Effects of an Electronic Medical Records-Linked Diabetes Self-Management System on Treatment Targets in Real Clinical Practice: Retrospective, Observational Cohort Study

BACKGRUOUND

This study evaluated the effects of a mobile diabetes management program called "iCareD" (College of Medicine, The Catholic University of Korea) which was integrated into the hospital's electronic medical records system to minimize the workload of the healthcare team in the real clinical practice setting.

METHODS

In this retrospective observational study, we recruited 308 patients. We categorized these patients based on their compliance regarding their use of the iCareD program at home; compliance was determined through self-monitored blood glucose inputs and message subscription rates. We analyzed changes in the ABC (hemoglobin A1c, blood pressure, and low-density lipoprotein cholesterol) levels from the baseline to 12 months thereafter, based on the patients' iCareD usage patterns.

RESULTS

The patients comprised 92 (30%) non-users, 170 (55%) poor-compliance users, and 46 (15%) good-compliance users; the ABC target achievement rate showed prominent changes in good-compliance groups from baseline to 12 months (10.9% vs. 23.9%, P<0.05), whereas no significant changes were observed for poor-compliance users and non-users (13.5% vs. 18.8%, P=0.106; 20.7% vs. 14.1%, P=0.201; respectively).

CONCLUSION

Implementing the iCareD can improve the ABC levels of patients with diabetes with minimal efforts of the healthcare team in real clinical settings. However, the improvement of patients' compliance concerning the use of the system without the vigorous intervention of the healthcare team needs to be solved in the future.

Optimal Coefficient of Variance Threshold to Minimize Hypoglycemia Risk in Individuals with Well-Controlled Type 1 Diabetes Mellitus

Background

This study investigated the optimal coefficient of variance (%CV) for preventing hypoglycemia based on real-time continuous glucose monitoring (rt-CGM) data in people with type 1 diabetes mellitus (T1DM) already achieving their mean glucose (MG) target.

Methods

Data from 172 subjects who underwent rt-CGM for at least 90 days and for whom 439 90-day glycemic profiles were available were analyzed. Receiver operator characteristic analysis was conducted to determine the cut-off value of %CV to achieve time below range (%TBR)<54 mg/dL <1 and =0.

Results

Overall mean glycosylated hemoglobin was 6.8% and median %TBR<54 mg/dL was 0.2%. MG was significantly higher and %CV significantly lower in profiles achieving %TBR<54 mg/dL <1 compared to %TBR<54 mg/dL ≥1 (all P<0.001). The cut-off value of %CV for achieving %TBR<54 mg/dL <1 was 37.5%, 37.3%, and 31.0%, in the whole population, MG >135 mg/dL, and ≤135 mg/dL, respectively. The cut-off value for %TBR<54 mg/dL=0% was 29.2% in MG ≤135 mg/dL. In profiles with MG ≤135 mg/dL, 94.2% of profiles with a %CV <31 achieved the target of %TBR<54 mg/dL <1, and 97.3% with a %CV <29.2 achieved the target of %TBR<54 mg/ dL=0%. When MG was >135 mg/dL, 99.4% of profiles with a %CV <37.3 achieved %TBR<54 mg/dL <1.

Conclusion

In well-controlled T1DM with MG ≤135 mg/dL, we suggest a %CV <31% to achieve the %TBR<54 mg/dL <1 target. Furthermore, we suggest a %CV <29.2% to achieve the target of %TBR<54 mg/dL =0 for people at high risk of hypoglycemia.

Determinants of diabetes self-care activities in patients with type 2 diabetes based on self-determination theory

AIMS

In type 2 diabetes control, self-management is an effective way to minimize the risk of developing complications and improve the quality of life. Self-determination theory (SDT) proposed a promising explanatory framework to predict self-regulated behavior which was particularly relevant for self-management. This study aimed to investigate whether SDT constructs can affect the self-management and controlling glycated hemoglobin A1c (HbA1c) levels in type 2 diabetic patients or not.

METHODS

This cross-sectional study was conducted from August to December 2022 at two diabetes clinics in Zahedan. The study included 300 patients with type 2 diabetes. Data collection was done using a researcher-administrated questionnaire that included demographic data, diabetes self-care activities, and self-determination constructs including autonomous support, autonomous motivation, and perceived competence.

RESULTS

The mean of the overall score of self-care activities was 34.62 ± 11.86 out of a maximum of 70. Patients in the fourth quarter (wealthiest) of the socioeconomic status had the highest mean self-care score (P = 0.003). There was a significant relationship between diet score with perceived competence (P = 0.009). Perceived competence (P<0.001) and controlled self-regulation (P<0.001) were the predictors of exercise score in diabetes patients. Independent self-regulation (P<0.001, r = 0.21) and overall self-regulation (P = 0.001, r = 0.19) were significantly related to blood-glucose testing score. There was a significant relationship between foot care score with perceived competence (P = 0.048, r = 0.11) and autonomous support (P = 0.013, r = 0.14). Multiple regression showed that exercise was the predictor of HbA1c (P = 0.014).

CONCLUSION

Exercise is crucial for achieving good individualized glycemic control and reducing the risk of diabetes complications. The findings provided valuable insights into the determinants of self-care activities in patients with type 2 diabetes and underscore the need for interventions that address socioeconomic disparities, enhance perceived competence, and provide autonomy support to improve diabetes self-care.

Clinical and Lifestyle Determinants of Continuous Glucose Monitoring Metrics in Insulin-Treated Patients with Type 2 Diabetes Mellitus

BACKGRUOUND

There was limited evidence to evaluate the association between lifestyle habits and continuous glucose monitoring (CGM) metrics. Thus, we aimed to depict the behavioral and metabolic determinants of CGM metrics in insulin-treated patients with type 2 diabetes mellitus (T2DM).

METHODS

This is a prospective observational study. We analyzed data from 122 insulin-treated patients with T2DM. Participants wore Dexcom G6 and Fitbit, and diet information was identified for 10 days. Multivariate-adjusted logistic regression analysis was performed for the simultaneous achievement of CGM-based targets, defined by the percentage of time in terms of hyper, hypoglycemia and glycemic variability (GV). Intake of macronutrients and fiber, step counts, sleep, postprandial C-peptide-to-glucose ratio (PCGR), information about glucose lowering medications and metabolic factors were added to the analyses. Additionally, we evaluated the impact of the distribution of energy and macronutrient during a day, and snack consumption on CGM metrics.

RESULTS

Logistic regression analysis revealed that female, participants with high PCGR, low glycosylated hemoglobin (HbA1c) and daytime step count had a higher probability of achieving all targets based on CGM (odds ratios [95% confidence intervals] which were 0.24 [0.09 to 0.65], 1.34 [1.03 to 1.25], 0.95 [0.9 to 0.99], and 1.15 [1.03 to 1.29], respectively). And participants who ate snacks showed a shorter period of hyperglycemia and less GV compared to those without.

CONCLUSION

We confirmed that residual insulin secretion, daytime step count, HbA1c, and women were the most relevant determinants of adequate glycemic control in insulin-treated patients with T2DM. In addition, individuals with snack consumption were exposed to lower times of hyperglycemia and GV.

Diabetes and blood glucose monitoring knowledge and practices among pharmacy professionals in Cambodia and Viet Nam: digital survey and education

BACKGROUND

In Southeast Asia, pharmacies are critical sources of healthcare advice for under-served communities, including those with/at risk of diabetes.

AIM

Explore knowledge/practices relating to diabetes and blood glucose monitoring (BGM) among pharmacy professionals in Cambodia and Viet Nam, using digital professional education to address gaps.

METHODS

An online survey was distributed to pharmacy professionals in Cambodia and Viet Nam registered on SwipeRx mobile application. Eligible participants dispensed medicines and/or were involved in purchasing products, and worked at retail pharmacies stocking ≥ 1 BGM product. An accredited continuing professional development module was then made available to pharmacy professionals and students on SwipeRx in both countries. After completing the 1-2 h module, users were required to correctly answer ≥ 60% (Cambodia) or ≥ 70% (Viet Nam) of knowledge assessment questions to achieve accreditation units from local partners.

RESULTS

Whereas 33% of survey respondents in Cambodia (N = 386) and 63% in Viet Nam (N = 375) reported performing blood glucose testing at the pharmacy, only 19% and 14% were aware that clients taking multiple daily doses of insulin should check blood glucose levels several times a day. Of 1,137 and 399 pharmacy professionals/students who completed the module and passed the assessment in Cambodia and Viet Nam, 1,124 (99%) and 376 (94%) received accreditation. Knowledge levels improved substantially in 10 of 14 learning areas in Cambodia and 6 of 10 in Viet Nam.

CONCLUSIONS

Digital education can strengthen pharmacy professional capacity to provide comprehensive and accurate information on diabetes management and the awareness of quality BGM products in Southeast Asia.

