Comparison of the efficacy of an education program for people with diabetes and insulin pump treatment (INPUT) in a randomized controlled trial setting and the effectiveness in a routine care setting: Results of a comparative effectiveness study

OBJECTIVE

To compare the efficacy of an education program for people with diabetes and insulin pump treatment (INPUT) in a randomized controlled trial (RCT) to the effectiveness in an implementation trial (IT).

METHODS

135 people with diabetes on insulin pump treatment (CSII) underwent structured education with INPUT under RCT-conditions, 191 people with diabetes on CSII underwent structured education with INPUT under IT-conditions. Baseline characteristics and treatment outcomes at the 6-month follow-up were compared.

RESULTS

At baseline, RCT-participants were younger (42.7 ± 14.2 vs. 47.2 ± 14.1 years, p = 0.005), had higher HbA1c-values (8.3 ± 0.8% vs. 7.8 ± 1.2%, p = 0.001) and had more diabetes-related distress (27.8 ± 16.4 vs 22.4 ± 14.4, p = 0.002). At follow-up, INPUT results were comparable under the RCT and IT settings. After adjustment for baseline HbA1c, reduction of HbA1c in the IT was significantly greater than in the RCT (Δ0.17%; 95% CI 0.023-0.319%, p = 0.024). Participants with higher HbA1c-levels, more diabetes-related distress and more hypoglycemia problems were most likely to benefit from INPUT regardless of the trial setting.

CONCLUSIONS

Efficacy of the INPUT program for people with CSII was demonstrated under RCT- and routine care conditions.

PRACTICE IMPLICATIONS

Education with the INPUT program is effective not only under standardized RCT conditions but also under conditions of routine care.

Perceived Benefits and Barriers Regarding CSII Treatment: Development and Psychometric Evaluation of the Insulin Pump Attitudes Questionnaire (IPA-Questionnaire)

BACKGROUND

Continuous subcutaneous insulin infusion is the most advanced and demanding form of insulin therapy. Various positive and negative expectations, attitudes and experiences can occur, influencing adherence to and efficacy of continuous subcutaneous insulin infusion therapy. A new questionnaire was developed to systematically assess perceived benefits, perceived barriers and handling of continuous subcutaneous insulin infusion therapy.

METHODS

The Insulin Pump Attitude Questionnaire was tested in two samples (n=265/452) comprising pump users and non-pump users. Reliability was assessed using Cronbach's Alpha estimation. Exploratory and confirmatory factor analyses were conducted to establish the factorial structure. Correlations with other questionnaires as well as group differences between pump users and non-pump users were used to assess validity.

RESULTS

Exploratory factor analysis revealed 26 items comprising six subscales: "Glycaemic Control", "Flexibility", "Impaired Body Image", "Technology Dependency", "Ease Of Use" and "Functionality". Confirmatory factor analysis confirmed this factor structure. The IPA sum score correlated significantly with diabetes distress (r=-0.30), self-efficacy (r=0.22), diabetes empowerment (r=0.36), psychological well-being (r=0.16) and treatment dissatisfaction (r=-0.24), supporting criterion validity with small to medium effect sizes. Furthermore, the IPA was able to differentiate between pump users and non-pump users with higher scores for pump users regarding "Glycaemic Control", "Flexibility", "Ease of use" and "Functionality" and lower scores for pump users regarding "Impaired Body Image" and "Technology Dependency".

CONCLUSIONS

The Insulin Pump Attitude Questionnaire is a reliable and valid new instrument to assess attitudes towards continuous subcutaneous insulin infusion. With six scales, the Insulin Pump Attitude Questionnaire provides a comprehensive analysis of possible benefits, barriers, and handling problems of continuous subcutaneous insulin infusion therapy. In clinical practice, the Insulin Pump Attitude Questionnaire might be used to address the different attitudes in pump users but also in people considering continuous subcutaneous insulin infusion therapy.

Iron deficiency in long standing type 1 diabetes mellitus and its association with depression and impaired quality of life

AIMS

Iron deficiency (ID) is the most frequent malnutrition worldwide and often associated with reduced quality of life (QoL) and depression. We aimed to investigate the iron status in middle-aged type 1 diabetes in relation to depression and QoL.

