Telemedicine and type 1 diabetes: is technology per se sufficient to improve glycaemic control?

Clinical evaluation of the implementation of the first pilot Russian integrated program for an integrated approach to the management of diabetes mellitus “NORMA”

BACKGROUND: Despite progress in the treatment of patients with diabetes mellitus (DM), the problem of achieving target values of glycemic control remains relevant. In this regard, the search for new integrated solutions that could strengthen disease control and improve clinical outcomes becomes relevant.

AIM: To assess the impact of the developed integrated approach to disease management on the clinical and metabolic outcomes of patients with type 1 (T1DM) and type 2 diabetes mellitus (T2DM) participating in the “NORMA” pilot program for 3 and 6 months.

MATERIALS AND METHODS: “NORMA” is the first Russian program designed to implement an integrated approach to DM management combines structured online education, blood glucose monitoring, supervision by endocrinologist, and administrative support. Interium retrospective analysis analysis of pre-existing data generated in the Program was performed from October 2020 to November 2021. Adults (≥18 years) with uncontrolled T1DM or T2DM on insulin (HbA1c>7,0%) with duration of DM ≥6 months were included. The following characteristics were considered: social-demographic parameters, duration of DM, complications, HbA1c, hypoglycemia events, daily insulin dose, patients’ perception of DM checklist (scaled 1-10), level of DM knowledge (questionnaire of 20 points).

RESULTS: Data from 185 persons were analyzed: 132 with T1DM and 53 with T2DM, 67% women, the mean age was 41.3±14.4 years; the median DM duration was 12.0 [6.0; 19.0] years, 30 persons (16.3%) were free of any DM complications. Mean HbA1c decreased from 8.8±1.5% to 7.4±1.2% at month 3, and to 7.6±1.5% at month 6 (p<0.001). HbA1c <7.0% was achieved in 38.9% and 38.1% participants after 3 and 6 months, respectively. The total insulin dose has not changed within the program. The DM knowledge level after 3 months of Program increased significantly by 25.4±15.0% (p<0.001). The mean scores of patients’ perceptions of DM after 3 and 6 months increased by 2.1±10.2 % and 2.4±11.0 % (p<0.01), but the median scores (interquartile range) did not change: 0.00% (-3.00–6.00%) and 0.50% (-3.00–9.00%) respectively.

CONCLUSION: In a real-life setting, the implementation of an integrated approach to the diabetes management was associated with the improvement of glycemic control without significant changes of total insulin dose.

Quality of Life Differences in Pre- and Post-Educational Treatment in Type 1 Diabetes Mellitus During COVID-19

Purpose

The coronavirus-19 (COVID-19) pandemic requires the use of online media to ensure monitoring of type 1 diabetes mellitus (T1DM) in children. Thus, this study aims to determine whether online education effectively improves the quality of life (QoL) in children with T1DM during the coronavirus-19 pandemic.

Patients and Methods

The study, conducted from March to October 2020, utilized the paired t-test before and after online education. Moreover, it adopts the recommended Pediatric Quality of Life Inventory (PedsQL) 3.2 diabetes module for the 33 patients registered in the Pediatric Endocrine Outpatient Clinic of Dr. Soetomo Hospital, Surabaya, Indonesia.

Results

The QoL of all children (p = 0.011), parents (p = 0.001), and both children and parents (overall; p = 0.002) have shown significant improvement after the treatment. The QoL of parents, as a subcriterion, improved after the treatment. However, the improvement in the children in subcriterion treatment II (p = 0.186) was not significant.

Conclusion

Online education has proven to create a better QoL almost in all children with T1DM during the coronavirus-19 pandemic.