Glycemia according to the Use of Continuous Glucose Monitoring among Adults with Type 1 Diabetes Mellitus in Korea: A Real-World Study

BACKGROUND

We explored the association between continuous glucose monitoring (CGM) use and glycemia among adults with type 1 diabetes mellitus (T1DM) and determined the status of CGM metrics among adults with T1DM using CGM in the real-world.

METHODS

For this propensity-matched cross-sectional study, individuals with T1DM who visited the outpatient clinic of the Endocrinology Department of Samsung Medical Center between March 2018 and February 2020 were screened. Among them, 111 CGM users (for ≥9 months) were matched based on propensity score considering age, sex, and diabetes duration in a 1:2 ratio with 203 CGM never-users. The association between CGM use and glycemic measures was explored. In a subpopulation of CGM users who had been using official applications (not "do-it-yourself" software) such that Ambulatory Glucose Profile data for ≥1 month were available (n=87), standardized CGM metrics were summarized.

RESULTS

Linear regression analyses identified CGM use as a determining factor for log-transformed glycosylated hemoglobin. The fully-adjusted odds ratio (OR) and 95% confidence interval (CI) for uncontrolled glycosylated hemoglobin (>8%) were 0.365 (95% CI, 0.190 to 0.703) in CGM users compared to never-users. The fully-adjusted OR for controlled glycosylated hemoglobin (<7%) was 1.861 (95% CI, 1.119 to 3.096) in CGM users compared to never-users. Among individuals who had been using official applications for CGM, time in range (TIR) values within recent 30- and 90-day periods were 62.45%±16.63% and 63.08%±15.32%, respectively.

CONCLUSION

CGM use was associated with glycemic control status among Korean adults with T1DM in the real-world, although CGM metrics including TIR might require further improvement among CGM users.

High prevalence with no gender difference of likely eating disorders in type 1 mellitus diabetes on insulin pump

AIM

The aim of this study was to determine the prevalence of likely eating disorders and insulin misuse in a prospective cohort of adults with type 1 diabetes mellitus (T1DM) treated with insulin pump therapy.

METHODS

This prospective study was held at the participants' home. The participants completed the SCOFF questionnaire as well as a question related to insulin misuse. Information about lifestyle, medical history, insulin pump and Continuous Glucose Monitoring (CGM) data were collected.

RESULTS

The analysis covered 198 participants with a median age of 51 [95% CI 38; 62] years. The prevalence of likely eating disorders was 21.7% (95% CI 16.3; 28.2) in the study population and 20.6% (95% CI 14.3; 28.6) and 24.2% (95% CI 14.6; 37.0) in males and females respectively. The prevalence of insulin misuse was 39.0% (95% CI 30.8; 47.7). There was no significant difference in prevalence between males and females for likely eating disorders and insulin misuse. The analysis of CGM data revealed no factors related to glycaemic control associated with likely eating disorders.

CONCLUSION

The results of this study indicate that the prevalence of likely eating disorders is high even in a middle-aged population with a T1DM and satisfactory glucose control.

Advances in Continuous Glucose Monitoring and Integrated Devices for Management of Diabetes with Insulin-Based Therapy: Improvement in Glycemic Control

Continuous glucose monitoring (CGM) technology has evolved over the past decade with the integration of various devices including insulin pumps, connected insulin pens (CIPs), automated insulin delivery (AID) systems, and virtual platforms. CGM has shown consistent benefits in glycemic outcomes in type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) treated with insulin. Moreover, the combined effect of CGM and education have been shown to improve glycemic outcomes more than CGM alone. Now a CIP is the expected future technology that does not need to be worn all day like insulin pumps and helps to calculate insulin doses with a built-in bolus calculator. Although only a few clinical trials have assessed the effectiveness of CIPs, they consistently show benefits in glycemic outcomes by reducing missed doses of insulin and improving problematic adherence. AID systems and virtual platforms made it possible to achieve target glycosylated hemoglobin in diabetes while minimizing hypoglycemia, which has always been challenging in T1DM. Now fully automatic AID systems and tools for diabetes decisions based on artificial intelligence are in development. These advances in technology could reduce the burden associated with insulin treatment for diabetes.

Comparison of Laser and Conventional Lancing Devices for Blood Glucose Measurement Conformance and Patient Satisfaction in Diabetes Mellitus

Self-monitoring of capillary blood glucose is important for controlling diabetes. Recently, a laser lancing device (LMT-1000) that can collect capillary blood without skin puncture was developed. We enrolled 150 patients with type 1 or 2 diabetes mellitus. Blood sampling was performed on the same finger on each hand using the LMT-1000 or a conventional lancet. The primary outcome was correlation between glucose values using the LMT-1000 and that using a lancet. And we compared the pain and satisfaction of the procedures. The capillary blood sampling success rates with the LMT-1000 and lancet were 99.3% and 100%, respectively. There was a positive correlation (r=0.974, P<0.001) between mean blood glucose levels in the LMT-1000 (175.8±63.0 mg/dL) and conventional lancet samples (172.5±63.6 mg/dL). LMT-1000 reduced puncture pain by 75.0% and increased satisfaction by 80.0% compared to a lancet. We demonstrated considerable consistency in blood glucose measurements between samples from the LMT-1000 and a lancet, but improved satisfaction and clinically significant pain reduction were observed with the LMT-1000 compared to those with a lancet.

Glucose Profiles Assessed by Intermittently Scanned Continuous Glucose Monitoring System during the Perioperative Period of Metabolic Surgery

BACKGROUND

Continuous glucose monitoring (CGM) has been widely used in the management of diabetes. However, the usefulness and detailed data during perioperative status were not well studied. In this study, we described the immediate changes of glucose profiles after metabolic surgery using intermittently scanned CGM (isCGM) in individuals with type 2 diabetes mellitus (T2DM).

METHODS

This was a prospective, single-center, single-arm study including 20 participants with T2DM. The isCGM (FreeStyle Libre CGM) implantation was performed within 2 weeks before surgery. We compared CGM metrics of 3 days before surgery and 3 days after surgery, and performed the correlation analyses with clinical variables.

RESULTS

The mean glucose significantly decreased after surgery (147.0±40.4 to 95.5±17.1 mg/dL, P<0.001). Time in range (TIR; 70 to 180 mg/dL) did not significantly change after surgery in total. However, it was significantly increased in a subgroup of individuals with glycosylated hemoglobin (HbA1c) ≥8.0%. Time above range (>250 or 180 mg/dL) was significantly decreased in total. In contrast, time below range (<70 or 54 mg/dL) was significantly increased in total and especially in a subgroup of individuals with HbA1c <8.0% after surgery. The coefficient of variation significantly decreased after surgery. Higher baseline HbA1c was correlated with greater improvement in TIR (rho=0.607, P=0.005).

CONCLUSION

The isCGM identified improvement of mean glucose and glycemic variability, and increase of hypoglycemia after metabolic surgery, but TIR was not significantly changed after surgery. We detected an increase of TIR only in individuals with HbA1c ≥8.0%.

Driving with Type 1 Diabetes: Real-World Evidence to Support Starting Glucose Level and Frequency of Monitoring During Journeys

There is limited evidence supporting the recommendation that drivers with insulin-treated diabetes need to start journeys with glucose >90 mg/dL. Glucose levels of drivers with type 1 diabetes were monitored for 3 weeks using masked continuous glucose monitoring (CGM). Eighteen drivers (median [IQR] age 40 [35, 51] years; 11 men) undertook 475 trips (duration 15 [13, 21] min). Hypoglycemia did not occur in any trip starting with glucose >90 mg/dL (92%; n = 436). Thirteen drivers recorded at least one trip (total n = 39) starting with glucose <90 mg/dL. Among these, driving glucose was <70 mg/dL in five drivers (38%) during 10 trips (26%). Among five drivers (28%), a ≥ 36 mg/dL drop was observed within 20 min of starting their journey. Journey duration was positively associated with maximum glucose change. These findings support current guidelines to start driving with glucose >90 mg/dL, and to be aware that glucose levels may change significantly within 20 min. A CGM-based, in-vehicle display could provide glucose information and alerts that are compatible with safe driving. Clinical Trial Registration number: ACTRN12617000520336.

Impact of flash glucose monitoring on quality of life and glycaemic control parameters in adults with type 1 diabetes mellitus⋆

INTRODUCTION

Flash glucose monitoring (FGM) improves some glycaemic control variables and quality of life parameters.

OBJECTIVE

Our aim was to evaluate the quality of life and glycaemic control parameters after initiating FGM in patients with type 1 diabetes (DM1) in clinical practice.

MATERIAL AND METHODS

A prospective observational study in DM1 patients that started using FGM between June 2019 and April 2020. We analysed their scores on the Diabetes Quality of Life (DQOL) questionnaire, Diabetes Distress Scale (DDS), Diabetes Treatment Satisfaction Questionnaire (DTSQ) and glycaemic control parameters at baseline and 3 months after the FGM onset.