METHODS

109 people with type 1 diabetes (54.1% male, mean age 56.2 years) were enrolled in a cross-sectional study at the diabetes clinic of the Goethe University Hospital. Iron, haemoglobin and ferritin levels were measured. Treatment satisfaction, QoL and depression were assessed using standardized questionnaires (Disease Specific Quality of Life scale, CES-D (Center for Epidemiological Studies Depression Scale) and WHO-5 well-being index.

RESULTS

Decreased serum iron (<60 µg/dl) and ferritin levels (<50 pg/nl) were observed in 18 (16.8%) and 28 (26.7%) patients, respectively. Anemia was present in 20 patients (18.34%). A high rate of depression was observed: 42.2% (WHO-5) and 40.7% (CES-D). The personal goals and current diabetes therapy satisfaction score (PWTSS) was significantly better in patients with sufficient iron status (ferritin level > 50 pg/ml, p = 0.018). Multiple regression analysis revealed iron status (p = 0.03) to be an independent predictor for better PWTSS. Insufficient iron status correlated significantly with depression as measured by WHO-5 (p = 0.044) and CES-D (p = 0.029).

CONCLUSIONS

Type 1 diabetes patients in the current study were frequently depressive and reported an impaired QoL that associated with iron insufficiency. If confirmed a better awareness is needed for depression and ID in long standing disease.

Cardivascular Risk Profile in Patients with Diabetes and Acromegaly or Cushing's Disease - Analysis from the DPV Database

BACKGROUND

Although diabetes is a common complication of acromegaly or Cushing´s disease, there are only few detailed studies with a focus on cardiovascular risk, metabolic control or diabetes therapy. Here, we provide a comprehensive characterization from the longitudinal DPV (Diabetes Patienten Verlaufsdokumentation) registry.

METHODS

Patients from the registry≥18 years of age with diabetes and acromegaly or Cushing´s disease were compared to patients with type 1 diabetes or type 2 diabetes using the statistical software SAS 9.4.

RESULTS

Patients with diabetes and acromegaly (n=52) or Cushing's disease (n=15) were significantly younger at diabetes onset (median age 50.1 and 45.0 vs. 59.0 years in type 2 diabetes; both p<0.05). Dyslipidemia was common in both diseases (71.0% and 88.9% vs. 71.8% in type 2 diabetes; n.s.), while hypertension was most frequent in acromegaly (56.8% vs. 20.9% in type 1 diabetes, p<0.00001). 36.5% of patients with acromegaly and 46.7% with Cushing´s disease receive insulin, compared to 50.4% with type 2 diabetes. Oral antidiabetic drugs were used in 36.5% of patients with acromegaly and 40% with Cushing´s disease, with a predominance of biguanides and dipeptidyl peptidase-4 inhibitors. HbA1c was well controlled in both groups (median 7.0% and 6.5%; vs. 7.2% in type 2 diabetes).

CONCLUSION

Patients with acromegaly are at a high risk for cardiovascular disease, reflected by dyslipidemia and hypertension. A high proportion of patients with diabetes in acromegaly or Cushing´s disease receives insulin. Based on a multicenter register, a sufficient number of patients with rare forms of diabetes can be analyzed.

Risk factors for decline in renal function among young adults with type 1 diabetes

AIMS

To investigate risk factors for declining renal function among subjects with type-1-diabetes.

METHODS

Observational study based on data from the diabetes registry DPV. 4424 type-1-diabetes subjects aged ≥18 years, age at onset <18 years were identified. Modification of Diet in Renal Disease (MDRD) equation was used to estimate glomerular filtration rate (eGFR). Annual rate of renal decline was estimated for each patient using hierarchic linear regression models. Additional regression models were fitted to adjust for covariates.

RESULTS

Median age was 26 [Q1; Q3: 21; 39] years. Annual decline of renal function was -1.22 (95% CI: -1.50; -0.94) ml/min/1.73 m². At baseline, higher eGFR was related to more rapid decline compared to impaired or reduced eGFR (GFR ≥ 90: -2.06 (-2.35; -1.76), 60 ≤ GFR < 90: 0.45 (0.08; 0.81), GFR < 60: 0.52 (-0.24; 1.29) ml/min/1.73 m², p < 0.01). During follow-up, the highest decline was associated with reduced renal function, whereas the lowest decline was related to normal kidney function (p < 0.01). Poor metabolic control (p = 0.04), hypertension (p < 0.01) and albuminuria (p = 0.03) were associated with more rapid loss of kidney function. No difference was observed among insulin regimen.