Treatment Success and User-Friendliness of An Electric Toothbrush App: A Pilot Study

Electronic and mobile health (eHealth/mHealth) are rapidly growing areas in medicine and digital technologies are gaining importance. In dentistry, digitalization is also an emerging topic, whereby more and more applications are being offered. As an example, using real-time feedback, digital application software (an app) was designed to help users brush their teeth more accurately. However, there is no data on the effectiveness and haptic of such apps. Therefore, a single-blinded, randomized controlled clinical trial was designed: twenty volunteers received an electric toothbrush with an associated app to assess whether the app-assisted toothbrushing is better than without. After a short period of familiarization with the electric toothbrush, plaque index (O‘Leary et al. 1972) was recorded and subjects were assigned to the test (with app; n = 10) or the control group (no app; n = 10). At the end of the 2-week pilot study period, plaque was again assessed and participants in the test group completed a questionnaire about the app’s user-friendliness. Statistical analysis revealed no significant differences between the test and control groups. The plaque index improved on average by 8.5% points in the test and 4.7% points in the control group. Fifty percent of the test group participants were of the opinion that they had achieved better cleaning results and would recommend the app to others, although the app contributed only marginally to increased plaque removal. However, such apps may nevertheless be helpful as motivational tools, especially when tracking and monitoring cleaning data. Therefore, more development and research on this topic is indicated.

Sustainable diabetes care services during COVID-19 pandemic

INTRODUCTION

The COVID-19 pandemic creates a challenge in the provision of care for patients with diabetes. Furthermore, those with uncontrolled diabetes are at a higher risk for complications due to COVID-19. The purpose of this study is to find an innovative method to sustain effective diabetes care services amidst the COVID-19 pandemic.

METHODS

Outpatient diabetes care was successfully transformed from traditional face-to-face encounters in the clinic to an online telemedicine service.

RESULTS

1,972 patients were encountered over a 4-week study period during which we had a low proportion of unreached patients (4%). Some patients were still seen in person because they came as walk-in visits or insisted to be seen in person.

CONCLUSION

Telemedicine has become an essential healthcare service and could be augmented by the use of technology like web-based applications and communication via transfer of data from patients' glucometer, insulin pumps, or sensors. Diabetes care can be transitioned to telemedicine effectively and would be successful in reaching more patients than by traditional face-to-face visits. This model of care is time consuming and unfortunately does not reduce the need for medical staff.

Télépied Study: A Single-Centre Trial in Diabetic Subjects Comparing Total Duration of Hospitalization Over a 1-Year Period Required for Complete Healing of a Foot Ulcer Using Telemedicine Management and a Referral Nurse Versus the Standard Care Pathway

PURPOSE

The aim of this study is to demonstrate that the total number of days in hospital required for healing of a de novo diabetes-related foot ulcer (DFU) is lower in patients followed up using a telemedicine platform (Télépied Follow-Up group [Group 2]) than in patients followed up using standard care (Standard Follow-Up control group [Group 1]). Patients are assigned to either Group 1 or Group 2 depending on whether their first inclusion visit is during an even or odd week. Patients included in Group 1 are to be followed at spaced intervals during day hospital visits by the investigator assisted by a specialized referral nurse as part of the regular follow-up procedure (dressing changes + ulcer monitoring). Between visits, an independent nurse (IN) provides local care on a daily basis. Patients included in Group 2 have their DFU treated by a referral nurse trained at the diabetic foot unit of the investigating centre, and they are also followed up by an IN under the supervision of a referral nurse. In Group 2, monitoring of lesions is performed weekly by the referral nurse using photos of the DFU with planimetry taken by the IN and sent to the referral nurse via telemedicine software. The referral nurse can, in turn, provide guidance to the IN on the care to be provided and/or decide that a further hospital visit is needed. Both treatment groups are to be followed for 12 months or until complete healing of the ulcer.

RESULTS

Recruitment for the study began in March 2017 and ended in May 2019, with the final study visit scheduled for May 2020.

CONCLUSION

The aim of the Télépied study is to assess the impact of ambulatory foot ulcer management in diabetics over a 1-year period by a non-specialized IN working under the supervision of a referral nurse via telemedicine follow-up versus standard follow-up by an IN alone. The primary endpoint is the total duration of hospitalization required until full healing of the ulcer.

Remote Monitoring of Diabetes: A Cloud-Connected Digital System for Individuals With Diabetes and Their Health Care Providers

Benefits of telemedicine have been proven in the field of diabetes. Among a number of technical solutions, Diabeo® has been studied in both type 1 and type 2 diabetes with intensive insulin therapy. This digital therapeutic system contains a self-monitoring glucose logbook and offers automated insulin dose recommendations thanks to a fully customizable algorithm. In addition, the cloud-based dedicated software also has features to facilitate remote monitoring, including a platform for diabetes nurses who perform coaching and treatment adjustment. A detailed description of this telemedicine system is provided, as well as results of completed clinical studies. In particular, TeleDiab 1's positive results on HbA1c in type 1 diabetes are detailed. We conclude with a discussion of the role of this telemedicine system within the landscape of mobile apps for diabetes.

