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Straton E, Bryant BL, Kang L, Wang C, Barber J, Perkins A, Gallant L, Marks B, Agarwal S, Majidi S, Monaghan M, Streisand R. ROUTE-T1D: A behavioral intervention to promote optimal continuous glucose monitor use among racially minoritized youth with type 1 diabetes: Design and development. Contemp Clin Trials 2024; 140:107493. [PMID: 38460913 DOI: 10.1016/j.cct.2024.107493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 02/13/2024] [Accepted: 03/05/2024] [Indexed: 03/11/2024]
Abstract
BACKGROUND Type 1 diabetes management is often challenging during adolescence, and many youth with type 1 diabetes struggle with sustained and optimal continuous glucose monitor (CGM) use. Due to racial oppression and racially discriminatory policies leading to inequitable access to quality healthcare and life necessities, racially minoritized youth are significantly less likely to use CGM. METHODS ROUTE-T1D: Research on Optimizing the Use of Technology with Education is a pilot behavioral intervention designed to promote optimal CGM use among racially minoritized youth with type 1 diabetes. Intervention strategies include problem solving CGM challenges and promoting positive caregiver-youth communication related to CGM data. RESULTS This randomized waitlist intervention provides participants with access to three telemedicine sessions with a Certified Diabetes Care and Education Specialist. Caregiver participants are also connected with a peer-parent coach. CONCLUSION Hypothesized findings and anticipated challenges are discussed. Future directions regarding sustaining and optimizing the use of diabetes technology among racially minoritized pediatric populations are reviewed.
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Affiliation(s)
- Emma Straton
- Children's National Hospital, Washington DC, United States of America
| | - Breana L Bryant
- Children's National Hospital, Washington DC, United States of America
| | - Leyi Kang
- Children's National Hospital, Washington DC, United States of America
| | - Christine Wang
- Children's National Hospital, Washington DC, United States of America
| | - John Barber
- Children's National Hospital, Washington DC, United States of America
| | - Amanda Perkins
- Children's National Hospital, Washington DC, United States of America
| | - Letitia Gallant
- Children's National Hospital, Washington DC, United States of America
| | - Brynn Marks
- Children's Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Shivani Agarwal
- Albert Einstein College of Medicine, Bronx, NY, United States of America
| | - Shideh Majidi
- Children's National Hospital, Washington DC, United States of America; The George Washington University School of Medicine, Washington, DC, United States of America
| | - Maureen Monaghan
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, United States of America
| | - Randi Streisand
- Children's National Hospital, Washington DC, United States of America; The George Washington University School of Medicine, Washington, DC, United States of America.
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Powell J, Mulani SR. Partnering for Better Health: Using Continuous Glucose Monitoring and Clinical Pharmacist Collaboration to Improve Glycemic Control in Underserved Patients With Type 2 Diabetes. Clin Ther 2024; 46:e7-e11. [PMID: 38165024 DOI: 10.1016/j.clinthera.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 09/08/2023] [Accepted: 10/08/2023] [Indexed: 01/03/2024]
Abstract
PURPOSE The purpose of this study was to examine the effect of initiating use of a continuous glucose monitor (CGM) in patients being treated for type 2 diabetes mellitus, specifically those who face barriers to obtaining this device because of its cost. METHODS This retrospective medical record review compared diabetes control of patients before and after use of a CGM device within a single primary care office. Patient medical records were reviewed 18 months after initial CGM was provided, and only those who received a CGM directly from the clinic were included in the review. Statistical analysis comparing the difference in mean baseline glycosylated hemoglobin (HbA1c) level with the first HbA1c level after CGM placement was completed using the paired t test for the primary outcome. FINDINGS A total of 41 patients who obtained at least 1 CGM reader and a minimum of a 30-day supply of sensors from the clinic were included in the review. The primary outcome resulted in a significant reduction in the mean (SD) first HbA1c level after CGM placements of -1.9% (2.5%) (P < .001) with a total of 10 and 22 patients with an HbA1c level <7% and 8%, respectively. This mean (SD) reduction in HbA1c level was also seen in both insulin-treated patients (-1.8% [2.8%], n = 30) and non-insulin-treated patients (-2% [2.8%], n=11). The largest reduction in the first HbA1c level after CGM placement was seen in those patients provided a CGM along with collaborative care with a clinical pharmacist. These patients saw a mean (SD) decrease of -2.5% [2.7%] (n = 26) in their HbA1c level with a mean (SD) decrease of -0.8% (1.6%) (n = 15) for those not comanaged by the clinical pharmacist. IMPLICATIONS The results of this study suggest that the use of CGM in the underserved population can lead to a significant improvement in glycemic control in patients with diabetes, regardless of treatment therapies used. Involving a multidisciplinary team in diabetes management, including clinical pharmacists, may further improve outcomes. Access to these devices in the underserved population may be crucial in reducing the risk of developing complications related to uncontrolled diabetes.
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Affiliation(s)
- Jason Powell
- University of Florida College of Pharmacy, Gainesville, Florida; University of Florida College of Medicine, Gainesville, Florida.
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Reutrakul S, Irsheed GA, Park M, Steffen AD, Burke L, Pratuangtham S, Baron KG, Duffecy J, Perez R, Quinn L, Withington MHC, Saleh AH, Loiacono B, Mihailescu D, Martyn-Nemeth P. Association between sleep variability and time in range of glucose levels in patients with type 1 diabetes: Cross-sectional study. Sleep Health 2023; 9:968-976. [PMID: 37709596 PMCID: PMC10840618 DOI: 10.1016/j.sleh.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 06/16/2023] [Accepted: 07/10/2023] [Indexed: 09/16/2023]
Abstract
OBJECTIVE Sleep and circadian disturbances emerge as novel factors influencing glycemic control in type 1 diabetes (T1D). We aimed to explore the associations among sleep, behavioral circadian parameters, self-care, and glycemic parameters in T1D. METHODS Seventy-six non-shift-working adult T1D patients participated. Blinded 7-day continuous glucose monitoring (CGM) and hemoglobin A1C (A1C) were collected. Percentages of time-in-range (glucose levels 70-180 mg/dL) and glycemic variability (measured by the coefficient of variation [%CV]) were calculated from CGM. Sleep (duration and efficiency) was recorded using 7-day actigraphy. Variability (standard deviation) of midsleep time was used to represent sleep variability. Nonparametric behavioral circadian variables were derived from actigraphy activity recordings. Self-care was measured by diabetes self-management questionnaire-revised. Multiple regression analyses were performed to identify independent predictors of glycemic parameters. RESULTS Median (interquartile range) age was 34.0 (27.2, 43.1) years, 48 (63.2%) were female, and median (interquartile range) A1C was 6.8% (6.2, 7.4). Sleep duration, efficiency, and nonparametric behavioral circadian variables were not associated with glycemic parameters. After adjusting for age, sex, insulin delivery mode/CGM use, and ethnicity, each hour increase in sleep variability was associated with 9.64% less time-in-range (B = -9.64, 95% confidence interval [-16.29, -2.99], p ≤ .001). A higher diabetes self-management questionnaire score was an independent predictor of lower A1C (B = -0.18, 95% confidence interval [-0.32, -0.04]). CONCLUSION Greater sleep timing variability is independently associated with less time spent in the desirable glucose range in this T1D cohort. Reducing sleep timing variability could potentially lead to improved metabolic control and should be explored in future research. DATA AVAILABILITY STATEMENT Data are available upon a reasonable request to the corresponding author.
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Affiliation(s)
- Sirimon Reutrakul
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Illinois Chicago, Chicago, Illinois, USA.
| | - Ghada Abu Irsheed
- College of Nursing, Department of Biobehavioral Nursing Science, University of Illinois Chicago, Chicago, Illinois, USA
| | - Minsun Park
- College of Nursing, Department of Biobehavioral Nursing Science, University of Illinois Chicago, Chicago, Illinois, USA
| | - Alana D Steffen
- College of Nursing, Department of Population Health Nursing Science, University of Illinois Chicago, Chicago, Illinois, USA
| | - Larisa Burke
- Office of Research Facilitation, College of Nursing, University of Illinois Chicago, Chicago, Illinois, USA
| | - Sarida Pratuangtham
- Department of Bioengineering, University of California San Diego, San Diego, California, USA
| | - Kelly Glazer Baron
- Division of Public Health, Department of Family and Preventive Medicine, The University of Utah, Salt Lake City, Utah, USA
| | - Jennifer Duffecy
- Department of Psychiatry, College of Medicine, University of Illinois Chicago, Chicago, llinois, USA
| | - Rose Perez
- College of Nursing, Department of Biobehavioral Nursing Science, University of Illinois Chicago, Chicago, Illinois, USA
| | - Laurie Quinn
- College of Nursing, Department of Biobehavioral Nursing Science, University of Illinois Chicago, Chicago, Illinois, USA
| | - Margaret H Clark Withington
- College of Nursing, Department of Biobehavioral Nursing Science, University of Illinois Chicago, Chicago, Illinois, USA
| | - Adam Hussain Saleh
- College of Nursing, Department of Biobehavioral Nursing Science, University of Illinois Chicago, Chicago, Illinois, USA
| | - Bernardo Loiacono
- College of Nursing, Department of Biobehavioral Nursing Science, University of Illinois Chicago, Chicago, Illinois, USA
| | - Dan Mihailescu
- Division of Endocrinology, Cook County Health, Chicago, Illinois, USA
| | - Pamela Martyn-Nemeth
- College of Nursing, Department of Biobehavioral Nursing Science, University of Illinois Chicago, Chicago, Illinois, USA
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Tianyi S, Yulong Z, Yanzhen J, Chen CJ, Liu JT. Micro interstitial fluid extraction and detection device integrated with the optimal extraction conditions for noninvasive glucose monitoring. Biosens Bioelectron 2023; 237:115515. [PMID: 37481866 DOI: 10.1016/j.bios.2023.115515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 07/01/2023] [Accepted: 07/03/2023] [Indexed: 07/25/2023]
Abstract
Interstitial fluid glucose sensors have promising prospects in noninvasive glucose monitoring. However, the commonly used method of extracting interstitial fluid, reverse iontophoresis (RI), still remains to be optimized to solve problems such as insufficient extraction flux and skin irritation. To find the optimal RI conditions, in this study we explored the effects of multiple factors such as current frequency, duration, duty cycle and their interactions on extraction with the design of experiments (DOE) method. A multifunctional extraction and detection device was designed to control extraction conditions and measure the surface water content of the extraction electrode in situ and real time. A micro glucose monitoring device (MicroTED) combined with a cheap and flexible paper-based electrode was developed under the determined optimal extraction conditions. In on-body continuous glucose monitoring tests carried out to verify the performance of the device, the optimized conditions can facilitate stable extraction of up to 1.0 mg without any skin discomfort. The mean Pearson correlation coefficient between the measurement results of MicroTED and commercial glucometer is above 0.9. In the Clarke error grid analysis, all data points fell within Clarke error grid areas A and B, demonstrating the feasibility of further clinical application of the device.
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Affiliation(s)
- Sun Tianyi
- School of Electronic, Electrical and Communication Engineering, University of Chinese Academy of Sciences, Beijing, China
| | - Zhou Yulong
- School of Electronic, Electrical and Communication Engineering, University of Chinese Academy of Sciences, Beijing, China
| | - Jing Yanzhen
- Research Center for Materials Science and Opti-Electronic Technology, School of Optoelectronics, University of Chinese Academy of Sciences, Beijing, China
| | - Ching-Jung Chen
- Research Center for Materials Science and Opti-Electronic Technology, School of Optoelectronics, University of Chinese Academy of Sciences, Beijing, China.
| | - Jen-Tsai Liu
- Research Center for Materials Science and Opti-Electronic Technology, College of Materials Science and Opti-Electronic Technology, University of Chinese Academy of Sciences, Beijing, China.