RESULTS

We recruited 114 patients, 56% male, mean age 37.2 (standard deviation, SD 12.4), with 18.7 (SD 11.5) years of DM1, 24.6% of which used continuous subcutaneous insulin infusion. Differences were observed (baseline vs. 3 months) in the DTSQ score (22 [15.5-27] vs. 25 [22-28], P < 0.001) and in the DQOL score (88 [74-104] vs. 84 [70-101], P = 0.017) but not in the DDS score. HbA1c was 7.8% (SD 1.3) vs. 7.4% (SD 1.1) (P < 0.001), without improvement in other glycaemic control variables, except for the mean number of hypoglycaemic events/14 days: 14 (SD 9) at baseline vs. 11.5 (SD 7) at 3 months (P < 0.001).

CONCLUSIONS

The initiation of FGM, combined with a structured educational programme, was associated with improvement in quality of life and patient satisfaction in DM1 patients. An improvement in HbA1c and a reduction in the number of hypoglycaemia events was observed, but not in the rest of glycaemic control parameters.

Effects of Teneligliptin on HbA1c levels, Continuous Glucose Monitoring-Derived Time in Range and Glycemic Variability in Elderly Patients with T2DM (TEDDY Study)

BACKGROUND

To evaluate the effects of teneligliptin on glycosylated hemoglobin (HbA1c) levels, continuous glucose monitoring (CGM)-derived time in range, and glycemic variability in elderly type 2 diabetes mellitus patients.

METHODS

This randomized, double-blinded, placebo-controlled study was conducted in eight centers in Korea (clinical trial registration number: NCT03508323). Sixty-five participants aged ≥65 years, who were treatment-naïve or had been treated with stable doses of metformin, were randomized at a 1:1 ratio to receive 20 mg of teneligliptin (n=35) or placebo (n=30) for 12 weeks. The main endpoints were the changes in HbA1c levels from baseline to week 12, CGM metrics-derived time in range, and glycemic variability.

RESULTS

After 12 weeks, a significant reduction (by 0.84%) in HbA1c levels was observed in the teneligliptin group compared to that in the placebo group (by 0.08%), with a between-group least squares mean difference of -0.76% (95% confidence interval [CI], -1.08 to -0.44). The coefficient of variation, standard deviation, and mean amplitude of glycemic excursion significantly decreased in participants treated with teneligliptin as compared to those in the placebo group. Teneligliptin treatment significantly decreased the time spent above 180 or 250 mg/dL, respectively, without increasing the time spent below 70 mg/dL. The mean percentage of time for which glucose levels remained in the 70 to 180 mg/dL time in range (TIR70-180) at week 12 was 82.0%±16.0% in the teneligliptin group, and placebo-adjusted change in TIR70-180 from baseline was 13.3% (95% CI, 6.0 to 20.6).

CONCLUSION

Teneligliptin effectively reduced HbA1c levels, time spent above the target range, and glycemic variability, without increasing hypoglycemia in our study population.

Real-World Analysis of Therapeutic Outcome in Type 1 Diabetes Mellitus at a Tertiary Care Center

Insulin replacement in type 1 diabetes mellitus (T1DM) needs intensified treatment, which can either be performed by multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII). This retrospective analysis of a real-world scenario aimed to evaluate whether glycaemic and cardiovascular risk factors could be controlled with CSII outclass MDI as suggested by recent evidence. Data from patients with either insulin pump (n=68) or injection (n=224) therapy at an Austrian tertiary care centre were analysed between January 2016 and December 2017. There were no significant differences with regard to the latest glycosylated hemoglobin, cardiovascular risk factor control or diabetes-associated late complications. Hypoglycaemia was less frequent (P<0.001), sensor-augmented therapy was more common (P=0.003) and mean body mass index (BMI) was higher (P=0.002) with CSII treatment. This retrospective analysis of real-world data in T1DM did not demonstrate the superiority of insulin pump treatment with regard to glycaemic control or cardiovascular risk factor control.

Efficacy and Safety of Self-Titration Algorithms of Insulin Glargine 300 units/mL in Individuals with Uncontrolled Type 2 Diabetes Mellitus (The Korean TITRATION Study): A Randomized Controlled Trial

BACKGROUND

To compare the efficacy and safety of two insulin self-titration algorithms, Implementing New Strategies with Insulin Glargine for Hyperglycemia Treatment (INSIGHT) and EDITION, for insulin glargine 300 units/mL (Gla-300) in Korean individuals with uncontrolled type 2 diabetes mellitus (T2DM).

METHODS

In a 12-week, randomized, open-label trial, individuals with uncontrolled T2DM requiring basal insulin were randomized to either the INSIGHT (adjusted by 1 unit/day) or EDITION (adjusted by 3 units/week) algorithm to achieve a fasting self-monitoring of blood glucose (SMBG) in the range of 4.4 to 5.6 mmol/L. The primary outcome was the proportion of individuals achieving a fasting SMBG ≤5.6 mmol/L without noct urnal hypoglycemia at week 12.

RESULTS

Of 129 individuals (age, 64.1±9.5 years; 66 [51.2%] women), 65 and 64 were randomized to the INSIGHT and EDITION algorithms, respectively. The primary outcome of achievement was comparable between the two groups (24.6% vs. 23.4%, P=0.876). Compared with the EDITION group, the INSIGHT group had a greater reduction in 7-point SMBG but a similar decrease in fasting plasma glucose and glycosylated hemoglobin. The increment of total daily insulin dose was significantly higher in the INSIGHT group than in the EDITION group (between-group difference: 5.8±2.7 units/day, P=0.033). However, body weight was significantly increased only in the EDITION group (0.6±2.4 kg, P=0.038). There was no difference in the occurrence of hypoglycemia between the two groups. Patient satisfaction was significantly increased in the INSIGHT group (P=0.014).

CONCLUSION

The self-titration of Gla-300 using the INSIGHT algorithm was effective and safe compared with that using the EDITION algorithm in Korean individuals with uncontrolled T2DM (ClinicalTrials.gov number: NCT03406663).

Current Advances of Artificial Pancreas Systems: A Comprehensive Review of the Clinical Evidence

Since Banting and Best isolated insulin in the 1920s, dramatic progress has been made in the treatment of type 1 diabetes mellitus (T1DM). However, dose titration and timely injection to maintain optimal glycemic control are often challenging for T1DM patients and their families because they require frequent blood glucose checks. In recent years, technological advances in insulin pumps and continuous glucose monitoring systems have created paradigm shifts in T1DM care that are being extended to develop artificial pancreas systems (APSs). Numerous studies that demonstrate the superiority of glycemic control offered by APSs over those offered by conventional treatment are still being published, and rapid commercialization and use in actual practice have already begun. Given this rapid development, keeping up with the latest knowledge in an organized way is confusing for both patients and medical staff. Herein, we explore the history, clinical evidence, and current state of APSs, focusing on various development groups and the commercialization status. We also discuss APS development in groups outside the usual T1DM patients and the administration of adjunct agents, such as amylin analogues, in APSs.

Less Nocturnal Hypoglycemia but Equivalent Time in Range Among Adults with Type 1 Diabetes Using Insulin Pumps Versus Multiple Daily Injections

Background: This prerandomization analysis from the Australian HCL-Adult trial (registration number: ACTRN12617000520336) compared masked continuous glucose monitoring (CGM) metrics among adults using insulin pumps versus multiple daily injections (MDIs), who were all self-monitoring blood glucose (SMBG). Methods: Adults with type 1 diabetes, using an insulin pump or MDIs without real-time CGM (and entering a trial of closed-loop technology), were eligible. MDI users were given an insulin dosage calculator. All participants received diabetes and carbohydrate-counting education, then wore masked CGM sensors for 3 weeks. Ethics Approval: HREC-D 088/16 Results: Adults using MDIs (n = 61) versus pump (n = 59) did not differ by age, sex, diabetes duration, insulin total daily dose, or HbA_1c at baseline. After education, median (interquartile range) CGM time in range (TIR) 70-180 mg/dL (3.9-10.0 mmol/L) was 54% (47, 62) for those using MDIs and 56% (48, 66) for those using pump (P = 0.40). All CGM metrics were equivalent for 24 h/day for MDI and pump users. Overnight, those using MDIs (vs. pump) spent more time with glucose <54 mg/dL (<3.0 mmol/L): 1.4% (0.1, 5.1) versus 0.5% (0.0, 2.0), respectively (P = 0.012). They also had more CGM hypoglycemia episodes (121 vs. 54, respectively; incidence rate ratio [95% confidence interval] 2.48 [1.51, 4.06]; P < 0.001). Conclusions: Adults with type 1 diabetes using pumps versus MDIs in conjunction with SMBG experienced less nocturnal hypoglycemia, measured by masked CGM, after equivalent diabetes and dietary education in conjunction with insulin dosage calculator provision to all. However, both groups had equivalent TIR. This observation may reflect advantages afforded by flexibility in basal insulin delivery provided by pumps.