A Randomized Controlled, Treat-to-Target Study Evaluating the Efficacy and Safety of Insulin Glargine 300 U/mL (Gla-300) Administered Using Either Device-Supported or Routine Titration in People With Type 2 Diabetes

BACKGROUND

The efficacy/safety of device-supported versus routine titration with Gla-300 in type 2 diabetes (T2DM) was evaluated.

METHOD

AUTOMATIX was a 16-week, randomized, open-label, parallel-group, multicenter, noninferiority trial in insulin-treated or insulin-naïve people with T2DM. The fasting self-monitored plasma glucose (FSMPG) target was 90-130 mg/dL (5.0-7.2 mmol/L). Primary endpoint: proportion of participants achieving target FSMPG at week 16 without severe hypoglycemia. Secondary endpoints included: proportion reaching FSMPG target without confirmed (≤70 mg/dL [≤3.9 mmol/L]) or severe hypoglycemia; time to first achieve FSMPG target; mean FSMPG and HbA1c change (baseline to week 16). Safety endpoints included hypoglycemia and adverse events. Patient-reported outcomes (PROs) were also assessed.

RESULTS

Participants were randomized to device-supported (n = 75) or routine titration (n = 76); 17 participants in the device-supported group discontinued device use. Noninferiority was achieved for the primary endpoint (device-supported: 45.9%, routine: 36.8%; weighted difference: 9.04 [95% CI: -6.75, 24.83]), but not superiority (P = .262). The proportion reaching FSMPG target range without confirmed (≤70 mg/dL [≤3.9 mmol/L]) or severe hypoglycemia was 34.3% vs 14.5%, respectively. The time at which 50% of the participants achieved the FSMPG target was less in the device-supported than routine titration arm (10 vs 13 weeks). Least squares mean HbA1c reduction, safety profiles, and PROs were similar in both arms. Mean "ease of use" score for the device, assessed by healthcare professionals and participants on a scale of 1-7, was ≥6.

CONCLUSIONS

Device-supported self-titration had a good safety/efficacy profile, and was noninferior to routine titration and well accepted by diabetes specialists and patients.

Virtual Coaching to Enhance Diabetes Care

Rates of diabetes are increasing worldwide and there is not a sufficient clinical workforce to care for these patients. Diabetes-related apps are a feasible way to provide diabetes education to large numbers of people with diabetes but attrition rates are high. Apps enhanced by virtual coaching may be a way to circumnavigate these problems. Virtual coaches are able to address common treatment barriers and other health disparities by providing data-driven individualized support in real time, at any time of day, and from anywhere. Enhanced glycemic benefits have been seen in those who use an app plus virtual coaching versus those who use an app alone, along with clinically meaningful behavior change, psychosocial effects, prolonged engagement, and high levels of satisfaction with the system. More research needs to be done to determine the longitudinal and widespread effects of virtual coaching in different populations.

Rapid Evidence Review of Mobile Applications for Self-management of Diabetes

BACKGROUND

Patients with diabetes lack information on which commercially available applications (apps) improve diabetes-related outcomes. We conducted a rapid evidence review to examine features, clinical efficacy, and usability of apps for self-management of type 1 and type 2 diabetes in adults.

METHODS

Ovid/Medline and the Cochrane Database of Systematic Reviews were searched for systematic reviews and technology assessments. Reference lists of relevant systematic reviews were examined for primary studies. Additional searches for primary studies were conducted online, through Ovid/Medline, Embase, CINAHL, and ClinicalTrials.gov . Studies were evaluated for eligibility based on predetermined criteria, data were extracted, study quality was assessed using a risk of bias tool, information on app features was collected, and app usability was assessed. Results are summarized qualitatively.

RESULTS

Fifteen articles evaluating 11 apps were identified: six apps for type 1 and five apps for type 2 diabetes. Common features of apps included setting reminders and tracking blood glucose and hemoglobin A1c (HbA1c), medication use, physical activity, and weight. Compared with controls, use of eight apps, when paired with support from a healthcare provider or study staff, improved at least one outcome, most often HbA1c. Patients did not experience improvements in quality of life, blood pressure, or weight, regardless of app used or type of diabetes. Study quality was variable. Of the eight apps available for usability testing, two were scored "acceptable," three were "marginal," and three were "not acceptable."