CONCLUSION

Among this large type-1-diabetes cohort, more rapid loss of kidney function was related to higher baseline eGFR, log-term worse metabolic control and diabetic comorbidities.

Polycystic Ovary Syndrome (PCOS) in Juvenile and Adult Type 1 Diabetes in a German/Austrian Cohort

Context While an association between PCOS and type 2 diabetes is well established, to date there have been few data on clinical care of type 1 diabetes (T1D) patients with PCOS. Objective The aim of our study was to characterize T1D patients with the comorbidity of PCOS within the DPV cohort with regard to diabetes phenotype, therapy and metabolic control. Design and Setting Clinical data from the prospective German/Austrian DPV cohort on patients with T1D and documented PCOS (n=76) were compared to female T1D controls (n=32,566) in reproductive age. Results The age at T1D manifestation in PCOS patients was later than in the control group (14.9±8.2 vs. 11.8±7.0 years, p<0.001). PCOS patients had higher BMI-SDS (0.92±0.11 vs. 0.38±0.01, p<0.001), metformin and oral contraceptives were used more frequently (p<0.001). A1c levels were significantly lower (7.92 +/- 0.23% vs. 8.43±0.01%, p<0.05) despite of lower insulin requirements (0.76±0.04 IU/kg/d vs. 0.84±0.00 IU/kg/d, p<0.05). In the PCOS group, higher rates of dyslipidemia (63.4 vs. 48.7%, p =0.032) and thyroid disorders (42.2% vs. 21.2%, p<0.001) were present. Discussion While patients with T1D and comorbid PCOS showed features of a "type 1.5 diabetes" phenotype, insulin requirements per kg body weight were not higher and metabolic control was better, which could be explained only partially by additional metformin therapy. A more precise genetic and metabolic characterisation of these patients is needed to answer open questions on the underlying autoimmune process and residual ß-cell function.

Defective IL-23/IL-17 Axis Protects p47phox-/- Mice from Colon Cancer

In the colon, a sophisticated balance between immune reaction and tolerance is absolutely required. Dysfunction may lead to pathologic phenotypes ranging from chronic inflammatory processes to cancer development. Two prominent modulators of colon inflammation are represented by the closely related cytokines interleukin (IL)-12 and IL-23, which initiate adaptive Th1 and Th17 immune responses, respectively. In this study, we investigated the impact of the NADPH oxidase protein p47phox, which negatively regulates IL-12 in dendritic cells, on colon cancer development in a colitis-associated colon cancer model. Initially, we found that IL-12−/− mice developed less severe colitis but are highly susceptible to colon cancer. By contrast, p47phox−/− mice showed lower tumor scores and fewer high grade tumors than wild-type (WT) littermates. Treatment with toll-like receptor 9 ligand CpG2216 significantly enhanced colitis in p47phox−/− mice, whereas tumor growth was simultaneously reduced. In tumor tissue of p47phox−/− mice, the IL-23/IL-17 axis was crucially hampered. IL-23p19 protein expression in tumor tissue correlated with tumor stage. Reconstitution of WT mice with IL-23p19−/− bone marrow protected these mice from colon cancer, whereas transplantation of WT hematopoiesis into IL-23p19−/− mice increased the susceptibility to tumor growth. Our study strengthens the divergent role of IL-12 and IL-23 in colon cancer development. With the characterization of p47phox as a novel modulator of both cytokines our investigation introduces a promising new target for antitumor strategies.

High plasma sST2 levels in gastric cancer and their association with metastatic disease

BACKGROUND

Gastric cancer (GC) is one of the most common and devastating tumor conditions. Its development is closely linked to an infection with Helicobacter pylori and chronic, cytokine-driven inflammation. The proinflammatory cytokine Interleukin-33 (IL-33), its membrane bound cellular receptor ST2L and its soluble receptor sST2 have recently been identified as important factors in various tumor conditions, but their role in GC remains ill-defined.