Non-invasive and minimally invasive glucose monitoring devices: a systematic review and meta-analysis on diagnostic accuracy of hypoglycaemia detection

BACKGROUND

The use of minimally and non-invasive monitoring systems (including continuous glucose monitoring) has increased rapidly over recent years. Up to now, it remains unclear how accurate devices can detect hypoglycaemic episodes. In this systematic review and meta-analysis, we assessed the diagnostic accuracy of minimally and non-invasive hypoglycaemia detection in comparison to capillary or venous blood glucose in patients with type 1 or type 2 diabetes.

METHODS

Clinical Trials.gov, Cochrane Library, Embase, PubMed, ProQuest, Scopus and Web of Science were systematically searched. Two authors independently screened the articles, extracted data using a standardised extraction form and assessed methodological quality using a review-tailored quality assessment tool for diagnostic accuracy studies (QUADAS-2). The diagnostic accuracy of hypoglycaemia detection was analysed via meta-analysis using a bivariate random effects model and meta-regression with regard to pre-specified covariates.

RESULTS

We identified 3416 nonduplicate articles. Finally, 15 studies with a total of 733 patients were included. Different thresholds for hypoglycaemia detection ranging from 40 to 100 mg/dl were used. Pooled analysis revealed a mean sensitivity of 69.3% [95% CI: 56.8 to 79.4] and a mean specificity of 93.3% [95% CI: 88.2 to 96.3]. Meta-regression analyses showed a better hypoglycaemia detection in studies indicating a higher overall accuracy, whereas year of publication did not significantly influence diagnostic accuracy. An additional analysis shows the absence of evidence for a better performance of the most recent generation of devices.

CONCLUSION

Overall, the present data suggest that minimally and non-invasive monitoring systems are not sufficiently accurate for detecting hypoglycaemia in routine use.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2018 CRD42018104812.

Comparison of Fingertip vs Palm Site Sampling on Pain Perception, and Variation in Capillary Blood Glucose Level among Patients with Diabetes Mellitus

Introduction: Glycaemic status of the patient is often monitored using capillary blood glucose test which is fairly accurate. Traditional finger stick sampling is done to obtain sample, which can be painful and may be a barrier for repeated testing. The current study was conducted to compare fingertip and palm site sampling on pain perception, and variation in capillary blood glucose level. Methods: This study was conducted among 284 diabetic patients, who were selected by convenience sampling method. The data was collected by measuring capillary blood glucose levels from fingertip and palm site of the left hand at an interval of 10 minutes using a standard glucometer. The level of pain perceptions was measured with a numerical rating pain scale. Data analysis was accomplished using descriptive analysis, Mann-Whitney U test and Kruskal- Wallis test. Results: The level of pain perception at the palm site (2) was lesser than fingertip (3) which was significant at P < 0.001. 223 (78.52%) of the participants experienced more pain at fingertip than palm site, the difference in the measured capillary blood glucose level between fingertip [mean (SD): 226.65 (87.86)] and palm site [mean (SD): 225.65(92.13)] was minimum. The agreement of palm site was 90.7% in single measurement and 95.1% in average measurement. Conclusion: The present study concludes that, majority of the participants experienced less pain perception at the palm site sampling (alternate site sampling) than fingertip sampling with very minimal variation in the blood glucose level.

Time in Range from Continuous Glucose Monitoring: A Novel Metric for Glycemic Control

Glycosylated hemoglobin (HbA1c) has been the sole surrogate marker for assessing diabetic complications. However, consistently reported limitations of HbA1c are that it lacks detailed information on short-term glycemic control and can be easily interfered with by various clinical conditions such as anemia, pregnancy, or liver disease. Thus, HbA1c alone may not represent the real glycemic status of a patient. The advancement of continuous glucose monitoring (CGM) has enabled both patients and healthcare providers to monitor glucose trends for a whole single day, which is not possible with HbA1c. This has allowed for the development of core metrics such as time spent in time in range (TIR), hyperglycemia, or hypoglycemia, and glycemic variability. Among the 10 core metrics, TIR is reported to represent overall glycemic control better than HbA1c alone. Moreover, various evidence supports TIR as a predictive marker of diabetes complications as well as HbA1c, as the inverse relationship between HbA1c and TIR reveals. However, there are more complex relationships between HbA1c, TIR, and other CGM metrics. This article provides information about 10 core metrics with particular focus on TIR and the relationships between the CGM metrics for comprehensive understanding of glycemic status using CGM.

Current status of continuous glucose monitoring among Korean children and adolescents with type 1 diabetes mellitus

Type 1 diabetes mellitus (T1DM) requires life-long insulin therapy because of diminished insulin-secretion capability. Glycemic control and glucose monitoring are important to prevent T1DM complications. Continuous glucose monitoring (CGM) measures glucose level, every one to five minutes, in the interstitial fluid from a subcutaneous sensor and facilitates better glycemic control, reduces hypoglycemia, and is safely used in the pediatric population. CGM can be categorized as retrospective, real-time, or intermittently scanned CGM, and all forms are available in Korea. The CGM device has 3 components: sensor, transmitter, and monitor/receiver. Key metrics of CGM include days of CGM application, percentage of time with CGM, mean glucose, glucose management indicator, glycemic variability, and use of Ambulatory Glucose Profile for CGM reports. CGM sensors and transmitters have been partly reimbursed by the Korean National Health Insurance Service (NHIS) since 2019, and 1,434 T1DM patients (male, 40.8%; age <20 years, 52.4%) in Korea were prescribed CGM as of December 2019. In Korea, the number of CGM users will increase due to reimbursement for CGM sensors and transmitters by the NHIS. Successful CGM use requires long-term policies to establish diabetes education and financial assistance. Clinicians should become well-acquainted with interpretation of CGM data and information updates to facilitate integration of CGM data into clinical practice among pediatric T1DM patients.

Lessons from Use of Continuous Glucose Monitoring Systems in Digital Healthcare

We live in a digital world where a variety of wearable medical devices are available. These technologies enable us to measure our health in our daily lives. It is increasingly possible to manage our own health directly through data gathered from these wearable devices. Likewise, healthcare professionals have also been able to indirectly monitor patients' health. Healthcare professionals have accepted that digital technologies will play an increasingly important role in healthcare. Wearable technologies allow better collection of personal medical data, which healthcare professionals can use to improve the quality of healthcare provided to the public. The use of continuous glucose monitoring systems (CGMS) is the most representative and desirable case in the adoption of digital technology in healthcare. Using the case of CGMS and examining its use from the perspective of healthcare professionals, this paper discusses the necessary adjustments required in clinical practices. There is a need for various stakeholders, such as medical staff, patients, industry partners, and policy-makers, to utilize and harness the potential of digital technology.

Teaching people to eat according to appetite - Does the method of glucose measurement matter?

BACKGROUND

Hunger training teaches people to eat according to their appetite using pre-prandial glucose measurement. Previous hunger training interventions used fingerprick blood glucose, however continuous glucose monitoring (CGM) offers a painless and convenient form of glucose monitoring. The aim of this randomised feasibility trial was to compare hunger training using CGM with fingerprick glucose monitoring in terms of adherence to the protocol, acceptability, weight, body composition, HbA1c, psychosocial variables, and the relationship between adherence measures and weight loss.

METHODS

40 adults with obesity were randomised to either fingerpricking or scanning with a CGM and followed identical interventions for 6 months, which included 1 month of only eating when glucose was under their individualised glucose cut-off. For months 2-6 participants relied on their sensations of hunger to guide their eating and filled in a booklet.

RESULTS

90% of the fingerpricking group and 85% of the scanning group completed the study. Those using the scanner measured their glucose an extra 1.9 times per day (95% CI 0.9, 2.8, p < 0.001) compared with those testing by fingerprick. Both groups lost similar amounts of weight over 6 months (on average 4 kg), were satisfied with the hunger training program and wanted to measure their glucose again within the next year. There were no differences between groups in terms of intervention acceptability, weight, body composition, HbA1c, eating behaviours, or psychological health. Frequency of glucose testing and booklet entry both predicted a clinically meaningful amount of weight loss.

CONCLUSIONS

Either method of measuring glucose is effective for learning to eat according to hunger using the hunger training program. As scanning with a CGM encouraged better adherence to the protocol without sacrificing outcome results, future interventions should consider using this new technology in hunger training programs.

Barriers and facilitators of self-monitoring of blood glucose engagement among women with gestational diabetes mellitus in China: A mixed-methods study

BACKGROUND

Self-monitoring of blood glucose (SMBG) is a crucial tool for maintaining glycemic control in women with gestational diabetes mellitus (GDM). However, to date, little is known about the current status of SMBG engagement among women with GDM in China.