DISCUSSION

Limited evidence suggests that use of some commercially available apps, when combined with additional support from a healthcare provider or study staff, may improve some short-term diabetes-related outcomes. The impact of these apps on longer-term outcomes is unclear. More rigorous and longer-term studies of apps are needed.

REGISTRATION

This review was funded by the Agency for Healthcare Research and Quality (AHRQ). The protocol is available at: http://www.effectivehealthcare.ahrq.gov/topics/diabetes-mobile-devices/research-protocol .

CoYoT1 Clinic: Home Telemedicine Increases Young Adult Engagement in Diabetes Care

BACKGROUND

Young adults with type 1 diabetes (T1D) experience poor glycemic control, disengagement in care, and are often lost to the medical system well into their adult years. Diabetes providers need a new approach to working with the population. The goal of this study was to determine whether an innovative shared telemedicine appointment care model (CoYoT1 Clinic [pronounced as "coyote"; Colorado Young Adults with T1D]) for young adults with T1D improves care engagement, satisfaction, and adherence to American Diabetes Association (ADA) guidelines regarding appointment frequency.

SUBJECTS AND METHODS

CoYoT1 Clinic was designed to meet the diabetes care needs of young adults (18-25 years of age) with T1D through home telemedicine. Visits occurred every 3 months over the 1-year study (three times by home telemedicine and one time in-person). Outcomes were compared to patients receiving treatment as usual (control).

RESULTS

Compared with controls, CoYoT1 patients attended significantly more clinic visits (P < 0.0001) and increased their number of clinic visits from the year before the intervention. Seventy-four percent of CoYoT1 patients were seen four times over the 12-month study period, meeting ADA guidelines, but none in the control group met the ADA recommendation. CoYoT1 patients used diabetes technologies more frequently and reported greater satisfaction with care compared with controls.

CONCLUSIONS

Delivering diabetes care by home telemedicine increases young adults' adherence to ADA guidelines and usage of diabetes technologies, and improves retention in care when compared to controls. Home telemedicine may keep young adults engaged in their diabetes care during this challenging transition period.

Accuracy of Automatic Carbohydrate, Protein, Fat and Calorie Counting Based on Voice Descriptions of Meals in People with Type 1 Diabetes

The aim of this work was to assess the accuracy of automatic macronutrient and calorie counting based on voice descriptions of meals provided by people with unstable type 1 diabetes using the developed expert system (VoiceDiab) in comparison with reference counting made by a dietitian, and to evaluate the impact of insulin doses recommended by a physician on glycemic control in the study&rsquo;s participants. We also compared insulin doses calculated using the algorithm implemented in the VoiceDiab system. Meal descriptions were provided by 30 hospitalized patients (mean hemoglobin A1c of 8.4%, i.e., 68 mmol/mol). In 16 subjects, the physician determined insulin boluses based on the data provided by the system, and in 14 subjects, by data provided by the dietitian. On one hand, differences introduced by patients who subjectively described their meals compared to those introduced by the system that used the average characteristics of food products, although statistically significant, were low enough not to have a significant impact on insulin doses automatically calculated by the system. On the other hand, the glycemic control of patients was comparable regardless of whether the physician was using the system-estimated or the reference content of meals to determine insulin doses.

Distal technologies and type 1 diabetes management

Type 1 diabetes requires intensive self-management to avoid acute and long-term health complications. In the past two decades, substantial advances in technology have enabled more effective and convenient self-management of type 1 diabetes. Although proximal technologies (eg, insulin pumps, continuous glucose monitors, closed-loop and artificial pancreas systems) have been the subject of frequent systematic and narrative reviews, distal technologies have received scant attention. Distal technologies refer to electronic systems designed to provide a service remotely and include heterogeneous systems such as telehealth, mobile health applications, game-based support, social platforms, and patient portals. In this Review, we summarise the empirical literature to provide current information about the effectiveness of available distal technologies to improve type 1 diabetes management. We also discuss privacy, ethics, and regulatory considerations, issues of global adoption, knowledge gaps in distal technology, and recommendations for future directions.