METHODS

Thirty patients with adenocarcinoma of the stomach or the esophagogastric junction were prospectively enrolled in the current study. 51 patients with Helicobacter pylori positive or negative gastritis and 40 healthy volunteers served as control group. Levels of IL-33 and sST2 were determined by ELISA and their relation to HP-status, tumor stage and survival was assessed.

RESULTS

Soluble ST2 levels in GC were significantly higher than in gastritis or healthy controls (p< 0.0001). Furthermore, higher levels of sST2 were seen in patients with lower degree of tumor differentiation. Soluble ST2 was significantly associated with a more advanced tumor stage (p= 0.018), metastatic disease (p= 0.014) and significantly correlated with the duration of the disease (p= 0.0017). Calculating the ratio of IL-33/sST2 allowed the discrimination of tumor and non-tumor patients.

CONCLUSION

Soluble ST2 is associated with advanced and metastatic disease in GC patients and significantly correlates with the duration of the disease. The IL-33/sST2 ratio may offer a new, interesting approach in identifying GC patients.

Psoriasis and Diabetes: A Multicenter Study in 222078 Type 2 Diabetes Patients Reveals High Levels of Depression

OBJECTIVE

This study aimed to investigate the association between psoriasis and disease outcome in type 2 diabetes (T2D).

METHODS

222078 T2D patients (≥10 years old) from the prospective, multicenter diabetes patient registry were analyzed. Specific search items were used to identify psoriasis patients. Multiple regression models were fitted and adjusted for demographic confounder.

RESULTS

232 T2D patients had comorbid psoriasis. After adjusting psoriasis patients revealed a higher BMI (31.8 [31.0; 32.6] versus 30.6 [30.5; 30.6] kg/m2, p = 0.004) and HbA1c (64.8 [62.1; 67.6] versus 59.0 [58.9; 59.1] mmol/mol, p < 0.0001). Insulin was used more frequently (62.3 [55.7; 68.5] versus 50.9 [50.7; 51.1] %, p = 0.001), only OAD/GLP-1 was similar, and nonpharmacological treatment was less common (13.3 [9.5; 18.3] versus 21.9 [21.7; 22.1] %, p = 0.002). Severe hypoglycemia (0.31 [0.238; 0.399] versus 0.06 [0.057; 0.060] events per patient-year, p < 0.0001), hypertension (86.1 [81.1; 90.0] versus 68.0 [67.8; 68.2] %, p < 0.0001), and thyroid disease (14.0 [10.1; 19.2] versus 4.6 [4.5; 4.7] %, p < 0.0001) were more prevalent. Depression occurred more often (10.5 [7.1; 15.2] versus 2.8 [2.7; 2.8] %, p < 0.0001).

CONCLUSIONS

Clinical diabetes characteristics in psoriasis T2D patients were clearly worse compared to patients without psoriasis. Comorbid conditions and depression were more prevalent, and more intensive diabetes therapy was required.

Coronary artery disease as an independent predictor of survival in patients with type 2 diabetes and Charcot neuro-osteoarthropathy

AIMS

Charcot neuro-osteoarthropathy (CN) is a rare complication of diabetic foot syndrome associated with chronic inflammation of the foot and severe, limb-threatening musculoskeletal deformities. Aim of this study was to investigate patients with CN for comorbidities, amputations, ulcers, secondary diseases and mortality.

METHODS

The study was conducted at a specialized German hospital for patients with diabetes. One-hundred and eleven patients were enrolled, and their course was followed over a period of 15 years. Association of CN with comorbidity, foot ulcers, amputations and mortality was assessed. Clinical course of patients was followed using two standardized questionnaires.

RESULTS

Presence of CN was significantly associated with diabetic retinopathy (p = 0.047), plantar (p < 0.001), tarsal (p = 0.032) and middle-foot ulcers (p = 0.01). A significant correlation between the presence of CN and a history of amputations was seen (p = 0.022). Patients were at increased risk to suffer from subsequent amputations during follow-up when micro- and macrovascular comorbidities such as retinopathy (p = 0.01) and peripheral artery disease (p < 0.001) were present. Additionally, coronary artery disease (CHD) was identified as an independent predictor of mortality in the cohort of this study (OR 6.192, 95 % CI 1.155-33.208, p = 0.033). Median overall survival of patients with CN and CHD was significantly shorter than OS of patients without CHD (7.8 vs. 13.1 years, p = 0.0045, HR 2.8437, 95 % CI 0.9818-8.2364).

