An educational program for insulin self-adjustment associated with structured self-monitoring of blood glucose significantly improves glycemic control in patients with type 2 diabetes mellitus after 12 weeks: a randomized, controlled pilot study

The experiences and perspectives of people with gout on urate self-monitoring

INTRODUCTION

Gout management remains suboptimal despite safe and effective urate-lowering therapy. Self-monitoring of urate may improve gout management, however, the acceptability of urate self-monitoring by people with gout is unknown. The aim of this study was to explore the experiences of urate self-monitoring in people with gout.

METHODS

Semistructured interviews were conducted with people taking urate-lowering therapy (N = 30) in a 12-month trial of urate self-monitoring in rural and urban Australia. Interviews covered the experience of monitoring and its effect on gout self-management. Deidentified transcripts were analysed thematically.

RESULTS

Participants valued the ability to self-monitor and gain more understanding of urate control compared with the annual monitoring ordered by their doctors. Participants indicated that self-monitoring at home was easy, convenient and informed gout self-management behaviours such as dietary modifications, hydration, exercise and medication routines. Many participants self-monitored to understand urate concentration changes in response to feeling a gout flare was imminent or whether their behaviours, for example, alcohol intake, increased the risk of a gout flare. Urate concentrations were shared with doctors mainly when they were above target to seek management support, and this led to allopurinol dose increases in some cases.

CONCLUSION

Urate self-monitoring was viewed by people with gout as convenient and useful for independent management of gout. They believed self-monitoring achieved better gout control with a less restricted lifestyle. Urate data was shared with doctors at the patient's discretion and helped inform clinical decisions, such as allopurinol dose changes. Further research on implementing urate self-monitoring in routine care would enable an evaluation of its impact on medication adherence and clinical outcomes, as well as inform gout management guidelines.

PATIENT OR PUBLIC CONTRIBUTION

One person with gout, who was not a participant, was involved in the study design by providing feedback and pilot testing the semistructured interview guide. In response to their feedback, subsequent modifications to the interview guide were made to improve the understandability of the questions from a patient perspective. No additional questions were suggested.

A Systematic Review Supporting the Endocrine Society Guidelines: Management of Diabetes and High Risk of Hypoglycemia

CONTEXT

Interventions targeting hypoglycemia in people with diabetes are important for improving quality of life and reducing morbidity and mortality.

OBJECTIVE

To support development of the Endocrine Society Clinical Practice Guideline for management of individuals with diabetes at high risk for hypoglycemia.

METHODS

We searched several databases for studies addressing 10 questions provided by a guideline panel from the Endocrine Society. Meta-analysis was conducted when feasible. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess certainty of evidence.

RESULTS

We included 149 studies reporting on 43 344 patients. Continuous glucose monitoring (CGM) reduced episodes of severe hypoglycemia in patients with type 1 diabetes (T1D) and reduced the proportion of patients with hypoglycemia (blood glucose [BG] levels <54 mg/dL). There were no data on use of real-time CGM with algorithm-driven insulin pumps vs multiple daily injections with BG testing in people with T1D. CGM in outpatients with type 2 diabetes taking insulin and/or sulfonylureas reduced time spent with BG levels under 70 mg/dL. Initiation of CGM in hospitalized patients at high risk for hypoglycemia reduced episodes of hypoglycemia with BG levels lower than 54 mg/dL and time spent under 54 mg/dL. The proportion of patients with hypoglycemia with BG levels lower than 70 mg/dL and lower than 54 mg/dL detected by CGM was significantly higher than point-of-care BG testing. We found no data evaluating continuation of personal CGM in the hospital. Use of an inpatient computerized glycemic management program utilizing electronic health record data was associated with fewer patients with and episodes of hypoglycemia with BG levels lower than 70 mg/dL and fewer patients with severe hypoglycemia compared with standard care. Long-acting basal insulin analogs were associated with less hypoglycemia. Rapid-acting insulin analogs were associated with reduced severe hypoglycemia, though there were more patients with mild to moderate hypoglycemia. Structured diabetes education programs reduced episodes of severe hypoglycemia and time below 54 mg/dL in outpatients taking insulin. Glucagon formulations not requiring reconstitution were associated with longer times to recovery from hypoglycemia, although the proportion of patients who recovered completely from hypoglycemia was not different between the 2 groups.

CONCLUSION

This systematic review summarized the best available evidence about several interventions addressing hypoglycemia in people with diabetes. This evidence base will facilitate development of clinical practice guidelines by the Endocrine Society.