Connected Health Devices for Health Care in French General Medicine Practice: Cross-Sectional Study

Background

The integration of Connected Health Devices (CHDs) is growing within mobile health (mHealth) and telemedicine, encouraged by institutions and industries. The idea is to improve lifestyle habits and health behaviors as a preventive goal in an aging population with fewer physicians available. However, their ill-defined place in health care does not promote their use in current medical practice.

Objective

The primary objective of this study was to quantify CHDs’ use rate by general practitioners (GPs). A secondary objective was to evaluate their benefits and limitations in usual care.

Methods

A cross-sectional study through an Internet-based survey was addressed to French GPs via regional medical unions and continuous education agencies, supplemented with an informative website, from March 2015 to July 2015. Surveys where either the form was insufficiently filled or the main question was left unanswered were excluded from the study.

Results

A total of 1084 answers were analyzed, of which 19.46% (211/1084, 95% CI 17.1-21.8) GPs used CHDs, and 10.15% (110/1084, 95% CI 8.5-12.1) prescribed a CHD. CHD users statistically prescribed more CHDs (7.38% [80/1084] in the user group vs 2.86% [31/1084] in nonusers; P<.001) and were more likely to use them in the future. Major interests in their utilization were in patient monitoring for 84.96% (921/1084) and patient education for 75.83% (822/1084), especially for diabetes (89.67%, 972/1084) and hypertension (84.13%, 912/1084). Generated data had to be managed securely by the patient primarily for 85.79% (930/1084) of the GPs. CHDs had to not constrain GPs outside clinical consultation, nor restrain their time for 75.83% (822/1084). Additional actors in patient care were not desired for 79.98% (867/1084) of the GPs. Questions about data management issues and technical difficulties were raised.

Conclusions

CHDs are little used by French GPs and even less prescribed to their patients, as only a few GPs use these tools. Their benefits as tools of patient empowerment, although expected, remain to be demonstrated in real-life setups.

The evolution of publication hotspots in the field of telemedicine from 1962 to 2015 and differences among six countries

Introduction Telemedicine has been implemented in many countries and has captured the attention of many researchers. Herein, we aim to quantify publication hotspots in the field of telemedicine, analyse their evolution, compare them in different countries, and provide visual representations. Methods We used software tools to process PubMed entries for a 54-year period and identified publication hotspots using keyword frequency analysis. We employed a keyword co-occurrence analysis, principal component analysis, multidimensional scaling analysis, and network visualization technology. Results The number of Medical Subject Heading (MeSH) terms increased with time. The most common subcategories of telemedicine between 1962 and 2015 were Remote Consultation, Teleradiology, and Telepathology. The most popular information communication technologies in telemedicine publications were related to the Internet and cell phones. The topics of Patient Satisfaction, Treatment Outcomes, and Home Care Services associated with telemedicine were highlighted after the 1990s. Use frequency of the terms Cell Phones and Self-Care increased drastically in the past six years, and the publication focus in six countries that had the highest output was different. Knowledge network maps and perceptual maps show the relationship between high-frequency MeSH terms. Discussion The telemedicine field has experienced significant growth and expansion in knowledge and innovation in the last 54 years. Publication hotspots for telemedicine lean towards clinical treatment, home care services, and personal care, and countries emphasize publishing in areas related to their national characteristics. This study quantitatively discusses publication hotspots, provides an objective and systematic understanding of this field, and suggests directions for future telemedicine research.

Evidence-based Mobile Medical Applications in Diabetes

This article reviews mobile medical applications that are commercially available in the United States or European Union (EU) and are (1) associated with published data of clinical outcomes in the peer-reviewed literature during the past 5 years, (2) cleared by the US Food and Drug Administration (FDA) in the United States, or (3) a recipient of a CE (Conformité Européenne) mark by the EU. Many of these applications have been shown to positively affect outcomes in the short term, but long-term studies are needed. Until more data are available, consumers and professionals can consider guidance based on FDA/CE status.

Improved A1C Levels in Type 1 Diabetes with Smartphone App Use

OBJECTIVES

Smartphones are a potentially useful tool in diabetes care. We have developed an application (app) linked to a website, Intelligent Diabetes Management (IDM), which serves as both an insulin bolus calculator and an electronic diabetes diary. We have prospectively studied whether patients using this app improved control of their glucose levels.

