Clinical outcomes of a digitally supported approach for self-management of type 2 diabetes mellitus

Background

Self-management of Type 2 diabetes mellitus (T2D) is challenging. Regular self-monitoring of blood glucose and healthy lifestyles are required to improve glycometabolic control, thus delaying diabetes complications, and reducing hospitalizations. Digital technologies can empower patients in their disease management promoting self-management and motivation to change behaviors. We report the results of an exploratory trial aimed at evaluating the metabolic outcomes of using digital solutions for T2D self-management developed in the ProEmpower project, a European Commission funded Pre-Commercial Procurement.

Methods

Two digital solutions, DM4All and DiaWatch, which were codesigned with providers, patients, and caregivers, enabled the collection of clinical parameters by the patient using a smartphone integrated with the medical devices (glucometer, sphygmomanometer, scale, smart watch for heart rate monitoring and step counter). Data were automatically sent to the shared care plan allowing professionals to monitor adherence to treatment, set goals, and communicate more effectively with patients. At baseline and after an average follow-up of 8 months, glycosylated hemoglobin (HbA1c), body weight, blood pressure, and blood lipids were measured in 100 T2D patients using the ProEmpower solutions across different diabetes centers in Campania Region, age 45-79  years, both genders, and compared with a Control cohort of T2D patients (n = 100) with similar clinical characteristics and followed for a comparable period of observation in the same centers.

Results

At baseline, the ProEmpower participants and the Control subjects were on average overweight, with a similar BMI in the two cohorts, and mean HbA1c was at acceptable levels (around 7.0%). After the 8 month exploratory trial, body weight, HbA1c, systolic and diastolic blood pressure, and plasma and LDL-cholesterol significantly decreased in the ProEmpower participants compared to baseline (p < 0.05 for all). The changes in systolic and diastolic blood pressure, and plasma and LDL-cholesterol were significantly different from those observed in the Control cohort (p < 0.05 for all).

Conclusion

This pilot study showed positive effects on metabolic outcomes relevant to cardiovascular risk in T2D of adopting digital telemedicine self-monitoring solutions based on automation of measurements and coaching on healthy lifestyles promotion.

Gender differences in COVID-19 patients: a regional survey among physicians of Internal Medicine Wards

Severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2) has infected millions of individuals around the World. Hypertension (HT), chronic heart disease (CHD), and diabetes mellitus (DM), particularly in the elderly, increase susceptibility to SARS-CoV-2 infection. However, conflicting results [such as coronavirus 2019 (COVID-19) disease vulnerability, case fatality, etc.] have been reported about the response to infection and COVID-19 outcomes in men and women. Therefore, understanding predictors of Intensive Care Unit (ICU) admission might help future planning and management of the disease. We conducted a multicenter survey about COVID-19 involving internists from Internal Medicine Wards. This survey indirectly allowed us to analyze the information of 2400 patients hospitalized in 35 wards of Internal Medicine of the Campania Region between July and October 2020. Our investigation has detected that the infection is more frequent in males, and the number of male patients hospitalized in ICU is also higher than females, with a large proportion of hypertensive patients. Extensive prospective studies are required to confirm this finding and explore the mechanisms for which hypertensive males are exposed to a higher proportion of admission to ICU and higher case fatality rates.

Postprandial hyperglycemia: a new frontier in diabetes management?

Postprandial hyperglycemia is one of the earliest abnormalities of glucose homeostasis associated with type-2 diabetes and it is markedly exaggerated in diabetic patients with fasting hyperglycemia. An extensive body of data demonstrates a strong association between postprandial glucose levels and cardiovascular risk factors. Our article will focus on the concept of postprandial hyperglycemia, its physiopathology, its role on cardiovascular risk factors and the effects of new devices and a new faster insulin analog on postprandial hyperglycemia.

A clinical audit: diagnostic and epidemiological evaluation of the adrenal incidentaloma

BACKGROUND

Audit is a clinical instrument of government characterized by a whole process of evaluation inter pares to improve medical behaviors in the clinical practice. Different endocrinopathies are underestimated in the clinical and diagnostics practice but they can be a real problem in patients admitted in the departments of Internal Medicine. The adrenal incidentaloma is an accidental discovery with an incidence equal to 4% in radiologic studies but it's rarely considereted in the internal disorders. In the departments of Internal Medicine are hospitalized each year approximately 1450,000 patients and 58,000 about them show a surrenalic lesion identified with CT or MRI as Adrenal Incidentaloma.