OBJECTIVE

To describe the current status of SMBG engagement among women with GDM in China and identify its barriers and facilitators.

DESIGN AND SETTING

A mixed-methods design was conducted, comprising a cross-sectional survey and semi-structured interviews. The research data were collected in two tertiary hospitals in Hunan province, China.

PARTICIPANTS

A total of 323 women with GDM completed the survey from March 2018 to October 2018, and 11 of them participated in the interviews.

FINDING

In total, 35.6% of the participants actively engaged in SMBG. The participants who had an advanced maternal age (95% CI 0.253-0.947), did not own glucose meters (95% CI 0.054-0.364), did not receive SMBG-related information from health professionals (95% CI 0.232-.987), or received less SMBG information in general (95% CI 0.137-0.52) were less likely to engage in SMBG. Insufficient SMBG information and low awareness of SMBG were also summarized as the main barriers in the interview findings. Facilitators of SMBG engagement included SMBG-related social support (95% CI 1.573-6.135) and health concerns related to themselves and the unborn infant.

CONCLUSION

About one-third of Chinese women with GDM engaged in SMBG. An accurate and complete description of how SMBG should be performed is needed from health professionals. Strategies to obtain more SMBG-related social support and a greater emphasis on health concerns are recommended to increase SMBG engagement among women with GDM in China.

Accuracy and user performance evaluation of a blood glucose monitoring system which wirelessly transmits results to compatible insulin pumps

Objective: To perform evaluations of the CONTOUR PLUS LINK 2.4 blood glucose monitoring system (BGMS) assessed according to ISO 15197:2013 criteria.Methods: Clinical trial registered at ClinicalTrials.gov (NCT01824355). In a laboratory study (Study 1), capillary fingertip blood samples from 100 subjects were evaluated in duplicate, using three test strip lots. In a clinical trial (Study 2), 113 adults with diabetes were enrolled, and BGMS results and Yellow Springs Instruments (YSI) analyzer reference measurements were compared for subject- and trial staff-obtained fingertip blood and subject-obtained palm blood. Subjects completed a questionnaire to evaluate BGMS ease of use.Results: In Study 1, 100% of combined results (all test strip lots) fulfilled ISO 15197:2013 section 6.3 criteria. In Study 2, 97.7% of subject-obtained fingertip results and 100% of trial staff-obtained fingertip results met ISO 15197:2013 section 8 criteria. Additionally, 93.8% of palm results were within ± 15 mg/dL of mean YSI measurements for glucose concentrations <100 mg/dL or ± 15% for glucose concentrations ≥100 mg/dL. Most subjects found the BGMS easy to use. There were three non-serious, non-device related adverse events.Conclusion: The BGMS exceeded minimum ISO 15197:2013-specified accuracy criteria in the laboratory and in the hands of lay users with diabetes.

Determinants of the persistency of macrosomia and shoulder dystocia despite treatment of gestational diabetes mellitus

Aims

to identify potentially modifiable risk factors associated with the persistency of macrosomia and/or shoulder dystocia in infants born to women treated for gestational diabetes mellitus (GDM).

Methods

this case-control retrospective study included 113 cases complicated by macrosomia (ponderal index ≥97^th percentile) and/or shoulder dystocia, and 226 controls without these complications. Factors associated with macrosomia and/or shoulder dystocia and with failure of diabetes management were assessed by multivariable analyses.

Results

Macrosomia and/or shoulder dystocia were associated with previous delivery of a large for gestational age (LGA) infant (adjusted odds ratio, 2.34, 95% confidence interval [1.01–5.45]), three abnormal glucose values during oral glucose tolerance test (2.83 [1.19–6.72]), a higher gestational weight gain before treatment (1.08 [1.01–1.15]), and failure of diabetes management (2.68 [1.32–5.45]). A non-Euro Caucasian origin (3.08 [1.37–6.93]), previous delivery of a LGA infant (3.21 [1.31–7.87]), institution of treatment after 32 weeks of gestation (3.92 [1.86–8.25]), and insulin therapy (2.91 [1.20–7.03]) were associated with failure of diabetes management.

Conclusions

supportive care in at risk women, limitation of weight gain in early pregnancy, shortened delay between diagnosis and treatment of GDM, and intensive insulin dosage adjustments might be means to improve the neonatal prognosis of GDM.

Impact of Switching from Twice-Daily Basal Insulin to Once-Daily Insulin Glargine 300 U/mL in People with Type 1 Diabetes on Basal-Bolus Insulin: Phase 4 OPTIMIZE Study

INTRODUCTION

OPTIMIZE evaluated the efficacy, safety and treatment satisfaction of insulin glargine 300 U/mL once daily (Gla-300 OD) in people with type 1 diabetes mellitus (T1DM) previously uncontrolled on basal insulin twice daily (BID) as part of basal-bolus therapy.

METHODS

OPTIMIZE was a 28-week, prospective, interventional, single-arm phase 4 trial in adults with T1DM. At baseline, basal insulin BID treatment was switched to Gla-300 OD titrated to a fasting self-monitored blood glucose target of 4.4-7.2 mmol/L (80-130 mg/dL). The primary endpoint was the mean glycated haemoglobin (HbA_1c) change from baseline to week 24. Secondary endpoints included self-monitored blood glucose, fasting-plasma glucose, hypoglycaemia and patient-reported outcomes including the Diabetes Treatment Satisfaction Questionnaire status version (DTSQs).

RESULTS

Switching to Gla-300 OD significantly improved mean HbA_1c (8.54% at baseline and 8.27% at week 24 [last observation carried forward, N = 94, p < 0.0001]; mean difference 0.27% [95% CI 0.15, 0.40]). There was a statistically significant decrease in fasting self-monitored blood glucose during the study (analysis of variance for repeated measures, p = 0.014; N = 72). Eight-point self-monitored blood glucose was significantly improved between baseline and week 24 for post-breakfast (p = 0.009), post-dinner (p = 0.009) and bedtime (p = 0.049) values. The study did not allow for any significant effects on confirmed and/or severe hypoglycaemia at the ≤ 3.9 mmol/L [≤ 70 mg/dL] or < 3.0 mmol/L [< 54 mg/dL] blood glucose cut-offs to be observed. Statistically significant improvements were observed in DTSQs total scores from baseline (24.1) to week 24 (29.4, p < 0.0001).

CONCLUSIONS

A basal-bolus regimen including Gla-300 OD was associated with improvements in HbA_1c and treatment satisfaction in people with uncontrolled T1DM previously receiving basal-bolus insulin including a basal insulin BID analogue.

TRIAL REGISTRATION

EudraCT number: 2015-001186-46.

Continuous Glucose Monitoring Sensors for Diabetes Management: A Review of Technologies and Applications

By providing blood glucose (BG) concentration measurements in an almost continuous-time fashion for several consecutive days, wearable minimally-invasive continuous glucose monitoring (CGM) sensors are revolutionizing diabetes management, and are becoming an increasingly adopted technology especially for diabetic individuals requiring insulin administrations. Indeed, by providing glucose real-time insights of BG dynamics and trend, and being equipped with visual and acoustic alarms for hypo- and hyperglycemia, CGM devices have been proved to improve safety and effectiveness of diabetes therapy, reduce hypoglycemia incidence and duration, and decrease glycemic variability. Furthermore, the real-time availability of BG values has been stimulating the realization of new tools to provide patients with decision support to improve insulin dosage tuning and infusion. The aim of this paper is to offer an overview of current literature and future possible developments regarding CGM technologies and applications. In particular, first, we outline the technological evolution of CGM devices through the last 20 years. Then, we discuss about the current use of CGM sensors from patients affected by diabetes, and, we report some works proving the beneficial impact provided by the adoption of CGM. Finally, we review some recent advanced applications for diabetes treatment based on CGM sensors.

Frequency of Self-Monitoring of Blood Glucose during the School Day Is Associated with the Optimal Glycemic Control among Korean Adolescents with Type 1 Diabetes

BACKGROUND

This study aimed to evaluate the relationship between the frequency of self-monitoring of blood glucose (SMBG) and glycosylated hemoglobin (HbA1c) levels among Korean adolescents with type 1 diabetes mellitus (T1DM). Factors affecting the SMBG frequency were analyzed in order to improve their glycemic control.

METHODS

Sixty-one adolescents aged 13 to 18 years with T1DM were included from one tertiary center. Clinical and biochemical variables were recorded. Factors associated with SMBG frequency were assessed using structured self-reported questionnaires.