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Kutney K, Kaminski BA, Casey T, O'Riordan M, Gubitosi-Klug R. Reproducibility of in-home CFRD screening using continuous glucose monitoring and mixed meal tolerance test. J Clin Transl Endocrinol 2023; 33:100323. [PMID: 37705602 PMCID: PMC10495624 DOI: 10.1016/j.jcte.2023.100323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 07/23/2023] [Accepted: 08/24/2023] [Indexed: 09/15/2023] Open
Abstract
Background Cystic fibrosis related diabetes (CFRD) is associated with insulin-remediable pulmonary decline, so early detection is critical. Continuous glucose monitors (CGM) have shown promise in screening but are not recommended by clinical practice guidelines. Little is known about the reproducibility of CGM results for a given patient. Methods Twenty non-insulin treated adults and adolescents with CF placed an in-home CGM and wore it for two 14-day periods. Participants underwent a mixed meal tolerance test (MMTT) on day 5 of each 14-day period. Glycemic data from CGM 1 and CGM 2 were compared regarding published thresholds to define abnormality: percent time >140 mg/dL of ≥4.5%, percent time >140 mg/dL of >17.5%, and percent time >180 mg/dL of >3.4%. Results of the repeat MMTT were compared for peak glucose and 2-hour glucose thresholds: >140 mg/dL, >180 mg/dL, and >200 mg/dL. Results For percent time >140 mg/dL of ≥ 4.5%, five of 20 subjects had conflicting results between CGM 1 and CGM 2. For percent time >140 mg/dL of >17.5% and >180 mg/dL of >3.4%, only one of 20 subjects had conflicting results between CGM 1 and CGM 2. On the MMTT, few participants had a 2-hour glucose >140 mg/dL. Peak glucose >140 mg/dL, 180 mg/dL, and 200 mg/dL were more common, with 10-37% of participants demonstrating disagreement between CGM 1 and CGM 2. Conclusions Repeated in-home CGM acquisitions show reasonable reproducibility regarding the more stringent thresholds for time >140 mg/dL and >180 mg/dL. More data is needed to determine thresholds for abnormal mixed meal tolerance tests in CFRD screening.
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Affiliation(s)
- Katherine Kutney
- Case Western Reserve University, Cleveland OH, United States
- University Hospitals Rainbow Babies and Children’s Hospital, Cleveland OH, United States
| | - Beth A. Kaminski
- Case Western Reserve University, Cleveland OH, United States
- University Hospitals Rainbow Babies and Children’s Hospital, Cleveland OH, United States
| | - Terri Casey
- Case Western Reserve University, Cleveland OH, United States
- University Hospitals Rainbow Babies and Children’s Hospital, Cleveland OH, United States
| | - MaryAnn O'Riordan
- Case Western Reserve University, Cleveland OH, United States
- University Hospitals Rainbow Babies and Children’s Hospital, Cleveland OH, United States
| | - Rose Gubitosi-Klug
- Case Western Reserve University, Cleveland OH, United States
- University Hospitals Rainbow Babies and Children’s Hospital, Cleveland OH, United States
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Hanley M, Ryan DT, Kyle E, Kavanagh EC. Radiographic appearances of a continuous glucose monitor in a patient with lipodystrophy. Radiol Case Rep 2023; 18:3287-3290. [PMID: 37520385 PMCID: PMC10375375 DOI: 10.1016/j.radcr.2023.06.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/21/2023] [Accepted: 06/23/2023] [Indexed: 08/01/2023] Open
Abstract
We report the case of a 50-year old woman with a known history of lipodystrophy. A pelvic radiograph was taken for the investigation of right hip pain. The image shown demonstrates an indeterminate artefact projected over the right iliac fossa. A previous CT renal study was reviewed, demonstrating the same device in the subcutaneous tissues of the contralateral left lower quadrant which on close inspection was consistent with a continuous glucose monitoring device. Features of lipodystrophy were also noted on review of the CT imaging. Although many devices such as vagal stimulators and prosthetic valves are easily recognized by radiologists on radiographic images, they may be less familiar with devices such as continuous glucose monitors. The aim of this case report is to familiarize radiologists with the appearances of continuous glucose monitors to allow for effective reporting.
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de Vries SAG, Bak JCG, Verheugt CL, Stangenberger VA, Mul D, Wouters MWJM, Nieuwdorp M, Sas TCJ. Healthcare expenditure and technology use in pediatric diabetes care. BMC Endocr Disord 2023; 23:72. [PMID: 37029362 PMCID: PMC10080182 DOI: 10.1186/s12902-023-01316-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 03/06/2023] [Indexed: 04/09/2023] Open
Abstract
BACKGROUND Diabetes mellitus is one of the most common chronic diseases in childhood. With more advanced care options including ever-evolving technology, allocation of resources becomes increasingly important to guarantee equal care for all. Therefore, we investigated healthcare resource utilization, hospital costs, and its determinants in Dutch children with diabetes. METHODS We conducted a retrospective, observational analysis with hospital claims data of 5,474 children with diabetes mellitus treated in 64 hospitals across the Netherlands between 2019-2020. RESULTS Total hospital costs were €33,002,652 per year, and most of these costs were diabetes-associated (€28,151,381; 85.3%). Mean annual diabetes costs were €5,143 per child, and treatment-related costs determined 61.8%. Diabetes technology significantly increased yearly diabetes costs compared to no technology: insulin pumps € 4,759 (28.7% of children), Real-Time Continuous Glucose Monitoring € 7,259 (2.1% of children), and the combination of these treatment modalities € 9,579 (27.3% of children). Technology use increased treatment costs significantly (5.9 - 15.3 times), but lower all-cause hospitalisation rates were observed. In all age groups, diabetes technology use influenced healthcare consumption, yet in adolescence usage decreased and consumption patterns changed. CONCLUSIONS These findings suggest that contemporary hospital costs of children with diabetes of all ages are driven primarily by the treatment of diabetes, with technology use as an important additive factor. The expected rise in technology use in the near future underlines the importance of insight into resource use and cost-effectiveness studies to evaluate if improved outcomes balance out these short-term costs of modern technology.
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Affiliation(s)
- Silvia A G de Vries
- Department of Vascular Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands.
- Dutch Institute for Clinical Auditing, Leiden, The Netherlands.
| | - Jessica C G Bak
- Department of Vascular Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- Dutch Institute for Clinical Auditing, Leiden, The Netherlands
| | - Carianne L Verheugt
- Department of Vascular Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | | | - Dick Mul
- Diabeter, Center for Pediatric and Adult Diabetes Care and Research, Rotterdam, The Netherlands
| | - Michel W J M Wouters
- Dutch Institute for Clinical Auditing, Leiden, The Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Max Nieuwdorp
- Department of Vascular Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Theo C J Sas
- Diabeter, Center for Pediatric and Adult Diabetes Care and Research, Rotterdam, The Netherlands
- Department of Pediatrics, Division of Pediatric Endocrinology, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
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Ferreira M, Neves JS, Neves C, Carvalho D. Physical exercise and glycemic management in patients with type 1 diabetes on insulin pump therapy-a cross-sectional study. Acta Diabetol 2023; 60:881-889. [PMID: 36964201 DOI: 10.1007/s00592-023-02070-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 03/02/2023] [Indexed: 03/26/2023]
Abstract
AIMS Exercise is an important practice for control in type 1 diabetes (T1D). This study aims to assess de association between exercise and glycemic management in people with T1D and to identify the main barriers to exercise in T1D. METHODS We evaluated 95 people with T1D treated with insulin pump therapy. Participants answered a questionnaire about 1) exercise habits, 2) usual adjustments in insulin and food intake with exercise and 3) main barriers to exercise. Continuous glucose monitoring (CGM) was used to evaluate time in range (TIR), time below range (TBR) and time above range (TAR) during the last 60 days before the evaluation. CGM data during, before (2 h before) and after (24 h after) the last bout of exercise was also evaluated. RESULTS The mean age was 30.1 ± 12.1 years, and 51.6% were women. Participants that reported practicing exercise (55.8%) had a higher TIR (59.6 ± 16.3 vs. 48.7 ± 15.7, p = 0.012) and a lower TAR (32.6 ± 15.8 vs. 45.4 ± 17.7, p = 0.006). Comparing with the 60 days CGM data, the TBR was lower in the 2 h before exercise (- 1.8 ± 3.8, p = 0.0454) and TAR was lower during (- 16.9 ± 33.6, p = 0.0320) and in the 24 h after (- 8.7 ± 17.2, p = 0.032) the last bout of exercise. The absence of adjustments on insulin and food intake was associated with higher TBR after the exercise (13.44 ± 3.5, p < 0.05). Eating before the exercise and turning off the pump during the exercise were associated with lower TBR after exercise (food booster: - 7.56 ± 3.49, p < 0.05; turning off insulin pump - 8.87 ± 3.52, p < 0.05). The main barriers reported for exercise practicing were fear of hypoglycemia, lack of free time and work schedule. CONCLUSION Exercise was associated with better glycemic management in people with T1D. Addressing common barriers may allow a higher adherence to exercise in T1D.
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Affiliation(s)
- Margarida Ferreira
- Faculty of Medicine of Medicine of the University of Porto, Porto, Portugal.
| | - João Sérgio Neves
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário de São João, EPE, Porto, Portugal
- Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Celestino Neves
- Faculty of Medicine of Medicine of the University of Porto, Porto, Portugal
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário de São João, EPE, Porto, Portugal
- Instituto de Investigação E Inovação Em Saúde, University of Porto, Porto, Portugal
| | - Davide Carvalho
- Faculty of Medicine of Medicine of the University of Porto, Porto, Portugal
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário de São João, EPE, Porto, Portugal
- Instituto de Investigação E Inovação Em Saúde, University of Porto, Porto, Portugal
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Abstract
We compared the glucose management indicator (GMI) calculated using 14 days of continuous glucose monitor (CGM) data with GMI calculated using <14 days. Analysis included 581 individuals with type 1 diabetes or type 2 diabetes from five clinical trials. The correlation between the 14- and 7-day GMI was 0.95 and the correlation between 14 days versus 10, 5, and 3 days GMI was 0.98, 0.91, and 0.86, respectively. The percentages of GMI values within 0.3% of the 14-day GMI were 98% with 10-day GMI, 87% with 7-day GMI, 77% with 5-day GMI, and 60% with 3-day GMI. Minimal differences were observed between GMI computed using 14 days of data compared with GMI computed with 7 days. Although 10-14 days of CGM data are preferred for computing GMI, for most patients a satisfactory estimate of HbA1c can be obtained with 7 days of data.
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Affiliation(s)
- Ryan Bailey
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - Peter Calhoun
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - Richard M Bergenstal
- International Diabetes Center, HealthPartners Institute, Minneapolis, Minnesota, USA
| | - Roy W Beck
- Jaeb Center for Health Research, Tampa, Florida, USA
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Swaich H, Advani A. Sustained Improvement in Glycemic Control in Emerging Adults with Type 1 Diabetes 2 Years After the Start of the COVID-19 Pandemic. Diabetes Ther 2023; 14:153-165. [PMID: 36467396 PMCID: PMC9708124 DOI: 10.1007/s13300-022-01346-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 11/14/2022] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Although there were initial concerns that the public health response to the COVID-19 pandemic would adversely affect glycemic control in people with type 1 diabetes, several early continuous glucose monitor (CGM) studies reported an unexpected slight improvement in glucose metrics. Early emerging adulthood (roughly spanning the ages of 18-24 years) is often a vulnerable time in the life of a person with type 1 diabetes. Here, we set out to determine how the care and glucose management of emerging adults with type 1 diabetes changed over a period of approximately 2 years from the start of the COVID-19 pandemic. METHODS This was a retrospective study of a tertiary referral, multidisciplinary young adult diabetes clinic, spanning before and after the 777-day state of emergency in the City of Toronto. RESULTS Of 130 emerging adults with type 1 diabetes (80 male, 50 female; mean age 21.0 ± 2.1 years), baseline pre-pandemic HbA1c values were available for 120 individuals. During 24.9 ± 5.4 months of follow-up before and after the start of the COVID-19 pandemic, HbA1c fell from 8.5 ± 1.7% (69.3 ± 18.8 mmol/mol) to 8.1 ± 1.9% (65.2 ± 20.5 mmol/mol) (P < 0.05), with change in HbA1c from pre-lockdown levels being sustained throughout the second year of the pandemic. Over the same period, CGM use rose from 43% to 83%, primarily through increased uptake of intermittently scanned CGM, which is covered through the Ontario Drug Benefit program. Change in HbA1c was most evident in Dexcom G6 real-time CGM users - 0.7 ± 1.2% (- 9.8 ± 17.1 mmol/mol) (P < 0.01 vs. self-monitoring of blood glucose). CONCLUSION Among emerging adults with type 1 diabetes attending a multidisciplinary clinic in a high-income country, glycated hemoglobin levels are on average 0.4% (4.1 mmol/mol) lower than they were before the pandemic. This reduction in HbA1c is unlikely to be a consequence of early strict lockdowns given the length of time of follow-up. Rather, improved glycemic control coincided with increased utilization of wearable diabetes devices.