METHODS

Patients with type 1 diabetes were recruited. There was a 4-week observation period, midway during which we offered to review the participants' records. The app was then downloaded and participants' diabetes regimens entered on the synchronized IDM website. At 2, 4, 8, 12 and 16 weeks of the active phase, their records were reviewed online, and feedback was provided electronically. The primary endpoint was change in levels of glycated hemoglobin (A1C).

RESULTS

Of the 31 patients recruited, 18 completed the study. These 18 made 572±98 entries per person on the IDM system over the course of the study (≈5.1/day). Their ages were 40.0±13.9 years, the durations of their diabetes were 27.3±14.9 years and 44% used insulin pumps. The median A1C level fell from 8.1% (7.5 to 9.0, IQ range) to 7.8% (6.9 to 8.3; p<0.001). During the observation period, glucose records were reviewed for 50% of the participants. In the active phase, review of the glucose diaries took less time on the IDM website than using personal glucose records in the observation period, median 6 minutes (5 to 7.5 IQ range) vs. 10 minutes (7.5 to 10.5 IQ range; p<0.05).

CONCLUSIONS

Our smartphone app enables online review of glucose records, requires less time for clinical staff and is associated with improved glucose control.

Innovative health informatics as an effective modern strategy in diabetes management: a critical review

OBJECTIVE

Diabetes mellitus is the most common metabolic disorder in developing countries. Mobile health applications are helpful in improving the diabetes management. However, the effectiveness of these techniques needs to be assessed rigorously. Therefore, the authors have systematically reviewed the recent clinical studies using mobile health applications for diabetes management.

MATERIALS AND METHODS

Original articles that were published in ISI indexed journals listed in PubMed from the year 2007 till 2014 were searched using specific search key phrases. The intervention technology and study methodology were analysed to have a better understanding of the outcomes of each study.

RESULTS

Twenty-one articles were selected for the review. Most studies (76%) reported positive outcomes after use of the mobile health applications. Smartphone apps significantly improved the clinical outcomes. User-friendliness of the systems often influence the patient compliance and the clinical outcomes.

CONCLUSION

Smartphone/web applications offer significant benefits for patient care, education and behavioural modifications. Providing a continuous patient support using mobile may be a challenging task and would require adequate infrastructure and personnel.

Remote Patient Monitoring via Non-Invasive Digital Technologies: A Systematic Review

BACKGROUND

We conducted a systematic literature review to identify key trends associated with remote patient monitoring (RPM) via noninvasive digital technologies over the last decade.

MATERIALS AND METHODS

A search was conducted in EMBASE and Ovid MEDLINE. Citations were screened for relevance against predefined selection criteria based on the PICOTS (Population, Intervention, Comparator, Outcomes, Timeframe, and Study Design) format. We included studies published between January 1, 2005 and September 15, 2015 that used RPM via noninvasive digital technology (smartphones/personal digital assistants [PDAs], wearables, biosensors, computerized systems, or multiple components of the formerly mentioned) in evaluating health outcomes compared to standard of care or another technology. Studies were quality appraised according to Critical Appraisal Skills Programme.

RESULTS

Of 347 articles identified, 62 met the selection criteria. Most studies were randomized control trials with older adult populations, small sample sizes, and limited follow-up. There was a trend toward multicomponent interventions (n = 26), followed by smartphones/PDAs (n = 12), wearables (n = 11), biosensor devices (n = 7), and computerized systems (n = 6). Another key trend was the monitoring of chronic conditions, including respiratory (23%), weight management (17%), metabolic (18%), and cardiovascular diseases (16%). Although substantial diversity in health-related outcomes was noted, studies predominantly reported positive findings.

CONCLUSIONS

This review will help decision makers develop a better understanding of the current landscape of peer-reviewed literature, demonstrating the utility of noninvasive RPM in various patient populations. Future research is needed to determine the effectiveness of RPM via noninvasive digital technologies in delivering patient healthcare benefits and the feasibility of large-scale implementation.