Impact of Diabetes Medication Therapy Adherence Clinic (DMTAC) appointment intervals on glycemic control in public health clinics across Perak, Malaysia

INTRODUCTION

Frequent diabetes medication therapy adherence clinic (DMTAC) appointments may lead to more rapid glycaemic control. This study aimed to evaluate the association between appointment intervals and glycaemic control (haemoglobin A1c [HbA1c] level) along with blood pressure (BP) and lipid profile (LP) during DMTAC appointments.

METHOD

This study retrospectively reviewed all recorded baseline and completed DMTAC data, including HbA1c level, LP and BP, of 318 eligible participants from 29 DMTACs across Perak. The participants were divided into shorter appointment interval (SAI) (≤30 days) and longer appointment interval (LAI) groups.

RESULTS

The majority of the baseline socio-demographic and clinical characteristics did not significantly differ between the SAI and LAI groups (p>0.05). Ischaemic heart disease (Odds ratio, OR=3.457; 95% CI= 1.354-8.826; p=0.009) and hypertension (OR=0.521; 95% CI=0.276-0.992; p=0.044) were significantly associated with the appointment intervals. Upon completion of eight DMTAC visits, the HbA1c and FBS levels and DBP significantly improved (p<0.05). However, the mean HbA1c level (1.35±2.18% vs 0.87±2.11%, p=0.548), FBS level (1.25±4.82mmol/L vs 2.29±6.23mmol/L, p=0.538), SBP (3.28±21.82mmHg vs 3.65±18.35mmHg, p=0.343) and LDL level (0.09±0.98mmol/L vs 0.07±1.13mmol/L, p=0.246) did not significantly differ between the SAI and LAI groups.

CONCLUSION

Longer DMTAC appointment intervals had similar improvement in glycaemic controls, blood pressure and lipid profiles as compared to shorter appointment intervals. A longer interval can be scheduled for lower-risk patients to optimise the use of human resources and minimise costs.

Effect of Digital-Tool-Supported Basal Insulin Titration Algorithm in Reaching Glycemic Control in Patients with Type 2 Diabetes in Mexico

BACKGROUND

My Dose Coach (MDC) is a mobile application combined with a web portal that can suggest optimized basal insulin (BI) injection doses using Self-Measured Plasma Glucose (SMPG) and hypoglycemia data. This study aimed to evaluate its efficacy on patients reaching SMPG and Fasting blood glucose (FBG) target range 90-130 mg/dl (5-7.2 mmol/L) goals without severe hypoglycemic episodes. We also addressed the mean reduction in glycated hemoglobin (A1C), FBG, and SMPG and the improvement in the WHO's Five Well Being Index (WBI).

METHODS

This prospective pilot study involved the use of MDC in outpatients with type 2 diabetes (T2DM) from a Hospital in Northern Mexico. Patients on treatment with any BI were included in the study. The follow-up was of 16 weeks. Student t-tests or McNemar test were used for effect comparisons.

RESULTS

We included 158 patients (46.8% women), mean (SD) age 51 (10.3) years. We achieved SMPG target range in 58.9% [mean (95CI) reduction of 30.9 mg/dl (22.5-37.7; P < .001)] of the patients [66(28) days], with no severe hypoglycemia events. FBG goal was reached in 55.7% [mean (95CI) reduction of 63.4 mg/dl (49.6-77.2; P < .001)]. The mean (95CI) reduction of A1C was 1.78% (1.47-2, P < .01) with the last observation carried forward. There was a mean (95CI) increase of 2.23 (-3, -1.4, P < .01) points in WBI scale.

CONCLUSIONS

MDC successfully helped to achieve FBG and SMPG goals, reduced A1C, and increased WBI with no severe hypoglycemia events.

Self-Monitoring of Blood Glucose as an Integral Part in the Management of People with Type 2 Diabetes Mellitus

For decades, self-monitoring of blood glucose (SMBG) has been considered a cornerstone of adequate diabetes management. Structured SMBG can follow different monitoring patterns, and it results in improved glycemic control, reduced hypoglycemia, and a better quality of life of people with diabetes. The technology, usability, and accuracy of SMBG systems have advanced markedly since their introduction a few decades ago. Current SMBG systems are small and easy to use, require small (capillary) blood sample volumes, and provide measurement results within seconds. In addition, devices are increasingly equipped with features such as connectivity to other devices and/or digital diaries and diabetes management tools. Although measurement quality can come close to or equal that of the glucose monitoring systems used by healthcare professionals, several available SMBG systems still do not meet internationally accepted accuracy standards, such as the International Organization for Standardization 15197 standard. Reports from China, India, and Brazil based on local experience suggest that in addition of the accuracy issues of SMBG systems, other obstacles also need to be overcome to optimize SMBG usage. Nonetheless, adequate usage of SMBG data is of high relevance for the management of people with type 2 diabetes mellitus.