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Affiliation(s)
- Harshpreet Swaich
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 6-151 61 Queen Street East, Toronto, ON M5C 2T2 Canada
| | - Andrew Advani
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 6-151 61 Queen Street East, Toronto, ON M5C 2T2 Canada
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Pauley ME, Tommerdahl KL, Snell-Bergeon JK, Forlenza GP. Continuous Glucose Monitor, Insulin Pump, and Automated Insulin Delivery Therapies for Type 1 Diabetes: An Update on Potential for Cardiovascular Benefits. Curr Cardiol Rep 2022; 24:2043-2056. [PMID: 36279036 PMCID: PMC9589770 DOI: 10.1007/s11886-022-01799-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/10/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW The incidence of type 1 diabetes (T1D) is rising in all age groups. T1D is associated with chronic microvascular and macrovascular complications but improving glycemic trends can delay the onset and slow the progression of these complications. Utilization of technological devices for diabetes management, such as continuous glucose monitors (CGM) and insulin pumps, is increasing, and these devices are associated with improvements in glycemic trends. Thus, device use may be associated with long-term prevention of T1D complications, yet few studies have investigated the direct impacts of devices on chronic complications in T1D. This review will describe common diabetes devices and combination systems, as well as review relationships between device use and cardiovascular outcomes in T1D. RECENT FINDINGS Findings from existing cohort and national registry studies suggest that pump use may aid in improving cardiovascular risk factors such as hypertension and dyslipidemia. Furthermore, pump users have been shown to have lower arterial stiffness and better measures of myocardial function. In registry and case-control longitudinal data, pump use has been associated with fewer cardiovascular events and reduction of cardiovascular disease (CVD) and all-cause mortality. CVD is the leading cause of morbidity and mortality in T1D. Consistent use of diabetes devices may protect against the development and progression of macrovascular complications such as CVD through improvement in glycemic trends. Existing literature is limited, but findings suggest that pump use may reduce acute cardiovascular risk factors as well as chronic cardiovascular complications and overall mortality in T1D.
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Affiliation(s)
- Meghan E Pauley
- Department of Pediatrics, Section of Pediatric Endocrinology, Children's Hospital Colorado and University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Kalie L Tommerdahl
- Department of Pediatrics, Section of Pediatric Endocrinology, Children's Hospital Colorado and University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO, USA
- Ludeman Family Center for Women's Health Research, University of Colorado School of Medicine, Aurora, CO, USA
| | - Janet K Snell-Bergeon
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO, USA
| | - Gregory P Forlenza
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO, USA
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12
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Vasigh M, Hopkins R. Insulin edema after initiation of hybrid closed-loop insulin pump therapy with continuous glucose monitoring: a case report. Clin Diabetes Endocrinol 2022; 8:6. [PMID: 36180933 PMCID: PMC9524106 DOI: 10.1186/s40842-022-00143-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 09/06/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Insulin edema is a rare complication which can present after initiation or intensification of insulin therapy in people with diabetes. Initiation of closed-loop hybrid insulin pump therapy can result in rapid improvement in glycemic control for people with diabetes. We present a case in which transition to a closed-loop hybrid insulin pump system, followed by significant improvement in glycemic control, led to development of insulin edema in a person with type 1 diabetes. CASE PRESENTATION We present a 51-year-old woman with type 1 diabetes of 16 years duration, on insulin pump therapy for more than 10 years, who presented for follow-up 7 weeks after transitioning to a hybrid closed-loop insulin pump system with continuous glucose monitoring (CGM). She complained of weight gain and bilateral lower extremity edema which had started two weeks after the change in pump modality. Laboratory studies and echocardiogram did not reveal any etiology of the acute edema. HbA1c was 3.3% lower than the previous measurement 15 weeks earlier, and there was a significant increase in the daily total insulin dose. With exclusion of other causes of acute edema, the patient was diagnosed with insulin edema and started on hydrochlorothiazide. On follow up, her lower extremity edema significantly improved although her weight did not return to baseline. CONCLUSION To our knowledge, this is the first case of insulin edema reported in a person with type 1 diabetes using CGM and a hybrid closed-loop insulin pump system. The increase in total daily insulin dose, rapid improvement of glycemic control, and lack of hypoglycemic episodes were important factors to consider in evaluation of this case. Use of hybrid closed-loop systems can help achieve rapid improvement in glycemic control in people with diabetes. This case suggests that consideration should be given to adjusting initial blood glucose targets when starting these remarkable new technologies in people with baseline poor glycemic control.
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Affiliation(s)
- Mostafa Vasigh
- Department of Medicine, State University of New York Upstate Medical University, Syracuse, USA
| | - Rachel Hopkins
- Department of Medicine, Division of Endocrinology, State University of New York Upstate Medical University, 750 East Adams Street, Syracuse, NY, 13210, USA.
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13
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Szmuilowicz ED, Aleppo G. Combination Use of U-500 Regular Insulin via Insulin Pump and Rapid-Acting U-100 Prandial Injections for Treatment of Pre-Existing Type 2 Diabetes in Pregnancy. Diabetes Technol Ther 2022; 24:525-530. [PMID: 35167366 DOI: 10.1089/dia.2022.0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The high-dose large-volume insulin injections that may become necessary during pregnancy due to marked pregnancy-induced insulin resistance may result in suboptimal therapeutic effectiveness. Use of U-500 insulin, a concentrated insulin formulation, has been suggested during pregnancy. However, the pharmacokinetic properties of U-500 insulin monotherapy can impede achievement of strict pregnancy glycemic targets. We propose a novel regimen for treatment of severe pregnancy-induced insulin resistance that enables precise delivery of U-500 basal insulin therapy through continuous subcutaneous insulin infusion (CSII) while maintaining the desired kinetics of prandial rapid-acting U-100 insulin therapy. This combination approach, guided by continuous glucose monitoring data, enabled achievement of pregnancy glycemic targets while reducing basal insulin requirements by approximately one-third. We report our method for (1) conversion to U-500 insulin delivery through CSII during pregnancy and (2) conversion from U-500 basal insulin delivery through CSII to U-100 intravenous insulin infusion therapy at delivery, to offer clinicians who encounter similar challenging scenarios a novel approach to diabetes management during pregnancy in the setting of marked insulin resistance.
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Affiliation(s)
- Emily D Szmuilowicz
- Division of Endocrinology, Metabolism and Molecular Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Grazia Aleppo
- Division of Endocrinology, Metabolism and Molecular Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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14
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Zheng M, Khoja A, Patel A, Luo Y, He Q, Zhao X, Yang S, Hu P, Lin W. Changes in glycaemic control of oral anti-diabetic medications assessed by continuous glucose monitors among patients with type 2 diabetes: a protocol of network meta-analysis. Syst Rev 2022; 11:110. [PMID: 35655228 PMCID: PMC9161457 DOI: 10.1186/s13643-022-01986-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 05/23/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Continuous glucose monitors (CGMs) can measure interstitial fluid glucose levels to provide comprehensive real-time glucose profile among people with type 2 diabetes. These can accurately detect glucose levels, hyperglycaemia and hypoglycaemia events compared with conventional self-monitoring. Increased application of CGMs provides a valuable opportunity to evaluate glucose control on oral anti-diabetic medications. This review will compare the efficacy and safety of oral anti-diabetic medications among patients with type 2 diabetes, evaluated by CGM. METHODS The following databases will be searched: Cochrane Library, PubMed, EMBASE, CINAHL, PsycINFO, Scopus and grey literature (ClinicalTrials.gov, PsycEXTRA, ProQuest Dissertations, Google Scholar and Theses Global) for the identification of studies. The review will include and summarise evidence from randomised clinical trials that use CGMs for blood glucose management in adults (aged ≥ 18 years), published in English between January 2000 and May 2021 without any restrictions of countries. Reference list of all selected articles will independently be screened to identify additional studies left out in the initial search. Primary outcomes will be HbA1c (≤ 7.0%), time spent with hypoglycaemia (< 70 mg/dl) or hyperglycaemia (≥ 180 mg/dl). Secondary outcomes will be change in weight, blood pressure and related comorbidities (cardiovascular mortality, heart failure events, myocardial infarction and stroke). Study selection, data extraction and quality assessment will be conducted independently by at least two reviewers. A third reviewer will determine and resolve discrepancies. At least two independent reviewers will cross-check data synthesis. The quality of evidence of the review will be assessed according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Tool. DISCUSSION The review is anticipated to provide up to date evidence for further studies and clinic practices regarding glycaemic control, hypoglycaemia, and hyperglycaemia issues. The results will be published in a peer-reviewed journal. TRIAL REGISTRATION PROSPERO CRD42020188399 .
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Affiliation(s)
- Mingyue Zheng
- School of Health and Rehabilitation, Chengdu University of Traditional Chinese Medicine, Chengdu, 611137, China.,Adelaide Medical School, University of Adelaide, Adelaide, SA, 5005, Australia
| | - Adeel Khoja
- Adelaide Medical School, University of Adelaide, Adelaide, SA, 5005, Australia
| | - Anamica Patel
- Observatory Evidence Service, Public Health Wales, Cardiff, CF10 4BZ, UK
| | - Yunting Luo
- Center of Infectious Diseases, West China Hospital, Sichuan University, Chengdu, 610041, China.,Institute for Disaster Management and Reconstruction, Sichuan University, Chengdu, 610207, China
| | - Qian He
- Oftendon Trauma, No. 1 Orthopedics Hospital of Chengdu, Chengdu, 610000, China
| | - Xuan Zhao
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, 611137, China
| | - Shenqiao Yang
- School of Health and Rehabilitation, Chengdu University of Traditional Chinese Medicine, Chengdu, 611137, China
| | - Peng Hu
- School of Health and Rehabilitation, Chengdu University of Traditional Chinese Medicine, Chengdu, 611137, China.
| | - Wei Lin
- School of Management, Chengdu University of Traditional Chinese Medicine, Chengdu, 611137, China
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15
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Scully KJ, Palani G, Zheng H, Moheet A, Putman MS. The Effect of Control IQ Hybrid Closed Loop Technology on Glycemic Control in Adolescents and Adults with Cystic Fibrosis-Related Diabetes. Diabetes Technol Ther 2022; 24:446-452. [PMID: 35020476 PMCID: PMC9208855 DOI: 10.1089/dia.2021.0354] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background: Cystic fibrosis-related diabetes (CFRD) is associated with pulmonary decline, compromised nutritional status, and earlier mortality. Although diabetes technology is increasingly being used in individuals with CFRD, there is a paucity of data investigating the impact of hybrid closed loop (HCL) technology on glycemia in this patient population. Materials and Methods: In this multicenter retrospective study of 13 adults and adolescents with CFRD, 14 days of continuous glucose monitor data were analyzed at baseline, 1 and 3 months after transition to the Tandem t:slim X2 pump with Control IQ™ technology, a HCL system. Results: Control IQ initiation was associated with a significant increase in % time in target range (70-180 mg/dL), as well as decreases in average glucose, % time in hyperglycemic ranges (% time >180 mg/dL, % time >250 mg/dL), and glycemic variability (standard deviation, coefficient of variation). There was no significant change in % time in hypoglycemia ranges (% time <54 mg/dL, % time <70 mg/dL). Conclusions: To our knowledge, this is the first study to report a beneficial effect of Food and Drug Administration (FDA)-approved HCL technology on glycemia in adults and adolescents with CFRD to date. Future studies are needed to understand the potential long-term glycemic benefits of HCL devices and to explore the impact of this technology on heath-related quality of life, pulmonary function, nutritional status, and mortality.