METHODS

Through a search in the radiological archives, were reviewed all abdominal CT performed in the year 2012 in 8 departments of Internal Medicine of 8 Italian public hospitals. They also examined all medical records of these patients to value clinical management of the adrenal masses and the real incidence of the adrenal incidentaloma.

RESULTS

Distribution of pathological results show an important incidence about adrenal incidentaloma in Italian patients although this pathology is represented as a rare disease and its clinical and economic burden are significant. Many questions remain unanswered as the association between duration and severity of the disease, morbidity and how the dimensions affecting it. These results need to be supported by important studies with long follow-up to realize an easy diagnosis.

CONCLUSIONS

The results of this audit confirm the real incidence of this pathology in the internistic patients and the final target is to implement changes about therapeutic diagnostic pathway of the hospital patients in the internal medicine departments.

The management of the patient with malnutrition: from evidence to clinical practice

Malnutrition can be defined as a state of nutrition in which a deficiency or excess (or imbalance) of energy, protein and other nutrients causes measurable adverse effects on tissue/body form (body shape, size, composition) body function and clinical outcome. Malnutrition is a highly prevalent condition in the acute hospital setting with studies reporting rates of approximately 40%. Malnutrition is associated with many adverse outcomes including depression of the immune system, impaired wound healing, muscle wasting, longer lengths of hospital stay and increased mortality. Unidentified malnutrition not only heightens the risk of adverse complications for patients but results in an increase in health care costs. This can be prevented if special attention is given to their nutritional care. For this reason, hospital and healthcare organizations should have a policy and a specific set of protocols for identifying patients at nutritional risk, leading to appropriate care plans. The objective of this monograph is to provide evidence-based recommendations for the proper management of malnutrition by multi-parametric analysis of the guidelines available to date.

Insulin therapy in the hospital setting: a time for a change?

The number of people with diabetes mellitus worldwide is expected to be more than double from 171 million in 2000 to 366 million in 2030. Approximately 25% of all hospital inpatient days are affected by diabetes. In Italy there are more than 12,000 hospitalizations excesses for 100,000 people per year, with a huge economic impact. Ever since its discovery in the 1920s, insulin has been the milestone of type 1 diabetes treatment and its use is increasingly necessary for the successful management of type 2 diabetes. Often patients believe that injecting insulin can be painful, inconvenient and embarrassing; generally they are afraid of gaining weight and of hypoglycemia. On the other side, physician’s concerns regarding insulin administration include potential dosing errors and patient non-compliance. Ever since its discovery in the mid-1920s, insulin was administered subcutaneously using a vial and syringe. In 1985 the first pen device was launched. Currently disposable insulin pens are the most used and preferred by patients in the daily use, but are not routinely used for diabetic inpatients. In this paper we will focus on the pros and cons of insulin administration with pens in the hospital setting.

Clinical governance and internal medicine: a marriage of convenience?

Amplification in health expectations, increase in new technologies, decrease in economic resources and the breakdown of traditional control systems have led to the development of clinical governance (CG). The aim of the present pilot study was to investigate the application of CG tools in significant sample of Italian internal medicine wards (IMW). A 37-item questionnaire was developed and administered to 39 physicians, within 33 IMWs throughout Italy. Thanks to the data analysis, the perceived usefulness, the utilization rate of CG tools, the correlations between CG use, wards characteristics, and/or localization were studied. We identified at what organizational level the CG tools were applied and used. fifty-two percent of the studied tools were being used in the investigated hospitals. The average utility and utilization rate was different depending on the region of provenance. This research showed that CG is a methodology often used by Italian hospitals physicians, especially for inpatient care. The encouraging results of this pilot study could suggest opportunities to extend the survey at national level, to generalize the results.

The discharge of patients with diabetes from Internal Medicine Units: a clinical audit