Systematic review and meta-analysis of diabetes specialist delivered insulin education for adults with type 2 diabetes in outpatient settings

OBJECTIVE

We conducted a systematic review and meta-analysis of insulin education for people with type 2 diabetes to assess its effectiveness in improving glycaemic levels.

METHODS

We searched the following online databases from the earliest record to 17 February 2020: MEDLINE, EMBASE, PsycINFO, CINAHL, Web of science, Cochrane Library and https://clinicaltrials.gov. Data was extracted on publication status, participants' characteristics at baseline, intervention and control group, study design, and data for primary and secondary outcomes, change in HbA1c(%), change in weight (Kilogram). The review was registered with international prospective register of systematic reviews registration (PROSPERO):CRD42020167769.

RESULTS

Eighteen papers were included in the systematic review. In the meta-analysis there was a small statistically significant improvement in HbA1c (0.39% points/4.4 mmol/mol reduction) in the insulin education group compared to control conditions (N = 10 studies, n = 3307 participants, SMD = -0.22, 95% CI = -0.34, -0.10, I² = 66% p = 0.002). There was a small non-significant increase in weight (0.54 Kg) in the insulin education group compared to control conditions (N = 6 studies, n = 470 participants, SMD = 0.03, 95% CI = -0.10, 0.17, I² = 0.0%, p = 0.82). Quality of evidence was rated low to very low.

CONCLUSIONS

Enhanced insulin education delivered by diabetes specialists is potentially more effective than standard care. Further research is required to reach robust conclusions.

Glucose biosensors in clinical practice: principles, limits and perspectives of currently used devices

The demand of glucose monitoring devices and even of updated guidelines for the management of diabetic patients is dramatically increasing due to the progressive rise in the prevalence of diabetes mellitus and the need to prevent its complications. Even though the introduction of the first glucose sensor occurred decades ago, important advances both from the technological and clinical point of view have contributed to a substantial improvement in quality healthcare. This review aims to bring together purely technological and clinical aspects of interest in the field of glucose devices by proposing a roadmap in glucose monitoring and management of patients with diabetes. Also, it prospects other biological fluids to be examined as further options in diabetes care, and suggests, throughout the technology innovation process, future directions to improve the follow-up, treatment, and clinical outcomes of patients.

Blood Glucose Monitoring and Sharing Amongst People With Diabetes and Their Facilitators: Cross-sectional Study of Methods and Practices

BACKGROUND

The last two decades have witnessed a burgeoning rise in the prevalence of diabetes globally. It has already reached epidemic proportions in Saudi Arabia, with reported high risk among women. As a result, diabetes monitoring and self-management programs are being highly prioritized for diabetes control and management.

OBJECTIVE

To investigate measuring and sharing practices of the self-monitoring of blood glucose (SMBG) among patients with type 1 or 2 diabetes using insulin.

METHODS

A cross-sectional study was conducted on a sample of 203 patients attending primary care clinics at a tertiary care center. The questionnaire assessed the measuring, recording, and sharing of SMBG practices of patients having diabetes with their physicians. The methods used for recording and sharing were categorized into paper-based and electronic-based. In addition, the determinants of the different methods used and frequency of sharing were analyzed.

RESULTS

The overall monitoring prevalence was 95% (193/203), and 57% (117/203) of participants shared the SMBG results. Among the 193 individuals that performed self-monitoring, 138 (72%) performed daily monitoring, and 147 (76%) recorded their blood sugar levels. Almost 55% (81/147) used paper-based materials like notebooks and paper for recording, while the rest (66/147, 45%) used digital devices like laptops and smartphones. A shift towards the use of digital devices and smart applications was observed in patients below 50 years of age. The digitally recorded blood glucose measurements were being shared thrice more often than the recordings made on paper or in notebooks (OR [odds ratio] 2.8; P=.01). Patients >50 years of age (OR 2.3; P=.02), with lesser formal education, married (OR 4.2; P<.001), with smaller family size (OR 2.6; P=.01), having type 2 diabetes (OR 4.1; P<.001) and any comorbid conditions (OR 2.6; P=.01) were associated with higher odds of using paper-based sharing methods. Only the female gender and type 2 diabetes were associated with increased frequency of sharing, while uncontrolled diabetes, the presence of other comorbidities, and duration of diabetes did not show any influence.