CONCLUSIONS

In our study, CHD was the most important factor of survival in CN patients. For optimal management of CN, adequate diagnostics and treatment of CHD according to current guidelines should be considered.

Adherence to clinical care guidelines for cystic fibrosis-related diabetes in 659 German/Austrian patients

BACKGROUND

In Germany/Austria, data on medical care for cystic fibrosis-related diabetes (CFRD) is limited.

METHODS

Anonymized data from 659 CFRD patients were analyzed and compared to the latest ADA/CFF guidelines.

RESULTS

Specialized diabetes clinics were attended less frequently than recommended (3.1 vs. 4.0 times yearly). 7.9% of patients had a complete profile of examinations: diabetes education (44.9%), HbA1c (88.8%), blood pressure (79.5%), BMI (86.5%), lipid status (37.5%), retinopathy (29.9%), microalbuminuria (33.2%), and self-monitoring of blood glucose (71.6%). HbA1c and blood pressure were measured less frequently than recommended (2.3 and 2.0 vs. 4.0 times yearly). Overall, guidelines were followed more frequently in children than adults. Contrary to recommendations, not all patients were treated with insulin (77.2 vs. 100.0%). Insulin therapy was initiated earlier in children than adults, but there was still a substantial delay (0.9 vs. 2.7years after diagnosis, p<0.001).

CONCLUSION

In CFRD patients studied, adherence to care guidelines was suboptimal.

Thyroid disease in insulin-treated patients with type 2 diabetes: a retrospective study

BACKGROUND

Diabetes mellitus and thyroid diseases frequently coexist. In order to evaluate how thyroid disorders interfere with glycemic control, we analysed insulin-treated type 2 diabetes patients with thyroid disease.

METHODS

Diabetes patients (n = 1.957) were retrospectively investigated. We focused on type 2 diabetes patients who had been admitted for insulin-treatment and diagnosed thyroid diseases (n = 328). Patients were divided into three groups according to thyroid disease manifestation in relation to diabetes onset: prior to (group 1), same year (group 2) and thyroid disease following diabetes (group 3).

RESULTS

Out of all diabetes patients 27.3% had a thyroid disorder with more women (62.2%) being affected (p < 0.001). Thyroid disease was predominantly diagnosed after diabetes onset. Patients with type 2 diabetes and prior appearance of thyroid disease required insulin therapy significantly earlier (median insulin-free period: 2.5 yrs; Q1 = 0.0, Q3 = 8.25) compared to patients who had thyroid dysfunction after diabetes onset (median insulin-free period: 8.0 yrs; Q1 = 3.0, Q3 = 12.0; p < 0.001). Age at diabetes onset correlated with insulin-free period (p < 0.001).

CONCLUSIONS

Thyroid disease may be a marker of a distinct metabolic trait in type 2 diabetes potentially requiring earlier insulin treatment.

Neoadjuvant chemoradiation versus perioperative chemotherapy followed by surgery in resectable adenocarcinomas of the esophagogastric junction: A retrospective single center analysis

The current study presents a retrospective comparison, performed at a single academic center, of preoperative chemoradiation (CRT) and perioperative chemotherapy (CT) in addition to surgery in locally advanced but resectable adenocarcinoma of the esophagogastric junction (AEG). A total of 29 consecutive patients with locally advanced AEGs were retrospectively analyzed. Treatment consisted of preoperative CRT (mean dose, 45.0 Gy) plus two cycles of CT with cisplatin and 5-FU or perioperative CT with epirubicin, cisplatin and capecitabine (three cycles preoperatively and postoperatively). Within four to six weeks following preoperative treatment, surgical therapy was performed. Median overall survival was 21.0 months in the perioperative CT group versus 41.7 months in the CRT group [P=0.36; hazard ratio (HR), 1.50; 95% confidence interval (CI), 0.58–3.84]. Three-year survival rates were 55 and 38%, respectively, in favor of the CRT group, and progression-free survival was 20.0 months in the CT group compared with 24.1 months in the CRT group (P=0.71; HR, 1.19; 95% CI, 0.46–3.05). The total number of major surgical complications was almost equal in the two groups. Margin-free resections were achieved in all patients of the CRT group, but only 76.9% of the CT group (P=0.05). In addition, significantly higher R0 resection rates and an increased number of pathological complete remissions were demonstrated in the CRT group compared with those of the CT group. These results appear to indicate a trend for improved progression-free and overall survival for the CRT group. As postoperative morbidity and mortality rates were similar in the two groups, the results support the use of CRT for patients with advanced AEG tumors.

