Health care organization and use of technological devices in people with diabetes in Italy: Results from a survey of the Working Group on Diabetes and Technology

BACKGROUND AND AIM

The use of technology offers recognized benefits to persons with diabetes. The aim of this study was to evaluate the organization of healthcare facilities, the composition of the diabetes team, and the use of Continuous Subcutaneous Insulin Infusion (CSII) and Continuous Glucose Monitoring (CGM) in Italy.

METHODS AND RESULTS

Diabetes care centers were asked to complete a web survey based on information collected in 2018. Sixty-one pediatric and 243 adult centers participated in the survey, accounting for 507,386 patients, mostly with type 2 diabetes (86.4%). Fifty-three percent of pediatric centers and 11% of adult centers reported a team composed of diabetologists, nurses, and psychologists. Overall, 13,204 patients (2.6%) were using CSII (95% with type 1 diabetes), and 28,936 (5.7%), were using CGM (74% with type 1 diabetes). When stratifying for the type of diabetes, 24% and 40.8% of patients with type 1 were using CSII and CGM, respectively, whereas low use of technology was reported for patients with type 2 and women with gestational diabetes. The percentage of adult and pediatric patients with type 1 diabetes on CSII and CGM was respectively 21% and 32%, and 35% and 57%.

CONCLUSIONS

The spread of CGM and CSII increased in Italy between 2013 and 2018. However, the percentage of users is still lower than what is expected based on clinical indications for use of technology. The inadequate number of professionals in the diabetes care team and insufficient economic resources are relevant barriers to disseminating technology for diabetes management.

Risk for Coexistent Autoimmune Diseases in Familial and Sporadic Type 1 Diabetes is Related to Age at Diabetes Onset

OBJECTIVE

Type 1 diabetes (T1D) is frequently associated with other autoimmune diseases (AIDs). Although most of T1D patients are sporadic cases (S-T1D), 10% to 15% have a familial form (F-T1D) involving 2 or more first-degree relatives. This study evaluated the effect of T1D family aggregation and age onset on AIDs occurrence.

METHODS

In this observational, cross-sectional, case-control, single center study, we enrolled 115 F-T1D and 115 S-T1D patients matched for gender, age, T1D age onset, and duration. With respect to T1D age onset (before or after 18 years), both groups were further subdivided into young- or adult-onset F-T1D and young- or adult-onset S-T1D. The presence of organ-specific antibodies and/or overt AIDs was evaluated.

RESULTS

The F-T1D group had a higher percentage of AIDs (29.8% vs 18.4%, P = .04) and a significant earlier onset of AIDs at Cox regression analysis (P = .04) than the S-T1D group. Based on multivariate analysis, the adult-onset F-T1D subgroup had the highest prevalence of both additional organ-specific antibodies (60.5%) and overt AIDs (34.9%), whereas the adult S-T1D subgroup was the least frequently involved (29.1% and 12.7%, respectively). In F-T1D patients, offsprings develop T1D and AIDs earlier than their parents do.

CONCLUSIONS

In T1D patients, familial aggregation and adult-onset of T1D increase the risk for coexistent AIDs. These clinical predictors could guide clinicians to address T1D patients for the screening of T1D-related AIDs.

Short-term efficacy of high intensity group and individual education in patients with type 2 diabetes: a randomized single-center trial

PURPOSE

The aim of this randomized study was to examine the efficacy of two high intensity educational programs: the conversation maps-based (CM™) education and the individual education (IE), compared to usual care (UC) in a cohort of type 2 diabetic (T2DM) patients.

METHODS

Ninety T2DM outpatients (30 per group) were randomized and 79 finished the study and were analyzed. The CM™ and IE groups received four educational sessions at 0, 4, 8 and 12 weeks, while the UC group received two brief individual sessions at 0 and 12 weeks. We evaluated glycemic control (HbA1c), diabetes treatment, body mass index (BMI) and carried out a questionnaire survey at three time points (before intervention, at 12 and at 32 weeks) to assess patients' satisfaction, attitudes toward diabetes and dietary knowledge.