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Affiliation(s)
- Kevin J. Scully
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts, USA
- Address correspondence to: Kevin J. Scully, MB, BCh, BAO, Division of Endocrinology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115-5724, USA
| | - Gurunanthan Palani
- Division of Endocrinology, Diabetes and Metabolism, University of Minnesota, Minneapolis, Minnesota, USA
| | - Hui Zheng
- Biostatics Center, and Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Amir Moheet
- Division of Endocrinology, Diabetes and Metabolism, University of Minnesota, Minneapolis, Minnesota, USA
| | - Melissa S. Putman
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts, USA
- Diabetes Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA
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16
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Choudhary A, Adhikari S, White PC. Impact of the COVID-19 pandemic on management of children and adolescents with Type 1 diabetes. BMC Pediatr 2022; 22:124. [PMID: 35272660 PMCID: PMC8907397 DOI: 10.1186/s12887-022-03189-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 02/28/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The coronavirus disease-2019 (COVID-19) pandemic had widespread impacts on the lives of parents and children. We determined how the pandemic affected Type 1 diabetes patients at a large urban pediatric teaching hospital. METHODS We compared patient characteristics, glycemic control, PHQ-9 depression screen, in person and virtual outpatient encounters, hospitalizations and continuous glucose monitor (CGM) utilization in approximately 1600 patients in 1 year periods preceding and following the local imposition of COVID-related restrictions on 3/15/2020 ("2019" and "2020" groups, respectively). RESULTS In a generalized linear model, increasing age, non-commercial insurance, Black and Hispanic race/ethnicity, and non-utilization of CGMs were all associated with higher hemoglobin A1c (HbA1c), but there was no difference between the 2019 and 2020 groups. The time in range in CGM users was lower with non-commercial insurance and in Black and Hispanic patients; it improved slightly from 2019 to 2020. CGM utilization by patients with non-commercial insurance (93% of such patients were in government programs, 7% uninsured or "other") increased markedly. In 2020, patients with commercial insurance (i.e., private-pay or provided by an employer) had fewer office visits, but insurance status did not influence utilization of the virtual visit platform. There was no change in hospitalization frequency from 2019 to 2020 in either commercially or non-commercially insured patients, but patients with non-commercial insurance were hospitalized at markedly higher frequencies in both years. PHQ-9 scores were unchanged. CONCLUSIONS Hospitalization frequency, glycemic control and depression screening were unchanged in our large urban pediatric teaching hospital during the COVID pandemic. Increased utilization of CGM and rapid adoption of telemedicine may have ameliorated the impact of the pandemic on disease management.
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Affiliation(s)
- Abha Choudhary
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390-9063, USA.
| | - Soumya Adhikari
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390-9063, USA
| | - Perrin C White
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390-9063, USA
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17
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Marks BE, Williams KM, Sherwood JS, Putman MS. Practical aspects of diabetes technology use: Continuous glucose monitors, insulin pumps, and automated insulin delivery systems. J Clin Transl Endocrinol 2022; 27:100282. [PMID: 34917483 PMCID: PMC8666668 DOI: 10.1016/j.jcte.2021.100282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 11/01/2021] [Accepted: 11/27/2021] [Indexed: 02/06/2023] Open
Abstract
There have been tremendous advances in diabetes technology in the last decade. Continuous glucose monitors (CGM), insulin pumps, and automated insulin delivery (AID) systems aim to improve glycemic control while simultaneously decreasing the burden of diabetes management. Although diabetes technologies have been shown to decrease both hypoglycemia and hyperglycemia and to improve health-related quality of life in individuals with type 1 diabetes, the impact of these devices in individuals with cystic fibrosis-related diabetes (CFRD) is less clear. There are unique aspects of CFRD, including the different underlying pathophysiology and unique lived health care experience and comorbidities, that likely affect the use, efficacy, and uptake of diabetes technology in this population. Small studies suggest that CGM is accurate and may be helpful in guiding insulin therapy for individuals with CFRD. Insulin pump use has been linked to improvements in lean body mass and hemoglobin A1c among adults with CFRD. A recent pilot study highlighted the promise of AID systems in this population. This article provides an overview of practical aspects of diabetes technology use and device limitations that clinicians must be aware of in caring for individuals with CF and CFRD. Cost and limited insurance coverage remain significant barriers to wider implementation of diabetes technology use among patients with CFRD. Future studies exploring strategies to improve patient and CF provider education about these devices and studies showing the effectiveness of these technologies on health and patient-reported outcomes may lead to improved insurance coverage and increased rates of uptake and sustained use of these technologies in the CFRD community.
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Affiliation(s)
- Brynn E. Marks
- Division of Endocrinology and Diabetes, Children’s National Hospital, 111 Michigan Ave, NW, Washington, DC 20010, USA
| | - Kristen M. Williams
- Division of Pediatric Endocrinology, Diabetes, and Metabolism, Columbia University Irving Medical Center, 1150 St Nicholas Avenue, New York, NY 10032, United States
| | - Jordan S. Sherwood
- Diabetes Research Center, Division of Pediatric Endocrinology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
| | - Melissa S. Putman
- Division of Endocrinology, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115, United States
- Diabetes Research Center, Division of Endocrinology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
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18
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Cobry EC, Reznick-Lipina T, Pyle L, Slover R, Thomas JF, Alonso GT, Wadwa RP. Diabetes Technology Use in Remote Pediatric Patients with Type 1 Diabetes Using Clinic-to-Clinic Telemedicine. Diabetes Technol Ther 2022; 24:67-74. [PMID: 34524007 PMCID: PMC8783625 DOI: 10.1089/dia.2021.0229] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background: Clinic-to-clinic telemedicine can increase visit frequency in pediatric patients with type 1 diabetes (T1D) living far from a diabetes specialty clinic, but the impact on adoption of diabetes technology is unclear. Materials and Methods: Pediatric patients with T1D in Colorado and surrounding states who received diabetes care using clinic-to-clinic telemedicine were enrolled. Medical records and surveys were reviewed to ascertain technology use, and data were compared to patients from the main clinic population. Results: Patients (N = 128, baseline mean age 12.4 ± 4.2 years, median T1D duration 3.3 years [IQR 1.4-7.7], mean A1c 8.9% ± 1.8%, 60% male, 75% non-Hispanic white, 77% private insurance) who utilized telemedicine were included. Technology use among telemedicine patients was not associated with gender, T1D duration, insurance, distance from the main clinic or rural designation but was associated with ethnicity and A1c. Compared to the main clinic cohort (N = 3636), continuous glucose monitor (CGM) use and pump/CGM combination use was lower among patients participating in clinic-to-clinic telemedicine (CGM: 29.7% vs. 56.0%, P < 0.001; CGM/pump combination: 27.3% vs. 40.3%, P = 0.004). Technology use was associated with lower A1c regardless of cohort. Conclusions: Compared to patients attending in-person clinic, pediatric T1D patients who use clinic-to-clinic telemedicine due to their distance from the main clinic, have lower CGM and combination CGM/pump use. For both telemedicine and main clinic patients, CGM and CGM/pump combination was associated with lower A1c. Additional research is needed to explore reasons for this discrepancy and find methods to improve CGM use in this population.
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Affiliation(s)
- Erin C. Cobry
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Tyler Reznick-Lipina
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Laura Pyle
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado, USA
| | - Robert Slover
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - John F. Thomas
- Department of General Academic Pediatrics, Children's Hospital Colorado, Aurora, Colorado, USA
- Department of Epidemiology, Colorado School of Public Health, Aurora, Colorado, USA
| | - Guy Todd Alonso
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Raj Paul Wadwa
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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19
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Oser TK, Litchman ML, Allen NA, Kwan BM, Fisher L, Jortberg BT, Polonsky WH, Oser SM. Personal Continuous Glucose Monitoring Use Among Adults with Type 2 Diabetes: Clinical Efficacy and Economic Impacts. Curr Diab Rep 2021; 21:49. [PMID: 34882273 PMCID: PMC8655087 DOI: 10.1007/s11892-021-01408-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2021] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW This article reviews recent clinical efficacy research and economic analysis of the use of personal continuous glucose monitoring (CGM) in type 2 diabetes (T2D). RECENT FINDINGS Studies from the past 5 years include a variety of randomized controlled trials, meta-analyses, and other studies which generally favor CGM over self-monitoring of blood glucose (SMBG) in T2D, especially among people with T2D treated with insulin. Concurrently, some studies show no significant difference, but there is no evidence of worse outcomes with CGM. CGM is frequently associated with greater reduction in HbA1c than is SMBG. HbA1c reductions tend to be greater when baseline HbA1c is higher. Reductions in hypoglycemia and hyperglycemia have also been demonstrated with CGM in people with T2D, as have comfort with, preference for, and psychosocial benefits of CGM compared to SMBG. There is a small but growing evidence base on the economics and cost-effectiveness of CGM in T2D. CGM has been clearly demonstrated to have clinical benefits in people with T2D, especially among those treated with insulin. Economic and cost-effectiveness data are more scant but are generally favorable. CGM should be an important consideration in the management of T2D, and its use is likely to increase as efficacy data accumulate further and as costs associated with CGM gradually decrease.
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Affiliation(s)
- Tamara K. Oser
- Department of Family Medicine, University of Colorado School of Medicine, 12631 East 17thAvenue, Room 3513, Box F496, Aurora, CO 80045 USA
| | | | - Nancy A. Allen
- University of Utah College of Nursing, Salt Lake City, UT USA
| | - Bethany M. Kwan
- Department of Family Medicine, University of Colorado School of Medicine, 12631 East 17thAvenue, Room 3513, Box F496, Aurora, CO 80045 USA
| | - Lawrence Fisher
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, CA USA
| | - Bonnie T. Jortberg
- Department of Family Medicine, University of Colorado School of Medicine, 12631 East 17thAvenue, Room 3513, Box F496, Aurora, CO 80045 USA
| | | | - Sean M. Oser
- Department of Family Medicine, University of Colorado School of Medicine, 12631 East 17thAvenue, Room 3513, Box F496, Aurora, CO 80045 USA
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20
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Hicks R, Marks BE, Oxman R, Moheet A. Spontaneous and iatrogenic hypoglycemia in cystic fibrosis. J Clin Transl Endocrinol 2021; 26:100267. [PMID: 34745906 PMCID: PMC8551648 DOI: 10.1016/j.jcte.2021.100267] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/02/2021] [Accepted: 10/10/2021] [Indexed: 12/12/2022]
Abstract
Spontaneous episodes of hypoglycemia can occur in people with cystic fibrosis (CF) without diabetes, who are not on glucose lowering medications. Spontaneous hypoglycemia in CF could occur both in the fasting or postprandial state (reactive hypoglycemia). The pathophysiology of fasting hypoglycemia is thought to be related to malnutrition and increased energy expenditure in the setting of inflammation and acute infections. Reactive hypoglycemia is thought to be due to impaired first phase insulin release in response to a glucose load, followed by a delayed and extended second phase insulin secretion; ineffective counterregulatory response to dropping glucose levels may also play a role. The overall prevalence of spontaneous hypoglycemia varies from 7 to 69% as examined with oral glucose tolerance test (OGTT) or with continuous glucose monitoring (CGM) under free living conditions. Spontaneous hypoglycemia in CF is associated with worse lung function, higher hospitalization rates, and worse clinical status. In addition, patients with CF related diabetes on glucose-lowering therapies are at risk for iatrogenic hypoglycemia. In this article, we will review the pathophysiology, prevalence, risk factors, clinical implications, and management of spontaneous and iatrogenic hypoglycemia in patients with CF.