Treatment of Amanita phalloides intoxication by fractionated plasma separation and adsorption (Prometheus®)

OBJECTIVE

To investigate the effectiveness and safety of extracorporeal detoxification using the fractionated plasma separation and adsorption system (FPSA, Prometheus® 4008H, Fresenius Medical Care, Germany) in patients suffering from acute liver failure due to intoxication with Amanita phalloides (AP) toxin.

METHODS

The study population consisted of 20 patients with proven AP intoxication (FPSA treatment group n=9, control group n=11). Urinary amanitin toxin concentration was measured by the Amanitin ELISA Kit (Bühlmann Laboratories, Germany, cut off level 1.5 ng/ml). All patients received standard medical treatment with activated charcoal, i.v. crystalloid fluids, silibinine and N-acetylcysteine. Additionally 9 patients underwent treatment with FPSA until undetectable amanitin levels.

RESULTS

Mean urinary amanitin levels were significantly reduced by FPSA with 42.5 +/- 21.9 ng/ml before and 1.2 +/- 0.31 ng/ml after treatment (p=0.04). No hemodynamic, respiratory or hematological complications were observed. None of the patients had to undergo liver transplantation. All patients in the treatment group survived and were discharged fully recovered. One patient in the control group died due to shock and lactic acidosis; one patient remained dialysis dependent. Mean duration of hospital stay was 7.1 days in the treatment group and 11.7 days in the control group (p=0.30).

CONCLUSIONS

Use of liver support therapy by fractionated plasma separation and adsorption (Prometheus®) offers a safe way for elimination of Amanita toxin with the potential to avoid the need for liver transplantation.

[Gangliocytic paraganglioma--a rare differential diagnosis of a submucosal duodenal tumor]

We report on the case of a 36-year-old male patient who was found to have a submucosal duodenal tumour during the diagnostic work-up of gastrointestinal bleeding. After exclusion of other tumour manifestations complete endoscopic resection was performed. Histologically a gangliocytic paraganglioma was diagnosed, a very rare type of a duodenal neuroendocrine tumour. This case report discusses the epidemiology, diagnostic work-up and therapeutic options for this rare tumour type.

Prospective multicenter study evaluating fecal calprotectin in adult acute bacterial diarrhea

BACKGROUND

Every year, about 2.2 million deaths occur worldwide due to diarrhea. Reliable diagnosis of patients with acute infectious diarrhea remains a formidable challenge to the clinicians. This is the first study reporting use of fecal calprotectin in diagnosing acute diarrhea. The aim was to compare the diagnostic accuracy of fecal calprotectin, fecal lactoferrin, and guaiac-based fecal occult blood test in a diverse group of consecutive patients with acute diarrhea in which routine bacterial stool cultures and cytotoxins for Clostridium difficile were performed.

METHODS

This was a prospective case-control multicenter study from January 2004 until October 2007 in 2383 consecutive patients with acute diarrhea. They provided stool samples for performing cultures. Patients with positive cultures and an equal number of matched controls with negative cultures underwent fecal occult blood test and calprotectin and lactoferrin assays.

RESULTS

Calprotectin, lactoferrin, and fecal occult blood tests demonstrated sensitivity and specificity of 83% and 87%, 78% and 54%, and 38% and 85%, respectively, for diagnosing acute bacterial diarrhea.

CONCLUSIONS

Calprotectin showed high correlation with bacteriologically positive infectious diarrhea compared with lactoferrin and fecal occult blood test. It may potentially revolutionize management algorithm for patients with acute diarrhea. As a screening test, calprotectin can generate results within hours to support presumptive diagnosis of infectious diarrhea, which can decide suitability of stool samples for culture.