RESULTS

Average total daily SMBG frequency was 3.8±2.1 and frequency during the school day was 1.3±1.2. The mean HbA1c level was 8.6%±1.4%. As the daily SMBG frequency increased, HbA1c levels declined (P=0.001). The adjusted odds of achieving the target HbA1c in participants who performed daily SMBG ≥5 significantly increased 9.87 folds (95% confidence interval [CI], 1.58 to 61.70) compared with those performed SMBG four times a day. In the subjects whose SMBG frequency <1/day during the school day, an 80% reduction in the adjusted odds ratio 0.2 (95% CI, 0.05 to 0.86) showed compared to the group with performing two SMBG measurements in the school setting. The number of SMBG testing performed at school was significantly high for individuals assisted by their friends (P=0.031) and for those who did SMBG in the classrooms (P=0.039).

CONCLUSION

Higher SMBG frequency was significantly associated with lower HbA1c in Korean adolescents with T1DM. It would be necessary to establish the school environments that can facilitate adequate glycemic control, including frequent SMBG.

Improvement of Glycosylated Hemoglobin in Patients with Type 2 Diabetes Mellitus under Insulin Treatment by Reimbursement for Self-Monitoring of Blood Glucose

BACKGROUND

In Korea, the costs associated with self-monitoring of blood glucose (SMBG) for patients with type 2 diabetes mellitus (T2DM) under insulin treatment have been reimbursed since November 2015. We investigated whether this new reimbursement program for SMBG has improved the glycemic control in the beneficiaries of this policy.

METHODS

Among all adult T2DM patients with ≥3 months of reimbursement (n=854), subjects without any changes in anti-hyperglycemic agents during the study period were selected. The improvement of glycosylated hemoglobin (HbA1c) was defined as an absolute reduction in HbA1c ≥0.6% or an HbA1c level at follow-up <7%.

RESULTS

HbA1c levels significantly decreased from 8.5%±1.3% to 8.2%±1.2% during the follow-up (P<0.001) in all the study subjects (n=409). Among them, 35.5% (n=145) showed a significant improvement in HbA1c. Subjects covered under the Medical Aid system showed a higher prevalence of improvement in HbA1c than those with medical insurance (52.2% vs. 33.3%, respectively, P=0.012). In the improvement group, the baseline HbA1c (P<0.001), fasting C-peptide (P=0.016), and daily dose of insulin/body weight (P=0.024) showed significant negative correlations with the degree of HbA1c change. Multivariate analysis showed that subjects in the Medical Aid system were about 2.5-fold more likely to improve in HbA1c compared to those with medical insurance (odds ratio, 2.459; 95% confidence interval, 1.138 to 5.314; P=0.022).

CONCLUSION

The reimbursement for SMBG resulted in a significant improvement in HbA1c in T2DM subjects using insulin, which was more prominent in subjects with poor glucose control at baseline or covered under the Medical Aid system.

Recent Updates on Type 1 Diabetes Mellitus Management for Clinicians

Type 1 diabetes mellitus (T1DM) is a chronic autoimmune condition that requires life-long administration of insulin. Optimal management of T1DM entails a good knowledge and understanding of this condition both by the physician and the patient. Recent introduction of novel insulin preparations, technological advances in insulin delivery and glucose monitoring, such as continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring and improved understanding of the detrimental effects of hypoglycaemia and hyperglycaemia offer new opportunities and perspectives in T1DM management. Evidence from clinical trials suggests an important role of structured patient education. Our efforts should be aimed at improved metabolic control with concomitant reduction of hypoglycaemia. Despite recent advances, these goals are not easy to achieve and can put significant pressure on people with T1DM. The approach of physicians should therefore be maximally supportive. In this review, we provide an overview of the recent advances in T1DM management focusing on novel insulin preparations, ways of insulin administration and glucose monitoring and the role of metformin or sodium-glucose co-transporter 2 inhibitors in T1DM management. We then discuss our current understanding of the effects of hypoglycaemia on human body and strategies aimed at mitigating the risks associated with hypoglycaemia.

Flash Glucose Measurements in Children with Type 1 Diabetes in Real-Life Settings: To Trust or Not to Trust?

BACKGROUND AND AIMS

To evaluate the clinical accuracy of a flash glucose monitoring device FreeStyle Libre (FSL) among children with type 1 diabetes in real-world settings during a summer camp.

MATERIALS AND METHODS

During a summer camp, children with type 1 diabetes (n = 79, aged 8-18 years) were provided with FSLs for 12 days. On days 3, 7, and 11 of the study, they underwent supervised glucose testing at 8 timepoints. Glycemia was estimated by using FSL and measured with a personal glucometer within a period of 2 min. The glucose trend arrows were recorded.

RESULTS

The study was completed by 78 children (median: age 12.8 years, diabetes duration 5.8 years, HbA1c 58.5 mmol/mol). Mean absolute relative difference (MARD) between the FSL and the glucometer was 13.5% ± 12.9%. FSL was the most accurate in stable glycemic conditions: MARD 11.4% ± 10.4%, less accurate when glycemia was falling >2 mg/(dL·min) [0.111 mmol/(L·min)-MARD 22.6% ± 18.6%; P < 0.001 vs. stable conditions] and when the device could not determine the glucose trends (16.5% ± 16.3%, P = 0.01 vs. stable conditions). The FSL demonstrated lower accuracy during the day than the night [MARD 14.9% ± 14% vs. 11.2% ± 10.6%, P < 0.0001]. Out of 1655 data pairs of glucometer and FSL, using the Surveillance Error Grid methodology we determined that 80.36% of FSL readings were associated with no clinical risk, 18.73% with slight risk and only one high-risk measurement was detected.

CONCLUSION

FSL is accurate in children, but its accuracy depends on the glucose trend. Results flagged by the rapid fall flag and "trend undetermined" should be verified by blood glucose measurements.

The dapa study

OBJECTIVE

To assess adherence to self-monitoring of blood glucose and the main factors associated with it, particularly those related to self-perception of glycemia, in patients with diabetes on insulin therapy.

PATIENTS AND METHODS

An epidemiological, observational, prospective, multicenter study conducted in standard clinical practice in primary care, outpatient centers, and hospitals from different Spanish regions. Sociodemographic, clinical and treatment data were collected. Patients were considered adherent to self-monitoring if they performed the minimum number of controls recommended by the Spanish Society of Diabetes (SED).

RESULTS

Adherence was shown in 61.6% of patients. Factors associated to adherence included treatment with less than three insulin injections daily (OR 2.678; 95% CI 2.048- 3.5029; p <0.001), presence of peripheral vascular disease (OR 1.529; 95% CI 1.077 - 2.171; p=0.018), alcohol abstinence (OR 1.442; 95% CI 1.118 - 1.858; p=0.005), and collection of the glucose test strips from the pharmacy (OR 1.275; 95% CI 1.026 - 1.584; p=0.028). Adequate self-perception of glycemia was found in 21.4% of patients.

CONCLUSIONS

Our results show a suboptimal adherence to the recommended protocol for blood glucose self-monitoring in patients with diabetes on insulin therapy. Independent variables associated to good adherence were treatment with less than three insulin injections dailyu, presence of peripheral vascular disease, alcohol abstinence, and collection of glucose test strips from the pharmacy.

Factors associated with greater benefit of a national reimbursement policy for blood glucose test strips in adult patients with type 1 diabetes: A prospective cohort study

AIMS/INTRODUCTION

We aimed to identify factors independently associated with greater benefit of a national reimbursement policy for blood glucose test strips in adult patients with type 1 diabetes, in terms of glycemic control and the rate of severe hypoglycemia.

MATERIALS AND METHODS

This was a prospective cohort study of 466 adult patients with type 1 diabetes from five tertiary referral hospitals who registered for a national reimbursement program for blood glucose strips and were then followed-up for 12 months. Factors associated with a > 5% reduction in glycated hemoglobin (HbA1c) and decreased rate of severe hypoglycemia (SH) at 12 months from baseline were evaluated.

RESULTS

At the end of the 12 months of follow up, 158 of 466 patients (33.9%) achieved >5% reduction in HbA1c, and 47 of 111 patients (42.3%) had a decreased rate of SH relative to baseline. Higher HbA1c (P < 0.001), lower total daily insulin dose at baseline (P = 0.048) and an increase in self-monitoring of blood glucose (SMBG) frequency during follow up (P = 0.001) were independently associated with >5% reduction in HbA1c. A higher SMBG frequency (P < 0.001), higher rate of SH at baseline (P = 0.029) and lack of hypoglycemic unawareness (P = 0.044) were independently associated with an increase in the frequency of SMBG during follow up. Higher SMBG frequency at baseline (P < 0.001) was independently associated with a decreased rate of SH.

CONCLUSIONS

Several factors, including higher SMBG frequency at baseline, were independently associated with reduced HbA1c and a decreased rate of severe hypoglycemia, showing that patients with these characteristics derive the most benefit from reimbursement of blood glucose test strips.

