczecin, Poland
| | - Jarosław Ogonowski
- 3 Department of Civilization Diseases and Treatment of Obesity, Pomeranian Medical University , Szczecin, Poland
| | - Aleksandra Taszarek
- 1 Department of Hypertension and Internal Medicine, Pomeranian Medical University , Szczecin, Poland
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