RESULTS

All the three groups showed a significant and comparable reduction of both HbA1c and BMI. Diabetes therapy needed to be reinforced in a higher percentage of cases (39.3%) among UC patients compared to the IE (14.8%; p = 0.04) and the CM™ (8.3%; p = 0.01) groups. At 32 weeks Diabetes Treatment Satisfaction (DTSQ Q1 + Q4-8) significantly improved in the CM™ group (25.8 ± 4.5 vs. 22.4 ± 6.0; p < 0.01) and attitudes toward diabetes (ATT19) significantly improved in the IE group (58.0 ± 4.7 vs. 55.3 ± 5.1; p = 0.02).

CONCLUSIONS

Our trial provides preliminary data regarding the efficacy of structured group and individual education on achieving better glyco-metabolic control without drug therapy reinforcement and with positive effects on patients' attitude and treatment satisfaction.

Metabolic control and complications in Italian people with diabetes treated with continuous subcutaneous insulin infusion

BACKGROUND AND AIM

The objective of this cross-sectional study was to evaluate the degree of glycaemic control and the frequency of diabetic complications in Italian people with diabetes who were treated with continuous subcutaneous insulin infusion (CSII).

METHODS AND RESULTS

Questionnaires investigating the organisation of diabetes care centres, individuals' clinical and metabolic features and pump technology and its management were sent to adult and paediatric diabetes centres that use CSII for treatment in Italy. Information on standard clinical variables, demographic data and acute and chronic diabetic complications was derived from local clinical management systems. The sample consisted of 6623 people with diabetes, which was obtained from 93 centres. Of them, 98.8% had type 1 diabetes mellitus, 57.2% were female, 64% used a conventional insulin pump and 36% used a sensor-augmented insulin pump. The median glycated haemoglobin (HbA_1c) level was 60 mmol/mol (7.6%). The HbA_1c target (i.e. <58 mmol/mol for age <18 years and <53 mmol/mol for age >18 years) was achieved in 43.4% of paediatric and 23% of adult participants. Factors such as advanced pump functions, higher rate of sensor use, pregnancy in the year before the study and longer duration of diabetes were associated with lower HbA_1c levels. The most common chronic complications occurring in diabetes were retinopathy, microalbuminuria and hypertension. In the year before the study, 5% of participants reported ≥1 episode of severe hypoglycaemic (SH) episodes (SH) and 2.6% reported ≥1 episode of ketoacidosis.

CONCLUSIONS

Advanced personal skills and use of sensor-based pump are associated with better metabolic control outcomes in Italian people with diabetes who were treated with CSII. The reduction in SH episodes confirms the positive effect of CSII on hypoglycaemia.

CLINICAL TRIAL REGISTRATION NUMBER

NCT 02620917 (ClinicalTrials.gov).

Integrated insulin pump therapy with continuous glucose monitoring for improved adherence: technology update

Insulin pump therapy combined with real-time continuous glucose monitoring, known as sensor-augmented pump (SAP) therapy, has been shown to improve metabolic control and to reduce the rate of hypoglycemia in adults with type 1 diabetes compared to multiple daily injections or standard continuous subcutaneous insulin infusion. Glycemic variability is also reduced in patients on SAP therapy. This approach allows patients to monitor their glucose levels being informed of glycemic concentration and trend. Trained diabetic patients, therefore, can appropriately modify insulin infusion and/or carbohydrate intake in order to prevent hypo- or hyperglycemia. For these reasons, SAP therapy is now considered the gold standard for type 1 diabetes treatment. To be clinically effective, however, devices and techniques using advanced technology should not only have the potential to theoretically ameliorate metabolic control, but also be well accepted by patients in terms of satisfaction and health-related quality of life, because these factors will improve treatment adherence and consequently overall outcome. SAP therapy is generally well tolerated by patients; however, many clinical trials have identified significant noncompliance in the use of this device, most notably in the pediatric and adolescent populations. In this review we aim to analyze the main reasons for good or poor adherence to SAP therapy and to provide useful tips in order to fully benefit from this kind of novel therapeutic approach.