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Affiliation(s)
- Rebecca Hicks
- Division of Pediatric Endocrinology, David Geffen School of Medicine, UCLA, 10833 Le Conte Ave., MDCC 22-315, Los Angeles, CA, USA
| | - Brynn E Marks
- Division of Endocrinology and Diabetes, Children's National Hospital, 111 Michigan Avenue NW, Washington, DC, USA.,Department of Pediatrics, George Washington University School of Medicine & Health Sciences, Ross Hall, 2300 Eye Street, NW, Washington, DC, USA
| | - Rachael Oxman
- Division of Endocrinology, Diabetes and Metabolism, UCLA Santa Monica Medical Center, 2020 Santa Monica Boulevard, Suite 550, Santa Monica, CA, USA
| | - Amir Moheet
- Division of Endocrinology, Diabetes and Metabolism, University of Minnesota, 420 Delaware Street SE, MMC 101, Minneapolis, MN, USA
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21
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Marks BE, Kilberg MJ, Aliaj E, Fredkin K, Hudson J, Riva D, Román C, Kelly A, Putman MS. Perceptions of Diabetes Technology Use in Cystic Fibrosis-Related Diabetes Management. Diabetes Technol Ther 2021; 23:753-759. [PMID: 34185606 DOI: 10.1089/dia.2021.0201] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background: Diabetes technologies are associated with improvements in glycemic control and health-related quality of life among people with type 1 diabetes (T1D). Use and perceptions of continuous glucose monitors (CGM) and insulin pumps within the cystic fibrosis (CF) community have not been well studied. Methods: A 30-item online survey addressing cystic fibrosis-related diabetes (CFRD) diagnosis, CGM and insulin pump use, and perceptions of diabetes technologies was sent to a CF community group, including people with CF (pwCF) and parents of children with CF (cwCF). Results: The response rate was 11% (n = 120; 83 pwCF, 35 cwCF). Sixty-one percent of pwCF and 34% of cwCF reported a diagnosis of CFRD. CGM use was reported by 75% (n = 47) of respondents with CFRD but was discontinued by 19% (n = 9), most commonly due to cost and increased worry about glycemia. Insulin pump therapy was reported by 29% (n = 18 of 62) of respondents with CFRD and was discontinued by 28% (n = 5), most commonly due to pain or skin irritation. Overall, 91% agreed or strongly agreed that CGM facilitated CFRD management. Eighty-one percent agreed with at least five of seven positive statements about CGM as compared with 22% for insulin pumps. Potential embarrassment over device wear, concerns about cost, and pain were commonly held negative perceptions of both technologies. Conclusions: As compared with T1D and despite perceived benefits, rates of sustained diabetes technology use are low in the CFRD community. Better insurance coverage to mitigate cost, better patient education, and confirmation that these technologies improve health and patient-reported outcomes may increase uptake.
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Affiliation(s)
- Brynn E Marks
- Division of Endocrinology and Diabetes, Children's National Hospital, Washington, District of Columbia, USA
- Department of Pediatrics, George Washington University School of Medicine & Health Sciences, Washington, District of Columbia, USA
| | - Marissa J Kilberg
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Enid Aliaj
- Cystic Fibrosis Foundation, Bethesda, Maryland, USA
| | | | | | - Dara Riva
- Cystic Fibrosis Foundation, Bethesda, Maryland, USA
| | | | - Andrea Kelly
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Melissa S Putman
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts, USA
- Division of Endocrinology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Departments of Pediatrics and Medicine, Harvard Medical School, Boston, Massachusetts, USA
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22
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Lai CW, Lipman TH, Willi SM, Hawkes CP. Early Racial/Ethnic Disparities in Continuous Glucose Monitor Use in Pediatric Type 1 Diabetes. Diabetes Technol Ther 2021; 23:763-767. [PMID: 34143673 DOI: 10.1089/dia.2021.0120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Racial-ethnic disparities in technology use have been described in children with type 1 diabetes (T1D). It is not known whether these emerge early in disease management. This single-center retrospective study examined disparities in continuous glucose monitor (CGM) initiation and durability in the first-year after diagnosis of T1D in children. Of 345 eligible children, 46% started CGM within their first year. In non-Hispanic white (NHW) children, 51% started using CGM versus 28% of non-Hispanic black (NHB) children (P = 0.006). After stratifying by commercial/government insurance, a proxy for socioeconomic status, this difference persisted among those with commercial insurance. One-year post-CGM initiation, 96% (125/130) of NHW children were using CGM versus 73% (11/15) of NHB children (P = 0.003). Disparities in CGM use emerge early in care of children with T1D, with lower rates of initiation and sustained use of CGM in NHB children. Strategies addressing causes of these disparities should begin early in T1D management.
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Affiliation(s)
- Charlene W Lai
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Terri H Lipman
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Steven M Willi
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Colin P Hawkes
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
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23
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Sun MT, Li IC, Lin WS, Lin GM. Pros and cons of continuous glucose monitoring in the intensive care unit. World J Clin Cases 2021; 9:8666-8670. [PMID: 34734045 PMCID: PMC8546806 DOI: 10.12998/wjcc.v9.i29.8666] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/19/2021] [Accepted: 08/30/2021] [Indexed: 02/06/2023] Open
Abstract
Diabetes mellitus affects people worldwide, and management of its acute complications or treatment-related adverse events is particularly important in critically ill patients. Previous reports have confirmed that hyperglycemia can increase the risk of mortality in patients cared in the intensive care unit (ICU). In addition, severe and multiple hypoglycemia increases the risk of mortality when using insulin or intensive antidiabetic therapy. The innovation of continuous glucose monitoring (CGM) may help to alert medical caregivers with regard to the development of hyperglycemia and hypoglycemia, which may decrease the potential complications in patients in the ICU. The major limitation of CGM is the measurement of interstitial glucose levels rather than real-time blood glucose levels; thus, there will be a delay in the treatment of hyperglycemia and hypoglycemia in patients. Recently, the European Union approved a state-of-art artificial intelligence directed loop system coordinated by CGM and a continuous insulin pump for diabetes control, which may provide a practical way to prevent acute adverse glycemic events related to antidiabetic therapy in critically ill patients. In this mini-review paper, we describe the application of CGM to patients in the ICU and summarize the pros and cons of CGM.
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Affiliation(s)
- Ming-Tsung Sun
- Department of Medicine, Hualien Armed Forces General Hospital, Hualien 971, Taiwan
| | - I-Cheng Li
- Department of Medicine, Hualien Armed Forces General Hospital, Hualien 971, Taiwan
| | - Wei-Shiang Lin
- Department of Medicine, Tri-Service General Hospital, Taipei 114, Taiwan
| | - Gen-Min Lin
- Department of Medicine, Hualien Armed Forces General Hospital, Hualien 971, Taiwan
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24
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Yen PM, Young AS. Review of Modern Insulin Pumps and the Perioperative Management of the Type 1 Diabetic Patient for Ambulatory Dental Surgery. Anesth Prog 2021; 68:180-187. [PMID: 34606570 DOI: 10.2344/anpr-68-03-16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 08/08/2021] [Indexed: 01/25/2023] Open
Abstract
The use of continuous insulin pump systems for effective management of glycemic control in the patient with type 1 diabetes mellitus (T1DM) is steadily increasing. Although the types of devices and their respective manufacturers vary, insulin pumps all utilize similar underlying concepts based on the delivery of exogenous insulin to patients with T1DM in manners that more closely approximate the normal biologic function and performance of the pancreas. As insulin pumps becomes more commonplace and their use more widespread, the sedation or anesthesia provider must ensure familiarity with the basic knowledge of pump function and the various perioperative management considerations. This review provides a concise overview of the pathophysiology of T1DM, introduces foundational aspects of common insulin pump systems, and discusses several general recommendations regarding the perioperative management of insulin pumps during dental surgeries.
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Affiliation(s)
- Philip M Yen
- Assistant Clinical Professor, Department of Orofacial Sciences, UCSF School of Dentistry, San Francisco, California
| | - Andrew S Young
- Adjunct Assistant Professor of Clinical Dentistry, Division of Endodontics, Orthodontics and General Practice Residency, Herman Ostrow School of Dentistry of USC, Los Angeles, California
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25
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Hegedus E, Salvy SJ, Wee CP, Naguib M, Raymond JK, Fox DS, Vidmar AP. Use of continuous glucose monitoring in obesity research: A scoping review. Obes Res Clin Pract 2021; 15:431-438. [PMID: 34481746 DOI: 10.1016/j.orcp.2021.08.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/23/2021] [Accepted: 08/28/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND This scoping review provides a timely synthesis of the use of continuous glucose monitoring in obesity research with considerations to adherence to continuous glucose monitor devices and metrics most frequently reported. METHODS This scoping review was conducted adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist. Eligible studies (n = 31) evaluated continuous glucose monitor use in research on participants, of all ages, with overweight or obesity. RESULTS Reviewed studies varied in duration from one to 84 days (mean: 8.74 d, SD 15.2, range 1-84 d) with 889 participants total (range: 11-118 participants). Across all studies, the mean percent continuous glucose monitor wear time (actual/intended wear time in days) was 92% (numerator - mean: 266.1 d, SD: 452, range: 9-1596 d/denominator - mean: 271.6 d, SD: 451.5, range: 9-1596 d). Continuous glucose monitoring was utilized to provide biofeedback (n = 2, 6%), monitor dietary adherence (n = 2, 6%), and assess glycemic variability (n = 29, 93%). The most common variability metrics reported were standard deviation (n = 19, 62%), area under the curve (n = 12, 39%), and glycemic range (n = 12, 39%). CONCLUSIONS Available evidence suggests that continuous glucose monitoring is a well-tolerated and versatile tool for obesity research in pediatric and adult patients. Future investigation is needed to substantiate the feasibility and utility of continuous glucose monitors in obesity research and maximize comparability across studies.
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Affiliation(s)
- Elizabeth Hegedus
- Children's Hospital Los Angeles and Keck School of Medicine of USC, Center for Endocrinology, Diabetes and Metabolism, Los Angeles, CA, United States
| | - Sarah-Jeanne Salvy
- Cancer Research Center on Health Equity, Cedars-Sinai Medical Center, West Hollywood, CA, United States
| | - Choo Phei Wee
- Southern California Clinical and Translational Science Institute, Department of Preventive Medicine, Keck School of Medicine, Los Angeles, CA, United States
| | - Monica Naguib
- Children's Hospital Los Angeles and Keck School of Medicine of USC, Center for Endocrinology, Diabetes and Metabolism, Los Angeles, CA, United States
| | - Jennifer K Raymond
- Children's Hospital Los Angeles and Keck School of Medicine of USC, Center for Endocrinology, Diabetes and Metabolism, Los Angeles, CA, United States
| | - D Steven Fox
- Department of Pharmaceutical and Health Economics, School of Pharmacy of the University of Southern California, Los Angeles, CA, United States
| | - Alaina P Vidmar
- Children's Hospital Los Angeles and Keck School of Medicine of USC, Center for Endocrinology, Diabetes and Metabolism, Los Angeles, CA, United States.
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26
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Agarwal S, Crespo-Ramos G, Long JA, Miller VA. "I Didn't Really Have a Choice": Qualitative Analysis of Racial-Ethnic Disparities in Diabetes Technology Use Among Young Adults with Type 1 Diabetes. Diabetes Technol Ther 2021; 23:616-622. [PMID: 33761284 PMCID: PMC8501459 DOI: 10.1089/dia.2021.0075] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background: Racial-ethnic disparities in diabetes technology use are well documented in young adults (YA) with type 1 diabetes (T1D), but modifiable targets for intervention still need to be identified. Our objective was to explore YA perspectives on technology access and support in routine clinical care. Materials and Methods: Participants were YA with T1D of Hispanic or non-Hispanic Black race-ethnicity from pediatric and adult endocrinology clinics in the Bronx, NY. We conducted semistructured individual interviews to explore how health care and personal experiences affected technology use. Interviews were audio-recorded and transcribed for analysis. We used a modified inductive coding approach with two independent coders and iterative coding processes to improve data reliability and validity. Results: We interviewed 40 YA with T1D: mean age 22 years; 62% female; 72% Medicaid insured; 72% Hispanic; 28% non-Hispanic Black; and mean hemoglobin A1C 10.3%. Themes were categorized into potentially exacerbating and alleviating factors of racial-ethnic disparities in technology use. Exacerbating factors included perceptions that providers were gatekeepers of information and prescription access to technology, providers did not employ shared decision making for use, and YA biases against technology were left unaddressed. Alleviating factors included provider optimism and tailoring of technology benefits to YA needs, and adequate Medicaid insurance coverage. Conclusions: Our results reveal potential intervention targets at the provider level to increase technology uptake among underrepresented YA with T1D. Diabetes health care providers need to be aware of inadvertent withholding of information and prescription access to technology. Provider approaches that address YA technology concerns and promote shared decision making help to mitigate racial/ethnic disparities in technology use.