Accuracy and Precision of Measured Blood Sugar Values by Three Glucometers Compared to the Standard Technique

INTRODUCTION

The prevalence of diabetes mellitus has magnified, globally. Being cost effective and user friendly, using the glucometer systems has become more widespread. However, despite their advantages, there are controversies regarding their accuracy and precision.

AIM

To determine the accuracy and precision of the common glucometers of Bionime, Accu-check, and Beurer compared with the laboratory technique.

MATERIALS AND METHODS

In a cross-sectional study, 257 patients of a general internal unit of Imam Reza hospital of Kermanshah were recruited. The blood sample of the subjects was transferred to the laboratory, then, two samples of capillary blood were tested by the three glucometers. The data was entered into a checklist, then entered to SPSS-16.0 software, and analyzed by descriptive and inferential statistics.

RESULTS

In this study, there was a positive correlation between the three blood glucose measurement methods with the standard approach, significantly, which indicates acceptable accuracy. However, this correlation was higher in the Beurer Glucometer (r=0.976, p<0.001). There were no significant differences in repeated measurements of blood glucose in the glucometers of Beurer (t=0.96, p=0.92), and Bionime (t=0.50, p=0.61) by paired t-test, but this test was significant for Accu-chek system (t=2.7, p=0.006).

CONCLUSION

With respect to the acceptable accuracy and precision of Beurer and Bionime glucometers, it is suggested to use these methods for diabetic patients at homes as well as in the hospital units.

Self-monitoring of blood glucose (SMBG) and glycaemic control in Cameroon: Results of the International Diabetes Management Practices Study (IDMPS)

This study examined the relationship between self-monitoring of blood glucose (SMBG) and glycaemic control among patients from Cameroon. A minority of patients with diabetes owned a blood glucose meter; of these patients, most performed SMBG inconsistently. The lack of SMBG may be a contributing factor to the poor glycaemic control in the country.

Accuracy and Precision of Measured Blood Sugar Values by Three Glucometers Compared to the Standard Technique

INTRODUCTION

The prevalence of diabetes mellitus has magnified, globally. Being cost effective and user friendly, using the glucometer systems has become more widespread. However, despite their advantages, there are controversies regarding their accuracy and precision.

AIM

To determine the accuracy and precision of the common glucometers of Bionime, Accu-check, and Beurer compared with the laboratory technique.

MATERIALS AND METHODS

In a cross-sectional study, 257 patients of a general internal unit of Imam Reza hospital of Kermanshah were recruited. The blood sample of the subjects was transferred to the laboratory, then, two samples of capillary blood were tested by the three glucometers. The data was entered into a checklist, then entered to SPSS-16.0 software, and analyzed by descriptive and inferential statistics.

RESULTS

In this study, there was a positive correlation between the three blood glucose measurement methods with the standard approach, significantly, which indicates acceptable accuracy. However, this correlation was higher in the Beurer Glucometer (r=0.976, p<0.001). There were no significant differences in repeated measurements of blood glucose in the glucometers of Beurer (t=0.96, p=0.92), and Bionime (t=0.50, p=0.61) by paired t-test, but this test was significant for Accu-chek system (t=2.7, p=0.006).

CONCLUSION

With respect to the acceptable accuracy and precision of Beurer and Bionime glucometers, it is suggested to use these methods for diabetic patients at homes as well as in the hospital units.

Effects of Subcutaneous Injection MnO2 Micro- and Nanoparticles on Blood Glucose Level and Lipid Profile in Rat

BACKGROUND

The use of nanotechnology has led to rapid growth in various areas. Thus, health and safety issues of nanoparticles (NPs) should be promptly addressed. Manganese oxide (MnO₂) nanoparticles (NPs) are typically used for biomedical and industrial applications. However, characterizing the potential human health effects of MnO₂ NPs is required before fully exploiting these materials. The aim of this study was to investigate the toxicity of MnO₂ micro- and nanoparticles on blood glucose level and lipid profile in male Wistar rats.

METHODS

A total of 105 rats were divided into one control and two experimental groups. Each experimental group received a single subcutaneous injection of MnO₂ micro- and nanoparticles (100 μg/kg), respectively, every two weeks for 14 weeks. Their blood glucose, cholesterol, triglycerides, LDL, and HDL levels were then measured. The data presented as mean±SEM and compared with the repeated measures using the Prism statistical software (version 6.0).

RESULTS

Biochemical assessment in plasma samples showed that MnO₂ micro- and nanoparticles injection significantly (P<0.01) increased the plasma glucose and cholesterol levels in all and few weeks, respectively. MnO₂ nanoparticles significantly (P<0.01) decreased the HDL level in weeks 6, 12, and 14, but MnO₂ microparticles decreased the HDL level only in week 12. In both MnO₂ micro- and nanoparticles groups, LDL alterations were near to the control group, except for week 10. However, the same treatment had no effect on triglycerides concentrations compared to the control group.

CONCLUSION

Our results show that exposure to nanosized particles at subchronic doses caused adverse changes in animal biochemical profiles, especially in glucose level. It seems that the high oxidative power of these particles is the main reason for these disturbances.

[Effectiveness and economic impact of a program of integrated care with telemedicine support on insulin-treated type 2 diabetic patients (Study GITDIABE)]

AIM

To evaluate if insulin-treated type 2 diabetic patients with blood glucose self-monitoring (DIA), included in a program of integrated management of diabetes mellitus (DM), achieve a better level of metabolic control with telemedicine support than with conventional support, after 12 months follow-up. The impact on the use and cost of healthcare services, pharmaceutical expenditure, and consumption of test strips for blood glucose, was also assessed.

DESIGN

A prospective parallel cohorts study.

FIELD

Four basic health areas of an integrated healthcare organisation.

PARTICIPANTS

The study included 126 DIA patients aged 15 or more years, treated with rapid or intermediate Insulin and blood glucose self-monitoring, grouped into 42 cases and 84 controls, matched according to age, sex, level of metabolic control, and morbidity profile.

INTERVENTION

Telematics physician-patient communication and download of blood glucose self-monitoring data through the Emminens eConecta^® platform; test strips home delivered according to consumption. Hidden controls with usual follow-up.

MAIN MEASUREMENTS

Glycosylated haemoglobin (%HbA1c); perception of quality of life (EuroQol-5 and EsDQOL); cardiovascular risk; use of healthcare resources; consumption of test strips; pharmaceutical and healthcare expenditure.

RESULTS

Reduction of 0.38% in HbA1c in the cases (95% CI:-0.89% to 0.12%). No significant differences with regard to any of the activities registered, or any significant change in the quality of life.

CONCLUSIONS

The results obtained are similar to other equivalent studies. The profile of the patient is elderly and with multiple morbidities, who still have technological limitations. To surpass these barriers, it would be necessary to devote more time to the training and to the resolution of possible technological problems.

Differences in self-monitored, blood glucose test strip utilization by therapy for type 2 diabetes mellitus

AIMS

To determine whether blood glucose test strip (BGTS) utilization in patients with type 2 diabetes (T2D) is associated with the type of diabetes therapy, classified according to hypoglycemic risk.

METHODS

A retrospective, longitudinal (2006-2012) study of Canadian private drug plans (PDP) and Ontario Public Drug Programs (OPDP) prescription claims was conducted. Analyses were restricted to patients with T2D with or without a claim for BGTS. Daily BGTS utilization (TS/patient/day) was evaluated by diabetes therapy classified by hypoglycemic risk. Multivariate analyses were conducted to identify determinants of BGTS utilization.

RESULTS

The T2D cohort comprised 5,759,591 observations from 1,949,129 claimants. Mean BGTS utilization was 0.84 TS/patient/day and differed between PDP and OPDP (0.66 vs. 1.00). Daily utilization was greatest in patients receiving therapy associated with a pre-defined high risk of hypoglycemia [insulin: basal + bolus (2.16), premixed (1.65), basal (1.16), other insulin regimens (2.13), and sulfonylureas (0.74)] versus non-sulfonylurea non-insulin-based regimens (0.52). For non-insulin therapy, BGTS utilization was greater for patients on multiple non-insulin therapies versus monotherapy (0.74 vs. 0.53 TS/patient/day). In multivariate analyses, drivers for BGTS utilization included insulin use, previous BGTS use, and female gender. Previous diabetes therapy and duration of therapy were negatively correlated with BGTS utilization.

CONCLUSIONS

BGTS utilization varies depending on the type of therapy used to treat T2D according to hypoglycemic risk. Decision making regarding BGTS needs to account for robust analyses of current utilization and its value in those settings, including in patients not receiving diabetes therapy and the prevalence of circumstances conducive to more intensive monitoring.

Systematic literature review of use of blood glucose monitoring in phase III clinical studies of insulin analogs

BACKGROUND

Safe and effective insulin therapy for diabetes mellitus requires initial dose titration and regular adjustments based on blood glucose (BG) monitoring. Our objective was to explore the use of BG measurement in phase-III clinical studies of insulin analogs. These studies provide safety and efficacy information for regulatory authorities and are the basis for insulin analog regulatory approval.