CONCLUSIONS

Good monitoring and optimal sharing practices were found. Sharing using electronic devices can be emphasized. Diabetes self-management programs can incorporate the use of digital technology in training sessions. Digital literacy and its applications in health care may enhance SMBG practices resulting in better diabetes control.

Subclinical lipohypertrophy--Easily ignored complications of insulin therapy

AIMS

Subclinical lipohypertrophy is a lesion meeting ultrasonic criteria for lipohypertrophy that was not detected by inspection and palpation. Little information is published on subclinical lipohypertrophy among insulin injection people with diabetes. We aimed to investigate the subclinical lipohypertrophy prevalence, risk factors, and the association between subclinical lipohypertrophy and glycemic control.

METHODS

This observational study included 316 people with diabetes who had continuously received insulin therapy for at least one year. We performed ultrasound scanning and clinical examination for evidence of subclinical lipohypertrophy. Demographic characteristics, clinical information, and glycated hemoglobin were measured.

RESULTS

The overall prevalence of subclinical lipohypertrophy was 19.9%. By stepwise logistic regression, higher BMI (OR = 1.44, 95%CI: 1.15-1.81, P = 0.002), incorrect rotation of sites (OR = 3.11, 95%CI: 1.02-9.47, P = 0.046), insulin needle reusage for more than four times (OR = 10.00, 95%CI: 3.23-31.02, P = 0.000) and type 1 diabetes (OR = 6.33, 95%CI: 1.32-30.47, P = 0.021) remained associated with subclinical lipohypertrophy. Subclinical lipohypertrophy demonstrated a significant independent correlation with the nonoptimal glycemic control (OR = 9.97, 95% CI: 3.46-28.75, P = 0.000) when accounting for demographic and diabetes-related parameters.

CONCLUSIONS

Subclinical lipohypertrophy is common among insulin-injecting patients with diabetes and is related to glycemic control deterioration. Ultrasonography may be an ideal adjunct in the evaluation of easily ignored lipohypertrophy lesions, especially where poor glycemic control, incorrect injection behaviors, overweight or obesity are documented.

Diabetes management intervention studies: lessons learned from two studies

Introduction

Several clinical studies investigated improvements of patient outcomes due to diabetes management interventions. However, chronic disease management is intricate with complex multifactorial behavior patterns. Such studies thus have to be well designed in order to allocate all observed effects to the defined intervention and to exclude effects of other confounders as well as possible.

This article aims to provide challenges in interpreting diabetes management intervention studies and suggests approaches for optimizing study implementation and for avoiding pitfalls based on current experiences.

Main body

Lessons from the STeP and ProValue studies demonstrated the difficulty in medical device studies that rely on behavioral changes in intervention group patients. To successfully engage patients, priority should be given to health care professionals being engaged, operational support in technical issues being available, and adherence being assessed in detail.

Another difficulty is to avoid contamination of the control group with the intervention; therefore, strict allocation concealment should be maintained. However, randomization and blinding are not always possible. A limited effect size due to improvements regarding clinical endpoints in the control group is often caused by the Hawthorne effect. Improvements in the control group can also be caused with increased attention paid to the subjects. In order to reduce improvements in the control group, it is essential to identify the specific reasons and adjust study procedures accordingly. A pilot phase is indispensable for this. Another option is to include a third study arm to control for enhanced standard of care and study effects. Furthermore, retrospective data collection could be a feasible option. Adaptive study designs might reduce the necessity of a separate pilot study and combine the exploratory and confirmatory stages of an investigation in one single study.

Conclusion

There are several aspects to consider in medical device studies when using interventions that rely on changes in behavior to achieve an effective implementation and significant study results. Improvements in the control group may reduce effect sizes and limit statistical significance; therefore, alternatives to the traditional randomized controlled trials may be considered.