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Affiliation(s)
- Shivani Agarwal
- Fleischer Institute for Diabetes and Metabolism, Montefiore Medical Center, Bronx, New York, USA
- NY-Regional Center for Diabetes Translation Research, Albert Einstein College of Medicine, Bronx, New York, USA
- Address correspondence to: Shivani Agarwal, MD, MPH, Fleischer Institute for Diabetes and Metabolism, Albert Einstein College of Medicine, 1180 Morris Park Avenue, Bronx, NY 10461, USA
| | - Gladys Crespo-Ramos
- Fleischer Institute for Diabetes and Metabolism, Montefiore Medical Center, Bronx, New York, USA
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, New York, USA
| | - Judith A. Long
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Victoria A. Miller
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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27
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Dehghani Zahedani A, Shariat Torbaghan S, Rahili S, Karlin K, Scilley D, Thakkar R, Saberi M, Hashemi N, Perelman D, Aghaeepour N, McLaughlin T, Snyder MP. Improvement in Glucose Regulation Using a Digital Tracker and Continuous Glucose Monitoring in Healthy Adults and Those with Type 2 Diabetes. Diabetes Ther 2021; 12:1871-1886. [PMID: 34047962 PMCID: PMC8266934 DOI: 10.1007/s13300-021-01081-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/12/2021] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION While continuous glucose monitoring (CGM) has been shown to decrease both hyper- and hypoglycemia in insulin-treated diabetes, its value in non-insulin-treated type 2 diabetes (T2D) and prediabetes is unclear. Studies examining the reduction in hyperglycemia with the use of CGM in non-insulin-treated T2D are limited. METHODS We investigated the potential benefit of CGM combined with a mobile app that links each individual's glucose tracing to meal composition, heart rate, and physical activity in a cohort of 1022 individuals, ranging from nondiabetic to non-insulin-treated T2D, spanning a wide range of demographic, geographic, and socioeconomic characteristics. The primary endpoint was the change in time in range (TIR), defined as 54-140 mg/dL for healthy and prediabetes, and 54-180 mg/dL for T2D, from the beginning to end of a 10-day period of use of the Freestyle Libre CGM. Logged food intake, physical activity, continuous glucose, and heart rate data were captured by a smartphone-based app that continuously provided feedback to participants, overlaying daily glucose patterns with activity and food intake, including macronutrient breakdown, glycemic load (GL), and glycemic index (GI). RESULTS A total of 665 participants meeting eligibility and data requirements were included in the final analysis. Among self-reported nondiabetic participants, CGM identified glucose excursions in the diabetic range among 15% of healthy and 36% of those with prediabetes. In the group as a whole, TIR improved significantly (p < 0.001). Among the 51.4% of participants who improved, TIR increased by an average of 6.4% (p < 0.001). Of those with poor baseline TIR, defined as TIR below comparable A1c thresholds for T2D and prediabetes, 58.3% of T2D and 91.7% of healthy/prediabetes participants improved their TIR by an average of 22.7% and 23.2%, respectively. Predictors of improved response included no prior diagnosis of T2D and lower BMI. CONCLUSIONS These results indicate that 10-day use of CGM as a part of multimodal data collection, with synthesis and feedback to participants provided by a mobile health app, can significantly reduce hyperglycemia in non-insulin-treated individuals, including those with early stages of glucose dysregulation.
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Affiliation(s)
| | | | - Salar Rahili
- January AI, 1259 El Camino Real #231, Menlo Park, CA, 94025, USA
| | - Kirill Karlin
- January AI, 1259 El Camino Real #231, Menlo Park, CA, 94025, USA
| | - Darrin Scilley
- January AI, 1259 El Camino Real #231, Menlo Park, CA, 94025, USA
| | - Riya Thakkar
- January AI, 1259 El Camino Real #231, Menlo Park, CA, 94025, USA
| | - Maziyar Saberi
- January AI, 1259 El Camino Real #231, Menlo Park, CA, 94025, USA
| | - Noosheen Hashemi
- January AI, 1259 El Camino Real #231, Menlo Park, CA, 94025, USA
| | - Dalia Perelman
- January AI, 1259 El Camino Real #231, Menlo Park, CA, 94025, USA
| | - Nima Aghaeepour
- January AI, 1259 El Camino Real #231, Menlo Park, CA, 94025, USA
| | | | - Michael P Snyder
- January AI, 1259 El Camino Real #231, Menlo Park, CA, 94025, USA.
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28
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Abstract
Background: Recent studies highlight racial-ethnic disparities in insulin pump and continuous glucose monitor (CGM) use in people with type 1 diabetes (T1D), but drivers of disparities remain poorly understood beyond socioeconomic status (SES). Methods: We recruited a diverse sample of young adults (YA) with T1D from six diabetes centers across the United States, enrolling equal numbers of non-Hispanic (NH) White, NH Black, and Hispanic YA. We used multivariate logistic regression to examine to what extent SES, demographics, health care factors (care setting, clinic attendance), and diabetes self-management (diabetes numeracy, self-monitoring of blood glucose, and Self-Care Inventory score) explained insulin pump and CGM use in each racial-ethnic group. Results: We recruited 300 YA with T1D, aged 18-28 years. Fifty-two percent were publicly insured, and the mean hemoglobin A1c was 9.5%. Large racial-ethnic disparities in insulin pump and CGM use existed: 72% and 71% for NH White, 40% and 37% for Hispanic, and 18% and 28% for NH Black, respectively. After multiple adjustment, insulin pump and CGM use remained disparate: 61% and 53% for NH White, 49% and 58% for Hispanic, and 20 and 31% for NH Black, respectively. Conclusions: Insulin pump and CGM use was the lowest in NH Black, intermediate in Hispanic, and highest in NH White YA with T1D. SES was not the sole driver of disparities nor did additional demographic, health care, or diabetes-specific factors fully explain disparities, especially between NH Black and White YA. Future work should examine how minority YA preferences, provider implicit bias, systemic racism, and mistrust of medical systems help to explain disparities in diabetes technology use.
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Affiliation(s)
- Shivani Agarwal
- Fleischer Institute of Diabetes and Metabolism, New York-Regional Center for Diabetes Translation Research, Division of Endocrinology, Albert Einstein College of Medicine, Bronx, New York, USA
- Address correspondence to: Shivani Agarwal MD, MPH, Albert Einstein College of Medicine, 1180 Morris Park Avenue, Bronx, NY 10461, USA
| | - Clyde Schechter
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Jeffrey Gonzalez
- Fleischer Institute of Diabetes and Metabolism, New York-Regional Center for Diabetes Translation Research, Division of Endocrinology, Albert Einstein College of Medicine, Bronx, New York, USA
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, New York, USA
| | - Judith A. Long
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
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29
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O'Malley G, Messer LH, Levy CJ, Pinsker JE, Forlenza GP, Isganaitis E, Kudva YC, Ekhlaspour L, Raghinaru D, Lum J, Brown SA. Clinical Management and Pump Parameter Adjustment of the Control-IQ Closed-Loop Control System: Results from a 6-Month, Multicenter, Randomized Clinical Trial. Diabetes Technol Ther 2021; 23:245-252. [PMID: 33155824 PMCID: PMC8114941 DOI: 10.1089/dia.2020.0472] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background: Data are limited on the need for and benefits of pump setting optimization with automated insulin delivery. We examined clinical management of a closed-loop control (CLC) system and its relationship to glycemic outcomes. Materials and Methods: We analyzed personal parameter adjustments in 168 participants in a 6-month multicenter trial of CLC with Control-IQ versus sensor-augmented pump (SAP) therapy. Preset parameters (BR = basal rates, CF = correction factors, CR = carbohydrate ratios) were optimized at randomization, 2 and 13 weeks, for safety issues, participant concerns, or initiation by participants' usual diabetes care team. Time in range (TIR 70-180 mg/dL) was compared in the week before and after parameter changes. Results: In 607 encounters for parameter changes, there were fewer adjustments for CLC than SAP (3.4 vs. 4.1/participant). Adjustments involved BR (CLC 69%, SAP 80%), CR (CLC 68%, SAP 50%), CF (CLC 44%, SAP 41%), and overnight parameters (CLC 62%, SAP 75%). TIR before and after adjustments was 71.2% and 71.3% for CLC and 61.0% and 62.9% for SAP. The highest baseline HbA1c CLC subgroup had the largest TIR improvement (51.2% vs. 57.7%). When a CR was made more aggressive in the CLC group, postprandial time >180 mg/dL was 43.1% before the change and 36.0% after the change. The median postprandial time <70 mg/dL before making CR less aggressive was 1.8%, and after the change was 0.7%. Conclusions: No difference in TIR was detected with parameter changes overall, but they may have an effect in higher HbA1c subgroups or following user-directed boluses, suggesting that changes may matter more in suboptimal control or during discrete periods of the day. Clinical Trials Registration number: NCT03563313.
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Affiliation(s)
- Grenye O'Malley
- Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Laurel H. Messer
- Barbara Davis Center for Diabetes, University of Colorado, Aurora, Colorado, USA
| | - Carol J. Levy
- Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | | | - Gregory P. Forlenza
- Barbara Davis Center for Diabetes, University of Colorado, Aurora, Colorado, USA
| | - Elvira Isganaitis
- Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Yogish C. Kudva
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Laya Ekhlaspour
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Dan Raghinaru
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - John Lum
- Jaeb Center for Health Research, Tampa, Florida, USA
- Address correspondence to: John Lum, MS, Jaeb Center for Health Research, 15310 Amberly Drive, Suite 350, Tampa, FL 33647, USA
| | - Sue A. Brown
- Division of Endocrinology, Department of Medicine, Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
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30
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Abstract
The role of continuous glucose monitoring (CGM) in type 1 diabetes (T1D) is well established in improving glycemic control and reducing hypoglycemia. Type 2 diabetes (T2D) is more prevalent than T1D and management of T2D is more heterogeneous, requiring treatment ranging from lifestyle modification to oral medications to intensive insulin therapy. Recent randomized controlled trials in intensively insulin-treated T2D demonstrated the efficacy and safety of real-time CGM (rtCGM) in reducing glycated hemoglobin without increasing hypoglycemia. Although evidence is limited, early studies have indicated a role for rtCGM in selected patients with non-insulin requiring T2D to improve glycemic control and/or reduce hypoglycemia. Based on literature review, we summarized current data on the use of rtCGM in T2D management and provided future research direction to generate more evidence on the utility of CGM in this population.
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Affiliation(s)
- Melanie A. Jackson
- Division of Endocrinology, Diabetes, and Clinical Nutrition; Oregon Health and Science University, Portland, Oregon, USA
| | - Andrew Ahmann
- Harold Schnitzer Diabetes Health Center, Oregon Health and Science University, Portland, Oregon, USA
- Address correspondence to: Andrew Ahmann, MD, Harold Schnitzer Diabetes Health Center, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, OP05DC, Portland, OR 97239, USA
| | - Viral N. Shah
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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31
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Abstract
PURPOSE OF REVIEW As the prevalence of diabetes mellitus in the USA continues to rise, so does the popularity of diabetes management devices such as continuous glucose monitors (CGMs) and insulin pumps. The use of this technology has been shown to improve outpatient glycemic outcomes and quality of life and oftentimes may be continued in the hospital setting. Our aim is to review the current guidelines and available evidence on the continuation of insulin pumps and CGMs in the inpatient setting. RECENT FINDINGS Patients with diabetes are at higher risk for hospitalizations and complications due to hyper- or hypoglycemia, metabolic co-morbidities, or as seen recently, more severe illness from infections such as SARS-CoV-2. The maintenance of euglycemia is important to decrease both morbidity and mortality in the hospital setting. There is consensus among experts and medical societies that inpatient use of diabetes technology in carefully selected patients with proper institutional protocols is safe and can improve inpatient glycemic outcomes and reduce hypoglycemia. During the COVID-19 pandemic, CGMs played a vital role in managing hyperglycemia in some hospitalized patients. Insulin pumps and CGMs have the potential to transform glycemic management in hospitalized patients. In order for institutions to safely and effectively incorporate these technologies on their inpatient units, hospital-based providers will need to be able to understand how to manage and utilize these devices in their practice in conjunction with diabetes experts.