Using technology to advance type 1 diabetes care among women during the reproductive years and in pregnancy

The prevalence of diabetes is increasing globally. Technology to improve care among individuals with diabetes is constantly being developed. Women living with Type 1 Diabetes Mellitus (T1DM) have unique challenges affecting their glucose control relating to menstrual cycles, pregnancy, and menopause. The purpose of this review is to examine the literature related to the use of technology to help women with T1DM manage their diabetes during the reproductive years, pregnancy, and beyond. Continuous subcutaneous insulin infusion (CSII) therapy can provider equivalent or better glucose control when compared with multiple daily injections (MDI), with less hypoglycemia, diabetic ketoacidosis, and weight gain. The CSII therapy has features that could help improve glucose control over the menstrual cycle, menopause, and pregnancy, although the most studied of these stages is pregnancy. Continuous glucose monitoring (CGM) can be combined with any insulin delivery system (MDI or CSII) to provide data on glucose values every few minutes and show glucose trends over time. CGM introduction can highlight glucose variability for women with T1DM, may be beneficial during pregnancy, and can reduce hypoglycemia. Sensor-augmented pump therapy and hybrid artificial pancreas (closed-loop) systems are promising tools that improve outcomes among individuals with diabetes. The use of modern technology to improve glucose and metabolic control among menopausal women with diabetes has not been well studied. Internet and phone-based technologies are emerging as important tools that may help with diabetes self-care for women living with diabetes.

[Technological innovations in the treatment of type 1 diabetes in pediatrics]

Insulin pumps, continuous glucose monitoring sensors and algorithms for managing the doses of insulin necessary to control blood sugar levels within target values: more and more research is being carried out into "closed loop" systems. The artificial pancreas is today at the stage of clinical trials in adults and children.

Data-Driven Personalized Feedback to Patients with Type 1 Diabetes: A Randomized Trial

BACKGROUND

A mobile phone-based application can be useful for patients with type 1 diabetes in managing their disease. This results in large datasets accumulated on the patient's devices, which can be used for individualized feedback. The effect of such feedback is investigated in this article.

MATERIALS AND METHODS

We developed an application that included a data-driven feedback module known as Diastat for patients on self-measured blood glucose regimens. Using a stepped-wedge design, both groups initially received an application without Diastat. Group 1 activated Diastat after 4 weeks, whereas Group 2 activated Diastat 12 weeks after startup (T1). End points were glycated hemoglobin (HbA1c) level and number of out-of-range (OOR) measurements (i.e., outside the range 72-270 mg/dL).

RESULTS

Thirty patients were recruited to the study, and 15 were assigned to each group after the initial meeting. There were no significant differences between groups at T1 in HbA1c or OOR events. Overall, all patients had a decrease of 0.6 percentage points in mean HbA1c (P < 0.001) and 14.5 in median OOR events over 2 weeks (P < 0.001).

CONCLUSIONS

The study does not provide evidence that data-driven feedback improves glycemic control. The decrease in HbA1c was sizeable and significant, even though the study was not powered to detect this. The overall improvement in glycemic control suggests that, in general, mobile phone-based interventions can be useful in diabetes self-management.

The empirical evidence for the telemedicine intervention in diabetes management

OBJECTIVE

The research presented here assesses the scientific evidence for the telemedicine intervention in the management of diabetes (telediabetes), gestational diabetes, and diabetic retinopathy. The impetus derives from the confluence of high prevalence of these diseases, increasing incidence, and rising costs, while telemedicine promises to ameliorate, if not prevent, type 2 diabetes and its complications.

MATERIALS AND METHODS

A purposeful review of the literature identified relevant publications from January 2005 to December 2013. These were culled to retain only credible research articles for detailed review and analysis. The search yielded approximately 17,000 articles with no date constraints. Of these, 770 appeared to be research articles within our time frame. A review of the abstracts yielded 73 articles that met the criteria for inclusion in the final analysis. Evidence is organized by research findings regarding feasibility/acceptance, intermediate outcomes (e.g., use of service, and screening compliance), and health outcomes (control of glycemic level, lipids, body weight, and physical activity.)

RESULTS

Definitions of telediabetes varied from study to study vis-à-vis diabetes subtype, setting, technology, staffing, duration, frequency, and target population. Outcome measures also varied. Despite these vagaries, sufficient evidence was obtained from a wide variety of research studies, consistently pointing to positive effects of telemonitoring and telescreening in terms of glycemic control, reduced body weight, and increased physical exercise. The major contributions point to telemedicine's potential for changing behaviors important to diabetes control and prevention, especially type 2 and gestational diabetes. Similarly, screening and monitoring for retinopathy can detect symptoms early that may be controlled or treated.