Effect of diabetes self-management education (DSME) on glycated hemoglobin (HbA1c) level among patients with T2DM: Systematic review and meta-analysis of randomized controlled trials

BACKGROUND AND AIMS

Type 2 Diabetes mellitus (T2DM) has been a global public health issue causing in physical, financial and psychosocial crises. The aim of this systematic review and meta-analysis (SRMA) was to evaluate the Diabetes Self-Management Education or Support (DSME/S) on glycosylated hemoglobin (HbA1c) among T2DM patients.

METHODS

This SRMA was made according to preferred reporting Items for systematic review and Meta-analysis (PRISMA) guidelines. The relevant articles were searched from four databases: Cochrane Library, MEDLINE (EBSCOhost), MEDLINE/PubMed and SCOPUS. Quality assessment was carried out. Pooled standard mean difference in HbA1c were calculated to obtain the effect size with random effect assumption. Subgroup analysis was conducted for assessing heterogeneity among the studies.

RESULTS

A total of 1312 studies were identified from databases. Among these 25 studies met inclusion criteria. From these 20 were included in the meta-analysis. In meta-analysis a pooled standard mean difference in HbA1c was -0.604 (95% confidence interval = -0.854 -0.353, I² = 90.3, p < 0.001). In subgroup analysis a significant reduction was seen among studies with less than four months, upper middle followed by lower middle income countries (LMICs), Western Pacific (WP) followed by Middle Eastern and Northern African (MENA) regions with moderate to substantial heterogeneity.

CONCLUSION

However, there is paucity of studies in underdeveloped countries. Therefore, further studies validated to these contexts are needed to evaluate the DSME effectiveness.

TRIAL REGISTRATION

PROSPERO database CRD42020124236.

Benefit of Digital Tools Used for Integrated Personalized Diabetes Management: Results From the PDM-ProValue Study Program

BACKGROUND

Integrated personalized diabetes management (iPDM) is a digitally supported therapeutic concept to improve patient-physician interaction to overcome the aspects of clinical inertia. Integrated personalized diabetes management can support decision making and improve therapeutic outcomes of suboptimally controlled persons with insulin-treated type 2 diabetes (T2D). In this paper, we report the results of an analysis of the PDM-ProValue study program on the effectiveness and perceived benefit of this approach, with a focus on how physicians used and assessed the digital tools provided for the iPDM process.

MATERIALS AND METHODS

The study program included two 12-month, prospective, controlled, cluster-randomized multicenter trials. A total of 101 practices participated with 907 patients. Practices were cluster-randomized to an intervention group and a control group. Digital tools for data visualization and analysis applied were used. HCP were asked to assess the use, relevance, and usefulness of the tools.

RESULTS

A clear preference was stated for the visual overview over more statistically complex analyses. A total of 83% of the participants rated a high relevance of the "daily profile," 81% of the "total profile," and 68% the "risk illustrated by traffic light symbols" for the therapy decision. The overall iPDM process was very favorably rated with respect to structuredness and potential for personalized treatment and well accepted among health care professionals (HCP).

CONCLUSIONS

Embedding digital tools in a structured process (iPDM) were proved to provide a benefit for insulin-treated T2D patients and their physicians. These results offer insight for further development and improvement of the tools and add information on how to overcome clinical inertia.

A comparison of bolus insulin dose errors based on results of a clinical trial of five blood glucose monitoring systems

Aim: Inaccurate blood glucose monitoring system (BGMS) results may lead to insulin dosing errors and adverse clinical outcomes. Results & methodology: This post-hoc analysis used a model to estimate the bolus insulin dose error associated with each of the five BGMSs, for a hypothetical person with diabetes (assuming a standardized meal and target blood glucose of 100 mg/dl). Differences in dose-error distribution between BGMSs were statistically tested. The 95% dose-error range for each BGMS was (insulin units): CONTOUR^®PLUS, -1.1-0.7; Accu-Chek^® Active, -2.4-0.7; Accu-Chek^® Performa, -2.9-0.8; FreeStyle Freedom, from -5.5 to -0.5; OneTouch^® SelectSimple^™, -4.1-3.0. Conclusion: The CONTOUR^®PLUS BGMS was associated with a statistically significantly smaller model-estimated median bolus insulin dose-error and dosing error range, compared with the other BGMSs.

The impact of provision of self-monitoring of blood glucose supplies on self-care activities among patients with uncontrolled Type 2 diabetes mellitus: A prospective study

AIMS

Self-monitoring of blood glucose (SMBG) is an important self-care activity for patients with Type 2 diabetes mellitus (T2DM) to achieve glycaemic control. The aim of this study was to evaluate the impact of providing SMBG supplies on self-care among patients with uncontrolled T2DM.