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Affiliation(s)
- Tiffany Yeh
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, Weill Cornell Medicine / New York Presbyterian Hospital, 1305 York Avenue, 4th Floor, New York, NY, 10021, USA.
| | - Michele Yeung
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, Weill Cornell Medicine / New York Presbyterian Hospital, 1305 York Avenue, 4th Floor, New York, NY, 10021, USA
| | - Felicia A Mendelsohn Curanaj
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, Weill Cornell Medicine / New York Presbyterian Hospital, 1305 York Avenue, 4th Floor, New York, NY, 10021, USA
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32
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Pease A, Szwarcbard N, Earnest A, Andrikopoulos S, Wischer N, Zoungas S. Glycaemia and utilisation of technology across the lifespan of adults with type 1 diabetes: Results of the Australian National Diabetes Audit (ANDA). Diabetes Res Clin Pract 2021; 171:108609. [PMID: 33310120 DOI: 10.1016/j.diabres.2020.108609] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/30/2020] [Accepted: 12/02/2020] [Indexed: 01/22/2023]
Abstract
AIMS To evaluate the utilisation of technologies and associated glycaemia among adults with type 1 diabetes. METHODS De-identified data from adults with type 1 diabetes (≥18 years old) in the Australian National Diabetes Audit (ANDA)-2019 were analysed. Proportions using insulin pumps or injections with continuous glucose monitoring (CGM) or capillary-glucose testing were compared. Technology use among adults was compared to young people (<21 years old) with subsidised CGM. Glycaemia and complication-burden were assessed across management strategies. RESULTS 1,693 adults were analysed. Mean(±SD) age, diabetes duration, and HbA1c were 43.3 ± 17.0 years, 20.3 ± 14.3 years and 8.4% ± 1.7 [68 ± 19 mmol/mol], respectively. Among adults, 40% used at least one device, 27% used insulin pumps, and 23% used CGM. CGM was used by 62% of young people with subsidised access. Mean HbA1c was consistently lower among adults using CGM, insulin pumps, or combined insulin pump and CGM compared to standard care (8.3% ± 1.6 [67 ± 18 mmol/mol], 8.2% ± 1.4 [66 ± 15 mmol/mol], and 7.8% ± 1.4 [62 ± 15 mmol/mol] respectively compared to 8.6% ± 1.8 [70 ± 20 mmol/mol], p < 0.001). Technology use was not associated with diabetic ketoacidosis but CGM was associated with more hypoglycaemia. CONCLUSIONS Government subsidy is an important consideration for utilisation of technologies among adults with type 1 diabetes. Technology use across the adult lifespan was associated with lower HbA1c than insulin injections and capillary-glucose testing.
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Affiliation(s)
- Anthony Pease
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Monash Health, Melbourne, Victoria, Australia.
| | - Naomi Szwarcbard
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Alfred Health, Melbourne, Victoria, Australia.
| | - Arul Earnest
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
| | - Sofianos Andrikopoulos
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia.
| | - Natalie Wischer
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
| | - Sophia Zoungas
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Monash Health, Melbourne, Victoria, Australia; Alfred Health, Melbourne, Victoria, Australia.
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Fung A, Irvine M, Ayub A, Ziabakhsh S, Amed S, Hursh BE. Evaluation of telephone and virtual visits for routine pediatric diabetes care during the COVID-19 pandemic. J Clin Transl Endocrinol 2020; 22:100238. [PMID: 33072519 DOI: 10.1016/j.jcte.2020.100238] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/28/2020] [Accepted: 10/03/2020] [Indexed: 02/06/2023]
Abstract
Aims To evaluate pediatric type 1 diabetes telehealth visits during the COVID-19 pandemic, with a focus on assessing the usability of these visits and gathering patient perspectives. Methods An online survey, which included a validated telehealth usability questionnaire, was offered via email to families with a telephone or virtual visit since the COVID-19-related cancellation of routine in-person care. Survey data was linked with the British Columbia (BC) Clinical Diabetes Registry. Outcomes between groups were assessed using Welch's t-test. Associations with type of visit as well as with desire to return to in-person care were assessed with logistic regression models. Results The response rate was 47%. Of 141 survey respondents, 87 had clinical data available in the BC Clinical Diabetes Registry, and thus were included in our analysis. Overall, telephone and virtual visits were rated highly for usability. Telephone visits were easier to learn to use, and simpler to understand; however, telephone and virtual visits were similar across multiple areas. No factors associated with choosing one type of visit over the other, or with desire to return to in-person care, could be identified. 72% of participants want future telehealth care; however, some would like all future care to be in-person. Conclusions Telephone and virtual visits had impressive usability. Many families want telehealth to play a significant part in their future care.
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Sopfe J, Vigers T, Pyle L, Giller RH, Forlenza GP. Safety and Accuracy of Factory-Calibrated Continuous Glucose Monitoring in Pediatric Patients Undergoing Hematopoietic Stem Cell Transplantation. Diabetes Technol Ther 2020; 22:727-733. [PMID: 32105513 PMCID: PMC7591371 DOI: 10.1089/dia.2019.0521] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background: Pediatric patients undergoing hematopoietic stem cell transplantation (HSCT) may be at risk for malglycemia and adverse outcomes, including infection, prolonged hospital stays, organ dysfunction, graft-versus-host-disease, delayed hematopoietic recovery, and increased mortality. Continuous glucose monitoring (CGM) may aid in describing and treating malglycemia in this population. However, no studies have demonstrated safety, tolerability, or accuracy of CGM in this uniquely immunocompromised population. Materials and Methods: A prospective observational study was conducted, using the Abbott Freestyle Libre Pro, in patients aged 2-30 undergoing HSCT at Children's Hospital Colorado to evaluate continuous glycemia in this population. CGM occurred up to 7 days before and 60 days after HSCT, during hospitalization only. In a secondary analysis of this data, blood glucoses collected during routine HSCT care were compared with CGM values to evaluate accuracy. Adverse events and patient refusal to wear CGM device were monitored to assess safety and tolerability. Results: Participants (n = 29; median age 13.1 years, [interquartile range] [4.7, 16.6] years) wore 84 sensors for an average of 25 [21.5, 30.0] days per participant. Paired serum-sensor values (n = 893) demonstrated a mean absolute relative difference of 20% ± 14% with Clarke Error Grid analysis showing 99% of pairs in the clinically acceptable Zones (A+B). There were four episodes of self-limited bleeding (4.8% of sensors); no other adverse events occurred. Six patients (20.7%) refused subsequent CGM placements. Conclusions: CGM use appears safe and feasible although with suboptimal accuracy in the hospitalized pediatric HSCT population. Few adverse events occurred, all of which were low grade.
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Affiliation(s)
- Jenna Sopfe
- Department of Pediatrics, Center for Cancer and Blood Disorders, University of Colorado School of Medicine, Aurora, Colorado
- Address correspondence to: Jenna Sopfe, MD, Department of Pediatrics, Center for Cancer and Blood Disorders, University of Colorado School of Medicine, 13123 E 16th Avenue, B115, Aurora, CO 80045
| | - Tim Vigers
- Department of Biostatistics and Informatics, University of Colorado Denver, Aurora, Colorado
- Barbara Davis Center, University of Colorado Denver, Aurora, Colorado
| | - Laura Pyle
- Department of Biostatistics and Informatics, University of Colorado Denver, Aurora, Colorado
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Roger H. Giller
- Department of Pediatrics, Center for Cancer and Blood Disorders, University of Colorado School of Medicine, Aurora, Colorado
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Commissariat PV, Whitehouse AL, Hilliard ME, Miller KM, Harrington KR, Levy W, DeSalvo DJ, Van Name MA, Anderson BJ, Tamborlane WV, DiMeglio LA, Laffel LM. Sources and Valence of Information Impacting Parents' Decisions to Use Diabetes Technologies in Young Children <8 Years Old with Type 1 Diabetes. Diabetes Technol Ther 2020; 22:697-700. [PMID: 32077755 PMCID: PMC7718841 DOI: 10.1089/dia.2019.0497] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
There are multiple information sources available to assist families in learning about rapidly advancing diabetes technologies as care options for their children. This study explored where and from whom families of young children with type 1 diabetes get information about diabetes technologies and the valence (positive vs. negative) of that information. Semi-structured interviews were conducted with parents (86% mothers) of 79 youth <8 years old with type 1 diabetes for ≥6 months, ([mean ± standard deviation] age 5.2 ± 1.5 years, diabetes duration 2.4 ± 1.3 years, 77% white, A1c 63 ± 10 mmol/mol [7.9 ± 0.9%], 66% pump-treated, 58% using continuous glucose monitors [CGMs]). Interviews were transcribed and underwent content analysis to derive central themes. Most parents reported learning about new technologies from three direct sources: diabetes care providers, people with diabetes, and caregivers of children with diabetes. Parents also cited three indirect sources of information: online forums, publications, and diabetes-specific conferences. Parents reported hearing primarily positive things about technologies. Families not using pump and/or CGM noted reluctance to use technology due to family-specific concerns (e.g., cost, child's unwillingness to wear device) rather than information from outside sources. In this subset of parents, many still expressed willingness to initiate use once family-specific concerns were resolved. Parents of young children received largely positive information about diabetes technologies, primarily from health care providers and others familiar with using devices personally or for their children. To maximize diabetes technology use in young children, it is incumbent upon providers to ensure families receive balanced realistic information about benefits and barriers.
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Affiliation(s)
| | | | | | - Kellee M. Miller
- Jaeb Center for Health Research, Tampa, Florida
- Address correspondence to: Kellee M. Miller, PhD, Jaeb Center for Health Research, 15310 Amberly Drive, Suite 350, Tampa, FL 33647
| | | | - Wendy Levy
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Daniel J. DeSalvo
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Michelle A. Van Name
- Yale School of Medicine, Department of Pediatric Endocrinology and Diabetes, New Haven, Connecticut
| | | | - William V. Tamborlane
- Yale School of Medicine, Department of Pediatric Endocrinology and Diabetes, New Haven, Connecticut
| | - Linda A. DiMeglio
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Lori M. Laffel
- Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts
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Almehmadi A, Lightowler H, Chohan M, Clegg ME. The effect of a split portion of flaxseed on 24-h blood glucose response. Eur J Nutr 2020; 60:1363-1373. [PMID: 32699911 PMCID: PMC7987624 DOI: 10.1007/s00394-020-02333-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 07/07/2020] [Indexed: 11/30/2022]
Abstract
Purpose Flaxseed can be effective at lowering and stabilising blood glucose responses. The aim of this study was to determine whether flaxseed could lower blood glucose response more effectively when consumed as a single portion of 30 g, or a split portion consumed three times per day (10 g flaxseed per portion).
Methods The study was a randomised, repeated measures, cross-over design. Fifteen healthy participants consumed either (1) three flaxseed muffins containing a total of 30 g of flaxseed once in the morning, (2) three flaxseed muffins consumed at three different timepoints across the day (10 g flaxseed per muffin) or (3) three control muffins consumed at three different timepoints across the day (0 g flaxseed). The 24-h blood glucose response was measured using a continuous glucose monitor.
Results The results of this study demonstrated that flaxseed muffins given three times a day were effective at lowering and maintaining blood glucose levels over 24 h, compared to the control muffins and that both flaxseed treatments resulting in a lower blood glucose iAUC during the night. Conclusion The results of this study indicated that adding flaxseed to a daily diet produced a lower glucose profile over 24 h in a free-living context compared to the control muffins.
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Affiliation(s)
- Awatif Almehmadi
- Department of Sport, Health Sciences and Social Work, Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, OX3 0BP, UK.,Department of Clinical Nutrition, College of Applied Medical Sciences, Umm Al-Qura University, 21421, Makkah, Saudi Arabia
| | - Helen Lightowler
- Department of Sport, Health Sciences and Social Work, Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, OX3 0BP, UK
| | - Magali Chohan
- Department of Health and Exercise Science, Faculty of Sport, Health and Applied Science, St Mary's University, Twickenham, TW1 4SX, UK
| | - Miriam E Clegg
- Department of Food and Nutritional Sciences, School of Chemistry, Food and Pharmacy, University of Reading, Reading, RG6 6AP, UK.