The aim of the present study was to address it by conducting a clinical audit, one that focused on the quality evaluation of the assistance given to patients with diabetes at the moment of their discharge from hospital. The clinical audit was structured in 5 phases: i) preparation; ii) definition of criteria, indicators and standards; iii) retrospective data collection; iv) data analysis, identification of main deviations from standards; v) implementation of corrective measures. Twenty Departments of Internal Medicine from 10 Italian regions retrospectively reviewed medical reports obtaining a data collection from 1332 discharged patients with diabetes. Patients receiving instructions for home glycemic control/discharged patients, showed a mean performance =41.6% (range: 5.0-89.9); patients receiving instructions for hypoglycemic treatment/discharged patients, =32.4% (range: 0.0-92.1); patients receiving instructions for subcutaneous insulin administration/discharged patients, =60.4% (range: 56.5-100.0); patients receiving nutritional scheme or advice/discharged patients, =24.8 (range: 25.4-76.6); patients addressed to ambulatory control/discharged patients, =60.7% (range: 65.6-100.0); and finally patients with HbA1c reported in discharge report/discharged patients, =40.6% (range: 1.75-98.0). Results confirmed that all the levels are well below 70%, the acceptable level of quality. The clinical audit provided data that allows for better identification of deficient clinical behaviors and the addressing of them with specific ameliorative actions; a continuing process of check, re-check and feedback in order to further enhance the quality of assistance given to patients with diabetes discharged from hospital.

Effects of dietary saturated, monounsaturated and n-3 fatty acids on fasting lipoproteins, LDL size and post-prandial lipid metabolism in healthy subjects

BACKGROUND

The influence of the quality of dietary fat on some aspects of lipid metabolism-i.e. lipoprotein concentrations, post-prandial lipids and LDL size-is not completely understood, especially in healthy individuals.

OBJECTIVES

Aim of this study was to evaluate the effects of different types of dietary fat (monounsaturated vs. saturated fatty acids, and n-3 or placebo supplementation) on fasting lipoproteins, LDL size and post-prandial lipids in healthy people.

DESIGN

One hundred and sixty-two individuals were randomly assigned to follow two isoenergetic diets, one rich in saturated fatty acids (SFA diet) and the other in monounsaturated fatty acids (MUFA diet). Each group was further randomised to receive supplementation with fish oil (3.6 g/day) or placebo.

RESULTS

The type of diet significantly affected LDL cholesterol and triacylglycerol content, which was higher with the SFA diet and lower with the MUFA diet. The changes between the two diets were statistically significant for cholesterol (P<0.01) and triacylglycerol (P<0.03). VLDL cholesterol and triacylglycerol were significantly reduced and LDL cholesterol significantly increased by fish oil supplementation. Plasma triacylglycerol was significantly lower in those taking n-3 fatty acids, also 1 and 3 h after a test-meal. Neither type of diet nor n-3 supplementation affected LDL size.

CONCLUSIONS

A moderate substitution of saturated fatty acids with monounsaturated fatty acids has beneficial effects on lipid metabolism also in healthy individuals. A moderate supplementation of long-chain n-3 fatty acids in healthy individuals reduces both fasting and post-prandial triacylglycerol concentrations but increases LDL cholesterol, irrespective of the type of diet.

Assay of erythrocyte membrane fatty acids. Effects of storage time at low temperature

The study of the stability of saturated mono-, or polyunsaturated fatty acids, both esterified and not esterified, in plasma, circulating cells, and tissues is extremely important to validate the use of biological samples stored at low temperature in "biological banks", which are used for experimental, observational, dietary, or pharmacological studies. Since red blood cells are easily accessible cells, they are used as a marker of less-accessible tissues, especially in large-scale epidemiological studies. Data from the literature suggest that the addition of an antioxidant and the freezing of red blood cells do not cause any variation in the fatty acid composition for a period of 2-6 months up to 1 year. We evaluated the fatty acid concentration in red blood cells isolated from venous blood samples of one subject, preserved with butylated hydroxytoluene and N2 and stored at -80 degrees C for up to 2 years. Erythrocytes of venous samples of six subjects stored at -20 degrees C for 6 months without butylated hydroxytoluene and in the presence of air were used for comparison purposes. Our data demonstrate that a long storage time (2 years) does not significantly influence the erythrocyte fatty acid concentration when using very low temperatures (-80 degrees C) and antioxidants (butylated hydroxytoluene) in the presence of N2.

Is the erythrocyte membrane fatty acid composition a valid index of skeletal muscle membrane fatty acid composition?