CONCLUSIONS

Overall, there is strong and consistent evidence of improved glycemic control among persons with type 2 and gestational diabetes as well as effective screening and monitoring of diabetic retinopathy.

Clinical evaluation of the use of a multifunctional remotely controlled insulin pump: multicenter observational study

Current insulin pumps now feature advanced functions for calculating insulin dosages, delivering insulin and analyzing data, however, the perceived usefulness of these functions in clinical settings has not been well studied. We assessed the use and patient perceptions of an insulin delivery system (Accu-Chek® Combo, Roche Diagnostics, Mannheim, Germany) that combines an insulin pump and a handheld multifunctional blood glucose meter with integrated remote control functions. This prospective, observational, multicenter study enrolled 74 type 1 diabetes patients within 13 weeks after starting use of the pump system. At 4 to 24 weeks, investigators collected usage data from the latest 14-day period. Seventy-two patients completed the evaluation, aged 39 ± 15 years, diabetes duration 16 ± 13 years, HbA1c 8.3 ± 1.6%. At follow-up, 62 (86.1%) patients used the remote control for ≥50% of all boluses, 20 (27.8%) used the bolus advisor for ≥50% of all boluses, and 42 (58.3%) viewed at least 1 of the e-logbook reports. More than 95% of users appraised the functions as easy-to-use and useful; median scores from VAS (0 = useless to 100 = indispensable) ranged from 72 to 85. A high percentage of study patients used the system's advanced features, especially the remote control feature for bolusing. Overall, patients assessed the functions as useful and easy to use. Results support the implementation of these smart capabilities in further insulin pump developments.

Commercial Smartphone-Based Devices and Smart Applications for Personalized Healthcare Monitoring and Management

Smartphone-based devices and applications (SBDAs) with cost effectiveness and remote sensing are the most promising and effective means of delivering mobile healthcare (mHealthcare). Several SBDAs have been commercialized for the personalized monitoring and/or management of basic physiological parameters, such as blood pressure, weight, body analysis, pulse rate, electrocardiograph, blood glucose, blood glucose saturation, sleeping and physical activity. With advances in Bluetooth technology, software, cloud computing and remote sensing, SBDAs provide real-time on-site analysis and telemedicine opportunities in remote areas. This scenario is of utmost importance for developing countries, where the number of smartphone users is about 70% of 6.8 billion cell phone subscribers worldwide with limited access to basic healthcare service. The technology platform facilitates patient-doctor communication and the patients to effectively manage and keep track of their medical conditions. Besides tremendous healthcare cost savings, SBDAs are very critical for the monitoring and effective management of emerging epidemics and food contamination outbreaks. The next decade will witness pioneering advances and increasing applications of SBDAs in this exponentially growing field of mHealthcare. This article provides a critical review of commercial SBDAs that are being widely used for personalized healthcare monitoring and management.

Tele-diabetology to Screen for Diabetes and Associated Complications in Rural India: The Chunampet Rural Diabetes Prevention Project Model

Diabetes, with its acute and long-term complications, has become a major health hazard in developing countries. An estimated 62.4 million people in India have diabetes. With increasing urbanization and industrialization, we can expect huge numbers of people with diabetes in India in the future. Moreover, all diabetes efforts in India are currently focused in urban areas while 70% of India's population actually lives in rural areas. The current statistics demonstrates that urgent interventions are mandatory to curb the epidemic of diabetes and its complications at the grassroots level. This gap in providing diabetes care can be nullified by the use of tele-diabetology. This holds great potential to overcome barriers and improve quality and access to diabetes care to remote, underserved areas of developing counties. The Chunampet Rural Diabetes Prevention Project (CRDPP) has been developed and tested as a successful model for screening and delivering diabetes care to rural areas in developing countries. Using a tele-diabetology mobile van loaded with appropriate equipment, trained technicians, and satellite technology helped us to screen for diabetes and its complications and deliver diabetes care to remote villages in southern India. The Chunampet model can be applied in reaching out to remote areas where specialized diabetes care facilities may not be available.