Efficacy of real-time continuous glucose monitoring on glycaemic control and glucose variability in type 1 diabetic patients treated with either insulin pumps or multiple insulin injection therapy: a randomized controlled crossover trial

BACKGROUND

The aim of this study was to determine the efficacy of real-time continuous glucose monitoring in T1D patients treated with insulin pump therapy or multiple daily insulin therapy.

METHODS

Twenty adult patients (ten insulin pump therapy and ten multiple daily insulin) with poor glycaemic control (HbA1c  > 8.0%) were randomized into two groups for 6 months: the continuous glucose monitoring arm (using real-time continuous glucose monitoring) and the SMBG arm. After 2 months of wash-out, the participants crossed over. The primary outcome was HbA1c reduction. The secondary outcomes were hypoglycaemia and hyperglycaemia risk assessment (area under the curve < 70 mg/dL/day and AUC > 200 mg/dL/day, respectively) and glucose variability.

RESULTS

Fourteen patients (eight multiple daily insulin, six insulin pump therapy) used continuous glucose monitoring appropriately (at least 40% of the time). In these patients, the improvement in glycaemic control was more evident during the real-time continuous glucose monitoring period (7.76% ± 0.4 vs 8.54% ± 0.4, p < 0.05) than during the self-monitoring of blood glucose period (8.42% ± 0.4 vs 8.56% ± 0.5, p = 0.2). Better results with continuous glucose monitoring were observed in patients using multiple daily insulin with greater improvement in both glycaemic control (7.71% ± 0.2 vs 8.58% ± 0.2, p < 0.05) and glucose variability and with a marked reduction in the risk of both hypoglycaemia and hyperglycaemia.

CONCLUSIONS

Appropriate use of real-time continuous glucose monitoring improved glycometabolic control in T1D patients. The effects of continuous glucose monitoring were more evident in patients under multiple daily insulin treatment, compared with insulin pump therapy. Glucose variability, in addition to glycaemic control, was improved in compliant diabetic patients.

Healing of chronic necrobiosis lipoidica lesions in a type 1 diabetic patient after pancreas-kidney transplantation: a case report

Necrobiosis lipoidica (NL) is a degenerative disease of dermal connective tissue of unknown etiology characterized by erythematous plaques preferentially localized to distal extremities. Skin lesions show a chronic relapsing nature. NL is often associated with diabetes mellitus and satisfactory treatment options are lacking. We describe the spontaneous healing of NL lesions after pancreas and kidney transplantation in a Type 1 diabetic patient with chronic NL recalcitrant to a variety of standard treatments. The 31-yr-old male patient had experienced NL lesions for more than 15 yr; despite various systemic and topical treatments, the skin lesions had pregressively enlarged. Because of end-stage renal disease, a simultaneous pancreas and kidney transplantation was performed and immunosuppressive therapy with tacrolimus (TAC), mycophenolate mofetil (MMF), and prednisone was started. Pancreatic transplantation maintained satisfactory metabolic control with no need of exogenous insulin. After transplantation, skin lesions slowly healed without any specific treatment, leaving residual areas of fibrotic scars. A skin biopsy confirmed the absence of typical NL lymphocytic and histiocytic inflammatory response. Clinical remission of NL lesions may probably be explained by the concomitant effect of multiple-drug regimen for immunosuppression (TAC, MMF, and prednisone) and improved skin microcirculation secondary to the good metabolic control provided by pancreas transplantation.

Diabetic mastopathy: a case report

Diabetic mastopathy, although reported since 1984, is a poorly recognized diabetes complication. It more frequently affects pre-menopausal women with Type 1 diabetes mellitus and microvascular complications. The pathogenesis of this condition is believed to involve mammary tissue autoimmune reaction to the accumulation of abnormal matrix proteins, caused by hyperglycemia. The lesion often simulates breast cancer; its recognition, therefore, is important to avoid unnecessary diagnostic procedures and surgical treatments. We now report a case of diabetic mastopathy which clinically simulated breast cancer in a young pre-menopausal diabetic woman who, after sonography and mammography, was suggested surgery under suspicion of breast cancer. Histopathological examination by core-biopsy ruled out malignancy.