METHODS

A systematic review of phase-III studies of rapid-acting insulin analogs (insulin lispro, insulin aspart and insulin glulisine) and pre-mixed insulin analogs (biphasic insulin aspart and insulin lispro mix) was conducted. Studies were identified using manufacturers' databases. Search for reports was performed in Medline and registry of clinical trials (clinicaltrials.gov). The European Medicines Agency was contacted to provide Clinical Study Reports.

RESULTS

Forty-five studies were included. Regular BG measurements were reported in 100 % of the studies and were performed by either self-monitoring of blood glucose (SMBG) alone in 84 %, laboratory alone in 7 %, and both SMBG and laboratory in 9 % of studies. In total, 93 % of the studies reported SMBG. Most studies (91 %) reported insulin therapy adjustments based on BG measurements.

CONCLUSIONS

The findings suggest that BG monitoring and specifically SMBG are co-dependent technologies with insulin analogs. BG measurement is used in most phase-III registration studies for establishing safe and efficacious insulin administration and is recommended in the insulin labels. The indispensable role of SMBG in treatment of insulin-dependent patients should receive attention from health care payers to assess and reimburse SMBG along with insulin to avoid adverse events from inappropriate insulin administration and associated costs.

[Accuracy and reliability between glucose meters: A study under normal clinical practice conditions]

INTRODUCTION

The glucose meters usually show a high accuracy, and in clinical practice, capillary and plasma glucose (PG) are used interchangeably. However, many variables can affect the validity of these devices. The aim of this study was to determine the accuracy and reliability of 3 glucose meters that are currently used in a primary care centre.

MATERIAL AND METHODS

A sample of venous blood and a drop of capillary blood were obtained from 59 participants. The drop was analysed in 3 glucose meters: 2 FreeStyle^® Optium (OP1 and OP2), and one Accu-Chek^® Aviva. The PG acted as the reference value, and the haematocrit and plasma levels of urea, bilirubin, uric acid and triglycerides were also analysed. We used the Passing-Bablok regression for accuracy and the intraclass correlation coefficient and the Bland-Altman method for reliability. The current American Diabetes Association standard of a total error of±5% was applied.

RESULTS

Differences in mean±standard deviation (mg/dL) and the systematic error were 5.8±7 and 5.8% (OP1); 6.2±8 and 5.9% (OP2); 8.3±8 and 6.3% (Accu-Chek^®). The OP1/OP2 pair showed the highest level of reliability, with an intraclass correlation coefficient=0.97, bias=-0.4mg/dL, and a width of the 95% limits of agreement of 28.6mg/dL. The highest levels of accuracy and reliability were observed in high glucose ranges (PG≥126mg/dL).

CONCLUSIONS

Despite their clinically acceptable mean difference compared to the PG, the 3 glucose meters did not fulfill the current American Diabetes Association standard. The regular performance of quality control tests of these devices is recommended.

Explaining engagement in self-monitoring among participants of the DESMOND Self-monitoring Trial: a qualitative interview study

BACKGROUND

The Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND) Self-monitoring Trial reported that people with newly diagnosed type 2 diabetes attending community-based structured education and randomized to self-monitoring of blood glucose (SMBG) or urine monitoring had comparable improvements in biomedical outcomes, but differences in satisfaction with, and continued use of monitoring method, well-being and perceived threat from diabetes.

OBJECTIVES

To explore experiences of SMBG and urine monitoring following structured education. We specifically addressed the perceived usefulness of each monitoring method and the associated well-being.

METHODS

Qualitative semi-structured interviews with 18 adults with newly diagnosed type 2 diabetes participating in the DESMOND Self-monitoring Trial (SMBG, N=10; urine monitoring, N=8)~12 months into the trial. Analysis was informed by the constant comparative approach.

RESULTS

Interviewees reported SMBG as accurate, convenient and useful. Declining use was explained by having established a pattern of managing blood glucose with less frequent monitoring or lack of feedback or encouragement from health care professionals. Many initially positive views of urine monitoring progressively changed due to perceived inaccuracy, leading some to switch to SMBG. Perceiving diabetes as less serious was attributable to lack of symptoms, treatment with diet alone and-in the urine-monitoring group-consistently negative readings. Urine monitoring also provided less visible evidence of diabetes and of the effect of behaviour on glucose.

CONCLUSIONS

The findings highlight the importance for professionals of considering patients' preferences when using self-monitoring technologies, including how these change over time, when supporting the self-care behaviours of people with type 2 diabetes.

Evaluation of three glucometers for whole blood glucose measurements at the point of care in preterm or low-birth-weight infants

Purpose

We evaluated three blood glucose self-monitoring for measuring whole blood glucose levels in preterm and low-birth-weight infants.

Methods

Between December 1, 2012 and March 31, 2013, 230 blood samples were collected from 50 newborns, who weighed, ≤2,300 g or were ≤36 weeks old, in the the neonatal intensive care unit of Eulji University Hospital. Three blood glucose self-monitoring (A: Precision Pcx, Abbott; B: One-Touch Verio, Johnson & Johnson; C: LifeScan SureStep Flexx, Johnson & Johnson) were used for the blood glucose measurements. The results were compared to those obtained using laboratory equipment (D: Advia chemical analyzer, Siemens Healthcare Diagnostics Inc.).

Results

The correlation coefficients between laboratory equipment and the three blood glucose self-monitoring (A, B, and C) were found to be 0.888, 0.884, and 0.900, respectively. For glucose levels≤60 mg/dL, the correlation coefficients were 0.674, 0.687, and 0.679, respectively. For glucose levels>60 mg/dL, the correlation coefficients were 0.822, 0.819, and 0.839, respectively. All correlation coefficients were statistically significant. And the values from the blood glucose self-monitoring were not significantly different from the value of the laboratory equipment , after correcting for each device's average value (P>0.05). When using laboratory equipment (blood glucose ≤60 mg/dL), each device had a sensitivity of 0.458, 0.604, and 0.688 and a specificity of 0.995, 0.989, and 0.989, respectively.

Conclusion

Significant difference is not found between three blood glucose self-monitoring and laboratory equipment. But correlation between the measured values from blood glucose self-monitoring and laboratory equipment is lower in preterm or low-birth-weight infants than adults.

Adherence to hunger training using blood glucose monitoring: a feasibility study

BACKGROUND

"Hunger training", which aims to teach people to eat only when blood glucose is below a set target, appears promising as a weight loss strategy. As the ability of participants to adhere to the rigorous protocol has been insufficiently described, we sought to determine the feasibility of hunger training, in terms of retention in the study, adherence to measuring blood glucose, and eating only when blood glucose concentrations are below a set level of 4.7 mmol/L.

METHOD

We undertook a two-week feasibility study, utilising an adaptive design approach where the specific blood glucose cut-off was the adaptive feature. A blood glucose cut-off of 4.7 mmol/L (protocol A) was used for the first 20 participants. A priori we decided that if interim analysis revealed that this cut-off did not meet our feasibility criteria, the remaining ten participants would use an individualised cut-off based on their fasting glucose concentrations (protocol B).

RESULTS

Retention of the participants in the study was 97 % (28/29 participants), achieving our criterion of 85 %. Participants measured their blood glucose before 94 % (95 % CI 91, 98) of eating occasions (criterion 80 %). However, participants following protocol A, which used a standard blood glucose cut-off of 4.7 mmol/L, were only able to adhere to eating when blood glucose was below the prescribed level 66 % of the time, below our within-person criterion of 75 %. By contrast, those participants following protocol B (individualised cut-off) adhered to the eating protocol 84 % of the time, a significant (p = 0.010) improvement over protocol A.

CONCLUSION

Hunger training appears to be a feasible method, at least in the short-term, when an individualised fasting blood glucose is used to indicate that a meal can begin.

Screening for diabetes mellitus using gingival crevicular blood with the help of a self-monitoring device

Purpose

The purpose of study was to compare blood glucose in capillary finger-prick blood and gingival crevice blood using a self-monitoring blood glucose device among patients with gingivitis or periodontitis.

Methods

Thirty patients with gingivitis or periodontitis and bleeding on probing (BOP) were chosen. The following clinical periodontal parameters were noted: probing depth, BOP, gingival bleeding index, and periodontal disease index. Blood samples were collected from gingival crevicular blood (GCB) and capillary finger-prick blood (CFB). These samples were analyzed using a glucose self-monitoring device.

Results

Descriptive statistical analysis has been carried out in the present study. Data were analyzed using a Pearson's correlation coefficient and Student's t-test. A r-value of 0.97 shows very strong correlation between CFB and GCB, which was statistically highly significant (P<0.0001).

Conclusions

The authors conclude that GCB may serve as potential source of screening blood glucose during routine periodontal examination in populations with an unknown history of diabetes mellitus.