METHODS

This was a six-month, prospective study conducted in two primary care institutions. Patients ≥21 years old with uncontrolled T2DM (HbA1c > 7.0%) and polypharmacy (≥5 chronic medications) were included. All participants were given a free blood glucometer, test strips, and lancets, and were invited to consult pharmacists to learn about SMBG. The Summary of Diabetes Self-Care Activities questionnaire was administered at baseline and at six months.

RESULTS

A total of 167 patients were recruited and 150 (89.8%) completed the study. At six months, significant improvements from baseline were observed for overall self-care (+0.58, p = 0.008), glycemic control (-0.41%, p < 0.001) and all specific self-care activities. The mean change in the SMBG score in all the participants was found to have a strong positive correlation with the mean change in the overall self-care score (r_s = 0.580, p = 0.01).

CONCLUSIONS

Provision of SMBG supplies was effective in improving self-care among patients with uncontrolled T2DM, including non-insulin-treated patients.

The Impact of Structured Diabetes Education on Glycemic Control in Patients with Type 2 Diabetes at Initiation of Basal Insulin – The Basal-EDUC-RO Study: A Randomized Prospective Study

Background: Basal-EDUC-RO Study evaluated the impact of structured education provided at the initiation of basal insulin therapy on glycaemic control in patients with uncontrolled type 2 diabetes mellitus (T2D).

Methods: This was a prospective, multicenter, randomized, parallel group study (ACTRN12616001273471) which enrolled 711 patients initiated on insulin therapy with a basal insulin analogue. The subjects were randomized (1:1) to either structured education (structured education group; 353 patients) or standard education (control group; 358 patients) and followed for 6 months.

Results: The median HbA1c levels at 6 months after start of basal insulin were significantly lower in the structured education group than in the control group (7.2% vs. 7.4%, p <0.001). In the structured education group, 49.4% of subjects achieved HbA1c targets vs. 34.4% in the control group, p <0.001. Number of documented symptomatic hypoglycemic episodes (all and nocturnal) was lower in the intervention group (139 vs. 217 for all episodes and 13 vs. 26 for nocturnal hypoglycemia) but with no statistical significance. No effect of intervention was seen on body weight, but there was no weight gain in any of the groups at 6 months.

Conclusions: A structured diabetes education program delivered to patients with T2D started on a basal insulin analogue significantly improved glucose control at 6 months compared to a less intense education strategy. The positive effect was mainly seen on the percentage of patients who achieved individualized HbA1c pre-set targets, with a non-significant reduction in episodes of overall and nocturnal documented symptomatic hypoglycemia.

Integrated personalized diabetes management improves glycemic control in patients with insulin-treated type 2 diabetes: Results of the PDM-ProValue study program

AIMS

Globally, many patients with insulin-treated type-2 diabetes are suboptimally controlled. The PDM-ProValue study program evaluated whether integrated personalized diabetes management (iPDM) has the potential to improve clinical outcomes.

METHODS

101 practices with 907 patients participated in the 12-month, prospective, controlled, cluster-randomized study program. HbA1c levels, therapy changes, frequency of hypoglycemic episodes, patient reported outcomes, and physician satisfaction were assessed.

RESULTS

iPDM led to a greater reduction in HbA1c after 12 months vs. usual care (-0.5%, p < 0.0001 vs. -0.3%, p < 0.0001), (Diff. 0.2%, p = 0.0324). Most of the HbA1c reduction occurred after 3 months and remained stable thereafter. The percentage of patients with therapy adjustments was higher in the iPDM group at all visits (p < 0.01 at week 3, month 3, month 6). Patient adherence at month 12 was higher in the iPDM group compared to baseline (Odds ratio = 2.39; p = 0.0003); also, patient treatment satisfaction (DTSQc: 12.2 vs. 10.4, δ = 1.78, p = 0.004; DTSQs: 31.0 vs. 30.0, δ = 0.924, p = 0.02), and physician satisfaction was higher in the intervention group.

CONCLUSIONS

iPDM improved the use of diagnostic data leading to better glycemic control, more timely treatment adjustments (indicating reduced clinical inertia), and increased patient adherence and treatment satisfaction among patients and physicians.