Recent studies suggest that insulin sensitivity is related to the fatty acid composition of phospholipids in skeletal muscle (SM) membranes. Since it is difficult to obtain muscle biopsies, it may be useful to have information on the fatty acid composition using more accessible cells such as erythrocytes. This would be possible only if the composition of erythrocyte and muscle membranes are very similar. Since no comparative data are available, we evaluated the phospholipid fatty acid composition of erythrocyte and SM membranes in 16 individuals, 10 nondiabetics (male to female ratio, 4:6; age, 50 +/- 11 years; body mass index, 27 +/- 5 kg/m2; mean +/- SD) and 6 type 2 diabetic patients (male to female ratio, 2:4; age, 64 +/- 5 years; body mass index, 27 +/- 4 kg/m2). All patients underwent abdominal surgery, during which a biopsy of the abdominal rectus muscle (50 to 100 mg) was obtained. Erythrocyte and SM phospholipid fatty acids were extracted and then methylated; the methyl fatty acids were separated and quantified by gas chromatography. Compared with erythrocyte membranes, muscle membranes showed a significantly higher proportion of omega-6 polyunsaturated fatty acid ([PUFA] 43.0% +/- 3.1% v29.7% +/- 1.6%, P < .001) and lower saturated fatty acid ([SFA] 41.1% +/- 1.5% v 43.4% +/- 1.2%, P < .001), monounsaturated fatty acid ([MUFA] 11.5% +/- 1.7% v 20.0% +/- 1.9%, P < .001), and omega-3 PUFA (3.8% +/- 0.6% v 7.4% +/- 1.0%, P < .001). The greatest increase involved linoleic acid (26.9% +/- 2.8% v 10.3% +/- 1.6%, P < .001), whereas lignoceric acid (0.8% +/- 0.2% v 5.0% +/- 0.6%, P < .001) and oleic acid (10.4% +/- 1.6% v 13.5% +/- 1.3%, P < .001) were significantly lower. These results show that erythrocyte and muscle membrane phospholipid fatty acids are significantly different. Therefore, data on SM membranes cannot be extrapolated on the basis of measures of erythrocyte phospholipid fatty acid composition.

Long-term effects of fish oil on lipoprotein subfractions and low density lipoprotein size in non-insulin-dependent diabetic patients with hypertriglyceridemia

The effects of fish oil on lipoprotein subfractions and low density lipoprotein (LDL) size in non-insulin-dependent diabetes mellitus (NIDDM) patients with hypertriglyceridemia are unknown. To elucidate this, 16 NIDDM hypertriglyceridemic patients (plasma triglyceride 2.25- 5.65 mmol/l, plasma cholesterol < or = 7.75 mmol/l) were randomly assigned to a 6-month period with either moderate amounts of fish oil (n = 8) or placebo (n = 8) after 4 weeks of wash-out and 3 weeks of run-in. Diet and hypoglycemic treatment were unchanged throughout the experiment. LDL size were evaluated at baseline and after 6 months. Three VLDL and LDL subfractions were measured at the end of the two periods. The total lipid concentration of all very low density lipoprotein (VLDL) subfractions was lower at the end of fish oil treatment compared with placebo (large VLDL 124.3 +/- 19.7 mg/dl vs 156.7 +/- 45.5 mg/dl; intermediate VLDL 88.5 +/- 9.5 mg/dl vs 113.9 +/- 23.2 mg/dl; small VLDL 105.9 +/- 9.7 mg/dl vs 128.9 +/- 40.7 mg/dl) (mean +/- SEM), although the difference was not statistically significant. Moreover, at the end of the two treatments, the percentage distribution of VLDL subfractions was very similar (large 37.5 +/- 3.3% vs 37.6 +/- 2.6%, intermediate 27.6 +/- 0.9% vs 31.0 +/- 2.4%; small 34.9 +/- 3.7% vs 31.4 +/- 2.1%). Concerning LDL, no significant change in LDL size was observed after the two treatments (255.4 +/- 2.2 A vs 254.2 +/- 1.7 A, fish oil; 253.7 +/- 2.0 A vs 253.3 +/- 1.7 A, placebo). LDL subfraction distribution was also very similar (large 17 +/- 3% vs 17 +/- 2%; intermediate 62 +/- 3% vs 65 +/- 3%; small 21 +/- 3% vs 18 +/- 2%), at the end of the two periods, confirming the lack of effects on LDL size. In conclusion, our study indicates that in NIDDM patients with hypertriglyceridemia, fish oil does not induce any improvement in LDL distribution and LDL size despite its positive effects on plasma triglycerides.

Long-term effects of fish oil on insulin resistance and plasma lipoproteins in NIDDM patients with hypertriglyceridemia

OBJECTIVE

The aim of this study was to evaluate the long-term (6-month) effects of moderate fish oil supplementation on insulin sensitivity and plasma lipoproteins in NIDDM patients with hypertriglyceridemia.