A ten-year (1989-1998) perspective study of the incidence of Type 1 diabetes in the district of Catania (Sicily) in a 0-14 year age group

The aim of this report was to evaluate the incidence of Type 1 diabetes mellitus (T1DM) in the district of Catania (eastern Sicily) in children under 15 yr of age over a ten-yr period (01/01/1989 - 31/12/1998) in relation to age, sex, monthly-seasonal variability, calendar yr and spatial clustering. The estimated completeness of our register was 99.2%. The overall incidence rate was 12.38 per 100,000 during the period of the study. Twenty-four percent of cases were 0-4 yr at diagnosis, 42% were 5-9 yr and 34% were 10-14 yr. More males (no. 148) than females (no. 125) were newly diagnosed with a male/female ratio similar to the base population ratio in the range 0-14 yr and within age groups. The study revealed a non-random spatial distribution of T1DM incidence in children not accounted for by known demographic factors. A significant seasonal pattern and temporal trend of incidence were also detected.

Regulation of norepinephrine in the medial preoptic area of Siberian hamsters by gonadal steroids

Photoperiod has profound effects upon the neuroendocrine axis underlying reproductive physiology in seasonally breeding mammals. For long-day (LD) breeders, such as the Siberian hamster, exposure to a short-day (SD) photoperiod results in declines in circulating levels of gonadal steroids, luteinizing hormone (LH), and prolactin (PRL). The current study sought to investigate the effects of photoperiod and steroid levels on norepinephrine (NE), one of the major neurochemical regulators of gonadotropin-releasing hormone (GnRH) function. Since NE release within the medial preoptic area (mPOA) has been shown to stimulate the activity of GnRH cells, it was hypothesized that exposure to a short photoperiod would decrease NE levels. Furthermore, since gonadal steroids show negative feedback on GnRH function, it was hypothesized that gonadectomy would result in increased levels of NE. Adult male and female Siberian hamsters were gonadectomized and implanted with silastic capsules containing either cholesterol (C) or a mixture of estradiol (E) or testosterone (T). Microdialysis sampling within the mPOA was conducted after 8 weeks of exposure to either an LD or an SD photoperiod. Blood samples were analyzed for LH and PRL, while dialysis samples were analyzed for NE and its major metabolite 3-methoxy-4-hydroxyphenylglycol (MHPG). The results revealed significant suppression of LH and PRL by exposure to the SD photoperiod in both males and females. For LH, the steroid implants suppressed circulating hormone levels under both photoperiods, whereas for PRL, steroid treatment facilitated circulating levels. In contrast, there were no significant effects of photoperiod on NE or MHPG release for either males or females, but there was a significant decrease in extracellular levels of these neurochemicals in steroid-treated animals. These data suggest that photoperiodic modulation of GnRH neuronal function by NE is achieved largely through the indirect effects of photoperiod on circulating gonadal steroids.

Genotypic diversity and typing of cyanobacterial strains of the genus Arthrospira by very sensitive total DNA restriction profile analysis

Arthrospira maxima and A. platensis are two species of cyanobacteria cultivated and sold as health food, animal feed and source of food additives and fine chemicals. The genotypic diversity of several strains attributed to these two species on the basis of morphological criteria was investigated using very sensitive total DNA restriction profile analysis. The restriction profiles were obtained after sodium dodecyl sulphate polyacrylamide gel electrophoresis and silver staining. The unweighted pair-group method using arithmetic averages applied to the matrix of Dice similarity coefficient values clustered the electropherograms of the strains in two well-separated genotypic groups. These clusters corresponded to those obtained with morphological criteria. The molecular approach used was also able to type the examined strains.

Phototrophic biodeteriogens on lithoid surfaces: An ecological study

For two strains, the green alga Pleurococcus CVB4 and the cyanobacterium Lyngbya CCB2, isolated from the pioneering algal biocoenosis present on a marble statue, we determined the optimum range of growth in selective cultural media in relation to pH, light intensity, and temperature, together with the ability of these organisms to colonize stone surfaces that differed either in the structure-texture or in the physico-chemical composition of the various lithotypes. The results showed a higher capacity of the green alga to withstand environmental factor changes. For both organisms the preferential colonization of the stone surface was correlated primarily, together with the environmental factors (pH, temperature, irradiance), to the physical characteristics (roughness and porosity) and secondarily to the chemical composition of the assayed lithotypes.