Hypoglycaemia Remains the Key Obstacle to Optimal Glycaemic Control - Continuous Glucose Monitoring is the Solution

We queried PubMed and other internet databases to identify studies, meta-analyses, review articles and other data sources regarding hypoglycaemia incidence/costs/impacts and continuous glucose monitoring (CGM) use. Our analysis of the evidence showed that hypoglycaemia remains a significant health concern and a primary obstacle to optimal adherence to prescribed diabetes treatment. In addition to its adverse clinical consequences, hypoglycaemia negatively impacts quality of life and places additional financial burdens on patients, patient families, employers and healthcare payers. Clinical trials have shown that the use of CGM can reduce the incidence and duration of hypoglycaemic episodes. This article reviews relevant CGM studies, discusses the prevalence and clinical/financial implications of hypoglycaemia, and explores the strengths and limitations of current CGM systems in minimising the burden of hypoglycaemia.

Contribution of Structured Self-Monitoring of Blood Glucose to the Glycemic Control and the Quality of Life in Both Insulin- and Noninsulin-Treated Patients with Poorly Controlled Diabetes

BACKGROUND

The rate of glycemic control among diabetes patients in China is currently low. The current study aims at determining the effect of structured self-monitoring of blood glucose (SMBG) on blood glucose control as well as quality of life (QoL) in Chinese diabetes patients.

METHODS

In a 24-week, single-center, randomized, open-label, prospective trial, patients with glycated hemoglobin A_1c (HbA_1c) >8.0% were randomized to an intervention group for structured SMBG (n = 121) or a control group (n = 129). Patient data were analyzed separately according to treatment with or without insulin. At 0, 3rd, and 6th months, life satisfaction was assessed using the Chinese Normal Audit of Diabetes-Dependent Quality of Life (CN-ADDQoL) questionnaire.

RESULTS

The mean HbA_1c decrease from baseline to the study end was significant for both groups with insulin treatment (intervention group: -1.79% ± 1.97%, P < 0.001; control group: -1.05% ± 1.87%, P < 0.001) or without insulin treatment (intervention group: -1.91% ± 1.90%, P < 0.001; control group: -1.35% ± 1.82%, P < 0.001). Moreover, the insulin-treated patients in the intervention group showed a significantly more robust HbA_1c decrease than those in the control group (P = 0.007). Both therapeutic subgroups in the intervention group had a significantly higher frequency of SMBG than those in the control group (P < 0.001), but no strict deterioration of the QoL was detected. In addition, a significant HbA_1c reduction after 6 months of SMBG was seen for both insulin-treated patients (P = 0.027) and noninsulin-treated patients (P = 0.006) younger than 66 years.

CONCLUSIONS

Featured with no strict deterioration of QoL, structured SMBG was proven to be effective on the glycemic control in patients with insulin treatment, as well as in young and middle-aged patients without insulin treatment.

Evidence-based recommendations for insulin intensification strategies after basal insulin in type 2 diabetes

Over the time due to progressive nature of diabetes, proactive intensification of the existing insulin therapy becomes imminent as it minimizes patients' exposure to chronic hypo/hyperglycaemia and reduces weight gain while achieving individualized glycaemic targets. This review focuses on the strength of evidence behind various options for intensification, primarily the insulins as also the GLP-1 analogues. The recommendations presented here are meant to serve as a guide for the physician managing type 2 diabetes patients requiring insulin intensification upon failing of basal insulin therapy.

Use of an Integrated Tool for Interpretation of Blood Glucose Data Improves Correctness of Glycemic Risk Assessment in Individuals With Type 1 and Type 2 Diabetes

BACKGROUND

Manufacturers now incorporate blood glucose (bG) value interpretation tools into their monitoring systems; however, usability of these support tools has not been well studied. We evaluated the utility and perceived benefits of support tool use by individuals with type 1 (T1D) and type 2 diabetes (T2D).

METHODS

This 3-arm, randomized, simulation study assessed the impact of use of bG value interpretation support tools on participants' ability to correctly interpret bG values, using 1 of 3 tools: a new tool that uses colored scales with target range indicator (TRI), Colors and Smiley icons (already available). Participants assessed 50 bG values without use of any tool and repeated the assessment using 1 of the 3 tool configurations. Changes in percentage of correct responses when using a support tool and user perceptions were assessed.

RESULTS

Data sets from 140 participants were analyzed. Increases in correct responses were seen in all study groups but most notably in the TRI group (26%, P < .001) versus the Colors (3%, P = .018) and Smiley icons (6%, P < .001) groups. Significant improvements in confidence were seen among TRI users ( P = .023) but not among other tool users ( P > .627). Most TRI users felt confident (94%), agreed the tool will help them identify high and low values (96%) and will help them to make correct insulin dosage decisions (80%).