RESEARCH DESIGN AND METHODS

The study has been performed according to a randomized double-blind placebo-controlled design with a parallel group sequence. After a washout period of 4 weeks and a run-in period of 3 weeks, 16 NIDDM patients with hypertriglyceridemia (triglyceride [TG], 2.25-5.65 mmol/l) were randomly assigned to either fish oil (2.7 g/day eicosapentaenoic plus docosahexaenoic acid for 2 months, then 1.7 g/day for 4 more months) (n = 8) or placebo (n = 8). Diet and hypoglycemic drugs remained unchanged throughout the whole experiment. At baseline and after 6 months, insulin sensitivity was measured by euglycemic hyperinsulinemic clamp (insulin infused, 2.0 mIU.kg-1 body wt.min-1). At the same time, blood glucose control, fasting and postprandial serum insulin and nonesterified fatty acid (NEFA) concentrations, and fasting plasma lipoprotein concentrations were evaluated.

RESULTS

In the group treated with fish oil compared with the baseline, there was: 1) a significant reduction in both plasma TG (2.92 +/- 0.23 vs. 3.85 +/- 0.32 [mean +/- SE] mmol/l, P < 0.001) and VLDL-TG (2.35 +/- 0.24 vs. 4.25 +/- 0.66 mmol/l, P < 0.01), without significant changes in blood glucose control; 2) a significant reduction in fasting NEFA concentrations (572 +/- 100 vs. 825 +/- 131 mumol/l, P < 0.01); and 3) a significant enrichment in long-chain omega-3 fatty acids of erythrocyte membrane phospholipids. In the placebo group, there were no changes in any of the variables analyzed. The insulin-mediated glucose uptake was unchanged in both groups (fish oil, 4.04 +/- 0.82 mg.kg-1.min-1 at baseline and 3.96 +/- 0.50 mg.kg-1.min-1 at 6 months; placebo, 3.51 +/- 0.62 mg.kg-1.min-1 at baseline and 4.09 +/- 0.49 mg.kg-1.min-1 at 6 months).

CONCLUSIONS

In NIDDM patients with hypertriglyceridemia, moderate amounts of fish oil induce a long-term significant reduction in plasma triglycerides, VLDL triglycerides, and NEFA and a significant enrichment in the erythrocyte phospholipid content of long-chain omega-3 fatty acids, without deteriorating blood glucose control. However, this amount of omega-3 fatty acids was unable to improve insulin sensitivity in this group of patients.

Very low density lipoprotein subfraction abnormalities in IDDM patients: any effect of blood glucose control?

Normolipidaemic insulin-dependent diabetic (IDDM) patients are characterized by an increase in the smaller VLDL particles, considered to be the most atherogenic. Since blood glucose control is one of the main regulators of lipid metabolism in diabetic patients, it could influence the shift in the distribution of VLDL subfractions towards smaller particles. To evaluate this possibility, VLDL subfractions, post-heparin lipoprotein lipase and hepatic lipase activities have been evaluated in male IDDM patients with either unsatisfactory blood glucose control (group 1, HbA1c > 8%, n = 18) or good blood glucose control (group 2, HbA1c < 8%, n = 16) and in 16 normoglycaemic individuals. The three groups were comparable for sex, age, body mass index, and plasma lipid levels. Three VLDL subfractions (large, Svedberg flotation unit (Sf) 175-400; intermediate, Sf 100-175; small, Sf 20-100) were separated by density gradient ultracentrifugation and analysed for cholesterol, triglyceride, and phospholipid levels. When compared to control subjects both groups of IDDM patients showed a clear shift in VLDL subfraction distribution with a significant increase in the proportion of small VLDL (group 1; 49 +/- 2%; p < 0.005; group 2: 51 +/- 3%, p < 0.01; control subjects 40 +/- 2%) (mean +/- SEM) in relation to total VLDL. By contrast, the absolute lipid concentration of small VLDL was higher only in group 1, compared to control subjects (35 +/- 4 vs 27 +/- 3 mg/dl, p = 0.05). Post-heparin hepatic lipase activity was significantly reduced in both IDDM groups (group 1: 254 +/- 19 mU/ml, p < 0.05; group 2: 202 +/- 19 mU/ml, p < 0.005; control subjects 317 +/- 31 mU/ml). In conclusion, normolipidaemic IDDM patients show an increase in the smallest VLDL, whatever their degree of blood glucose control. However, this abnormality may be clinically relevant only in patients with unsatisfactory blood glucose control, since absolute lipid concentration of these potentially atherogenic particles is only increased in this group.