Incidence of type I diabetes in the district of Catania, Sicily

The incidence of type I (insulin-dependent) diabetes was determined in the district of Catania (eastern Sicily) in children under 15 years of age over a 3-year period (1 January 1989 to 31 December 1991). Two independent sources of information were used. The primary source was contact with all medical services in the province, and the secondary source was the personal identification cards issued to all diabetic patients by the National Health System necessary for obtaining free medical care. The information obtained was 99.6% complete. The overall incidence was 10.2/10(5) per year. This study provides the first standardized data on the incidence of type I diabetes in Sicily and is consistent with the possibility of regional deviations from the proposed north to south gradient.

Evaluation of albumin excretion rate in overnight versus 24-h urine

This study was performed to assess whether the albumin excretion rate (AER) measured in overnight urine (N-AER) and 24-h urine (24-h AER) gives comparable results. For this reason we evaluated N-AER and 24-h AER on the same day from 35 control subjects, 57 patients with insulin-dependent diabetes mellitus (IDDM), and 63 patients with non-insulin-dependent diabetes mellitus (NIDDM). AER values obtained from the two urine collection procedures were significantly different (P less than .01), with 24-h AER approximately 30% higher than N-AER. Moreover, when the same cutoff value (20 micrograms/min) was used to define the normal range, 21% of IDDM patients and 6.3% of NIDDM patients had on the same day normal N-AER and abnormal (greater than 20 micrograms/min) 24-h AER. Although N-AER values were significantly correlated to 24-h AER values (r = 0.67, P less than .001), it was not possible to assess an N-AER value able to predict a 24-h AER value greater than 20 micrograms/min. In conclusion, N-AER and 24-h AER cannot be used as an equivalent method to establish AER.

Serum thyroglobulin levels are elevated in newborns from iodine-deficient areas

Newborn infants have elevated serum thyroglobulin (Tg) levels and reduced iodination of Tg. To determine whether a relationship exists between serum Tg levels and the degree of Tg iodination, 699 newborn infants were studied in 3 areas of Sicily: a normal iodine-sufficient (control) area and 2 iodine-deficient areas. In the iodine-sufficient area, the mean cord serum Tg level was 25.8 ng/ml (median, 18.0; n = 183). In the iodine-deficient areas, the serum Tg levels in newborns were significantly higher, with mean levels of 43.4 ng/ml (median, 29.7; n = 304; P less than 0.01) and 60.1 ng/ml (median, 48.0; n = 212; P less than 0.005), respectively. The higher serum Tg level at birth was not entirely due to increased cord serum TSH levels, since newborns from the iodine-deficient areas with serum TSH levels at birth similar to those in infants from the control area had higher serum Tg levels. Serum Tg levels correlated with the serum T3 to T4 ratio, but not with serum TSH, T4, or T3 levels. These data suggest that iodine availability, which affects the degree of thyroid Tg iodination, partially determines serum Tg levels at birth.

Solitary autonomously functioning thyroid nodules and iodine deficiency

The prevalence, characteristics, and evolution of autonomously functioning thyroid nodules (AFTN) were studied in two population groups from northeastern Sicily. One group was living in an iodine-deficient area and another was living in an iodine-sufficient area. The prevalence of AFTN was significantly higher in the iodine-deficient area (4.4% of total patients vs. 2.7%). No significant difference between the two areas was observed in sex and age distribution and size of the nodules. In addition, a higher percentage of patients with toxic nodules (1.3%) was found in the group from the iodine-deficient area. Furthermore, in a selected group of patients followed for 1-6 yr, a higher percentage of patients from the iodine-deficient area had either an increase in the size of the lesion or an increase in thyroid hormone production leading to toxicity. These data suggest that iodine deficiency is one possible factor in the development of AFTN and that iodine deficiency may also be involved in the increased frequency of toxic evolution of these lesions.