CONCLUSIONS

Use of the TRI significantly increases users' ability to correctly and confidently determine their glycemic risk when self-monitoring bG levels. This suggests the tool may offer clinical value to individuals with T1D and T2D.

Clinical and socio-demographic determinants of self-care behaviours in patients with heart failure and diabetes mellitus: A multicentre cross-sectional study

BACKGROUND

Self-care is vital for patients with heart failure to maintain health and quality of life, and it is even more vital for those who are also affected by diabetes mellitus, since they are at higher risk of worse outcomes. The literature is unclear on the influence of diabetes on heart failure self-care as well as on the influence of socio-demographic and clinical factors on self-care.

OBJECTIVES

(1) To compare self-care maintenance, self-care management and self-care confidence of patients with heart failure and diabetes versus those heart failure patients without diabetes; (2) to estimate if the presence of diabetes influences self-care maintenance, self-care management and self-care confidence of heart failure patients; (3) to identify socio-demographic and clinical determinants of self-care maintenance, self-care management and self-care confidence in patients with heart failure and diabetes.

DESIGN

Secondary analysis of data from a multicentre cross-sectional study.

SETTING

Outpatient clinics from 29 Italian provinces.

PARTICIPANTS

1192 adults with confirmed diagnosis of heart failure.

METHODS

Socio-demographic and clinical data were abstracted from patients' medical records. Self-care maintenance, self-care management and self-care confidence were measured with the Self-Care of Heart Failure Index Version 6.2; each scale has a standardized score from 0 to 100, where a score <70 indicates inadequate self-care. Multiple linear regression analyses were performed.

RESULTS

Of 1192 heart failure patients, 379 (31.8%) had diabetes. In these 379, heart failure self-care behaviours were suboptimal (means range from 53.2 to 55.6). No statistically significant differences were found in any of the three self-care measures in heart failure patients with and without diabetes. The presence of diabetes did not influence self-care maintenance (p=0.12), self-care management (p=0.21) or self-care confidence (p=0.51). Age (p=0.04), number of medications (p=0.01), presence of a caregiver (p=0.04), family income (p=0.009) and self-care confidence (p<0.001) were determinants of self-care maintenance. Gender (p=0.01), number of medications (p=0.004) and self-care confidence (p<0.001) were significant determinants of self-care management. Number of medications (p=0.002) and cognitive function (p<0.001) were determinants of self-care confidence.

CONCLUSIONS

Self-care was poor in heart failure patients with diabetes mellitus. This population needs more intensive interventions to improve self-care. Determinants of self-care in heart failure patients with diabetes mellitus should be systematically assessed by clinicians to identify patients at risk of inadequate self-care.

Psychosocial Predictors and Outcomes of Delayed Breast Reconstruction in Mastectomized Women in Mainland China: An Observational Study

Background

The aim of the present study was to evaluate potential psychosocial factors that impact Chinese female breast cancer patients to select breast reconstruction (BR), and potential connection of psychosocial outcomes with their satisfaction with BR.

Methods

A total of 264 female breast cancer patients with mastectomy were recruited from 2012 to 2014. All patients were informed with BR options at their first visit. Personal and medical profiles were collected. Body image, self-esteem, depression and anxiety were assessed using validated scales. Patients who were selected to undergo BR after the first visit were followed up for six months. The same assessment was performed at 6 months post BR, and their satisfaction with BR was evaluated using the Alderman scale. Multivariate linear and logistic regressions were performed.

Results

Forty-seven percent of the patients (126/264) opted to undergo BR within six months after the initial visit. Multivariate logistic regression analysis revealed that self-esteem (P < 0.05), body image (P < 0.01), education level (P < 0.05), and their husband’s recommendation (P < 0.05) were highly related to the patients’ decision to undergo BR. In addition, multivariate linear regression analysis showed that patient satisfaction with BR was significantly associated with preoperative body image (P < 0.01), postoperative improvement in self-esteem (P < 0.01), improvement in body image (P < 0.01), reduction in depression (P < 0.05), pain (P < 0.05), and scarring (P < 0.01).

Conclusions

The psychosocial factors including self-esteem and body image are highly related to selecting the BR option and post-BR satisfaction in Chinese female breast cancer patients.