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Haslund-Thomsen H, Hasselbalch LA, Laugesen B. Parental Experiences of Continuous Glucose Monitoring in Danish Children with Type 1 Diabetes Mellitus. J Pediatr Nurs 2020; 53:e149-e155. [PMID: 32245681 DOI: 10.1016/j.pedn.2020.03.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 03/17/2020] [Accepted: 03/17/2020] [Indexed: 12/27/2022]
Abstract
PURPOSE To explore parents 'experience of having a child aged 4-9 years with type 1 diabetes mellitus (T1DM) using continuous glucose monitor (CGM). DESIGN AND METHODS The study was a qualitative study. Twelve families were recruited for individual or dyadic interviews through purposeful and convenience sampling procedures. RESULTS Thematic analysis generated three main themes: 1) Living in the context of the unpredictability of diabetes 2) Establishing a sense of control and security with the CGM 3) Learning to use and trust the CGM and educating other caregivers. CONCLUSIONS Living in the context of the unpredictability of T1DM causes a loss of stability and control as T1DM pervades family life and transforms everyday routines. CGM use seems to increase opportunities for other family activities, as it provides parents with a sense of control and moderates the pervasiveness of T1DM. Yet the parents have to learn how to trust and use the CGM and take on the burdensome task of training and trusting other caregivers. PRACTICE IMPLICATIONS The CGM is used as an integral part of T1DM care in everyday life. Therefore, it should be accessible to families. Health-care professionals should be aware of how to assist parents with how to use and trust the CGM. Furthermore, parents may need help and support in educating other caregivers on how to use the CGM. This could be done through teaching sessions, written materials and recorded demonstrations of CGM use.
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Affiliation(s)
- Helle Haslund-Thomsen
- Clinical Nursing research Unit, Aalborg University Hospital, Aalborg, Denmark; Clinic for Anesthesiology, Child Diseases, Circulation and Women, Aalborg University Hospital, Aalborg, Denmark; Pediatric Department, Clinic for Anesthesiology, Child Diseases, Circulation and Women, Aalborg University Hospital, Aalborg, Denmark.
| | - Line Aagaard Hasselbalch
- Clinic for Anesthesiology, Child Diseases, Circulation and Women, Aalborg University Hospital, Aalborg, Denmark; Pediatric Department, Clinic for Anesthesiology, Child Diseases, Circulation and Women, Aalborg University Hospital, Aalborg, Denmark
| | - Britt Laugesen
- Clinical Nursing research Unit, Aalborg University Hospital, Aalborg, Denmark; Danish Centre of Clinical Guidelines, Department of Clinical Medicine, Aalborg University, Denmark
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Abstract
Treatments for type 1 diabetes have advanced significantly over recent years. There are now multiple hybrid closed-loop systems commercially available and additional systems are in development. Challenges remain, however. This review outlines the recent advances in closed-loop systems and outlines the remaining challenges, including post-prandial hyperglycemia and exercise-related dysglycemia.
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Affiliation(s)
- Melanie Jackson
- Division of Endocrinology, Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, Portland, Oregon
| | - Jessica R. Castle
- Division of Endocrinology, Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, Portland, Oregon
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DeJournett J, Nekludov M, DeJournett L, Wallin M. Performance of a closed-loop glucose control system, comprising a continuous glucose monitoring system and an AI-based controller in swine during severe hypo- and hyperglycemic provocations. J Clin Monit Comput 2020; 35:317-325. [PMID: 32006145 PMCID: PMC7943496 DOI: 10.1007/s10877-020-00474-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 01/24/2020] [Indexed: 01/04/2023]
Abstract
Intensive care unit (ICU) patients develop stress induced insulin resistance causing hyperglycemia, large glucose variability and hypoglycemia. These glucose metrics have all been associated with increased rates of morbidity and mortality. The only way to achieve safe glucose control at a lower glucose range (e.g., 4.4–6.6 mmol/L) will be through use of an autonomous closed loop glucose control system (artificial pancreas). Our goal with the present study was to assess the safety and performance of an artificial pancreas system, composed of the EIRUS (Maquet Critical Care AB) continuous glucose monitor (CGM) and novel artificial intelligence-based glucose control software, in a swine model using unannounced hypo- and hyperglycemia challenges. Fourteen piglets (6 control, 8 treated) underwent sequential unannounced hypoglycemic and hyperglycemic challenges with 3 IU of NovoRapid and a glucose infusion at 17 mg/kg/min over the course of 5 h. In the Control animals an experienced ICU physician used every 30-min blood glucose values to maintain control to a range of 4.4–9 mmol/L. In the Treated group the artificial pancreas system attempted to maintain blood glucose control to a range of 4.4–6.6 mmol/L. Five of six Control animals and none of eight Treated animals experienced severe hypoglycemia (< 2.22 mmol/L). The area under the curve 3.5 mmol/L was 28.9 (21.1–54.2) for Control and 4.8 (3.1–5.2) for the Treated animals. The total percent time within tight glucose control range, 4.4–6.6 mmol/L, was 32.8% (32.4–47.1) for Controls and 55.4% (52.9–59.4) for Treated (p < 0.034). Data are median and quartiles. The artificial pancreas system abolished severe hypoglycemia and outperformed the experienced ICU physician in avoiding clinically significant hypoglycemic excursions.
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Affiliation(s)
- Jeremy DeJournett
- Ideal Medical Technologies, 18 N Kensington Rd, Asheville, NC 28804 USA
| | - Michael Nekludov
- Karolinska University Hospital, Karolinska Universitetssjukhuset, Eugeniavägen 3, 171 76 Solna, Sweden
| | - Leon DeJournett
- Ideal Medical Technologies, 18 N Kensington Rd, Asheville, NC 28804 USA
| | - Mats Wallin
- Maquet Critical Care AB, Röntgenvägen 2, 17154 Solna, Sweden
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Abstract
PURPOSE OF REVIEW To highlight global advancements in diabetes technology and compare available technologies and device approval processes in the USA and Europe and their impact on safety and innovation. RECENT FINDINGS The last two decades have seen a rapid growth in diabetes technology driven by the impetus to improve glycemic control, avoid complications of insulin therapy, improve quality of life, and hand more autonomy to individuals with diabetes. Meanwhile, changes to regulatory processes in the USA and Europe aim to facilitate entry of new devices into the marketplace. Major strides have been made in digitization of insulin pens, continuous glucose monitors and their integration with insulin pumps, automated insulin delivery systems, and closed-loop insulin pump systems. The centralized regulatory body in the USA and more decentralized approval bodies in Europe have led to differences in the rate of market availability of diabetes devices. While both US and Europe systems have different advantages and disadvantages in device approval, they continue to struggle with balancing accelerated device access with adequate clinical evidence and monitoring to ensure safety of such devices.
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Affiliation(s)
- Gonzalo J Acosta
- Department of Internal Medicine, Division of Endocrinology, Houston Methodist Hospital, 6565 Fannin St. Suite 1101, Houston, TX, 77030, USA
| | - Spandana Brown
- Department of Internal Medicine, Division of Endocrinology, Houston Methodist Hospital, 6565 Fannin St. Suite 1101, Houston, TX, 77030, USA
| | - Ashkan M Zand
- Department of Internal Medicine, Division of Endocrinology, Houston Methodist Hospital, 6565 Fannin St. Suite 1101, Houston, TX, 77030, USA
| | - Abhishek Kansara
- Department of Internal Medicine, Division of Endocrinology, Houston Methodist Hospital, 6565 Fannin St. Suite 1101, Houston, TX, 77030, USA.
| | - Archana Sadhu
- Department of Internal Medicine, Division of Endocrinology, Houston Methodist Hospital, 6565 Fannin St. Suite 1101, Houston, TX, 77030, USA
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Bergloff A, Stratton E, Briggs Early K. A Cross-Sectional Pilot Survey of Rural Clinic Attitudes and Proficiency with Insulin Pumps and Continuous Glucose Monitoring Devices. Diabetes Technol Ther 2019; 21:665-670. [PMID: 31339738 DOI: 10.1089/dia.2019.0161] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Purpose: To examine the perceptions, proficiencies, and barriers of diabetes device use among rural clinic providers. Methods: A total of 210 surveys were sent through e-mail and/or U.S. Postal Service to rural clinics throughout Alaska, Idaho, Montana, Oregon, Washington, and Utah based on discussions with rural clinic network leadership in the states. Responses were included if the participant was 18 years of age and older, and worked at a rural clinic as a physician, physician assistant, nurse, nurse practitioner, allied health worker, or clinic manager. Results: Respondents included clinic management (13%), midlevel providers (physician assistants and nurse practitioners) and allied health workers (pharmacists, dietitians, and social workers, 30.8%), nurses (30.8%), and physicians (23.1%). We had a low response rate (20%; n = 41), but of those who said they work with patients who have diabetes, only 47.4% indicated that they use diabetes devices as part of their patients' treatment. The most common barrier reported among respondents suggested that additional medical team expertise is needed in their community or clinic to adopt insulin pumps and/or continuous glucose monitoring for qualified patients (75.9% and 80.8%, respectively). Conclusion: Lack of provider experience and having patients managed by out-of-area experts were the biggest reasons for providers not seeing or managing patients using these devices. Lack of provider access, patient satisfaction with current diabetes regimens, unsupportive health care team, patient literacy, and patient fear showed limited to negligible endorsements from survey respondents. A variety of potential solutions to this problem of limited provider experience and training are also offered.
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Affiliation(s)
- Andrew Bergloff
- College of Osteopathic Medicine, Pacific Northwest University of Health Sciences (PNWU), Yakima, Washington
| | - Emily Stratton
- Emergency Medicine, SUNY Upstate Medical University, Syracuse, New York
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Chen E, King F, Kohn MA, Spanakis EK, Breton M, Klonoff DC. A Review of Predictive Low Glucose Suspend and Its Effectiveness in Preventing Nocturnal Hypoglycemia. Diabetes Technol Ther 2019; 21:602-609. [PMID: 31335193 DOI: 10.1089/dia.2019.0119] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
To evaluate the effectiveness of predictive low glucose suspend (PLGS) systems within sensor-augmented insulin infusion pumps at preventing nocturnal hypoglycemia in patients with type 1 diabetes (DM1), we performed a systematic review and meta-analysis of randomized crossover trials. Pubmed and Google Scholar were searched for randomized crossover trials, published between January 2013 and July 2018, in nonpregnant outpatients with DM1, which compared event rates during PLGS overnight periods and non-PLGS overnight periods. The primary outcome was the proportion of overnight periods with one or more hypoglycemic measurement. When available, individual patient data were used to assess the effect of clustering measurements within patients. Four studies (272 patients, 10,735 patient-nights: 5422 PLGS and 5313 non-PLGS) were included in the meta-analysis. Two studies reported patient-level data that permitted assessment of the effect of clustering measurements within patients. The effect on the risk difference was minimal. The proportion of overnight periods with one or more episodes of hypoglycemia was 19.6% for the PLGS periods and 27.8% for the non-PLGS periods. Based on the pooled estimate, PLGS overnight periods were associated with an 8.8% lower risk of hypoglycemia (risk difference -0.088; 95% CI -0.119 to -0.056, I2 = 67.4%, τ2 = 0.0006, 4 studies). PLGS systems can reduce nocturnal hypoglycemic events in patients with DM1.
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Affiliation(s)
- Ethan Chen
- Diabetes Research Institute at Mills-Peninsula Medical Center, San Mateo, California
| | - Fraya King
- Diabetes Research Institute at Mills-Peninsula Medical Center, San Mateo, California
| | - Michael A Kohn
- Department of Epidemiology and Biostatistics, University of California, San Francisco School of Medicine, San Francisco, California
| | - Elias K Spanakis
- Division of Endocrinology, Baltimore Veterans Affairs Medical Center, Baltimore, Maryland
- Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, Maryland
| | - Marc Breton
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia
| | - David C Klonoff
- Diabetes Research Institute at Mills-Peninsula Medical Center, San Mateo, California
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Sherwood JS, Jafri RZ, Balliro CA, Zheng H, El-Khatib FH, Damiano ER, Russell SJ, Putman MS. Automated glycemic control with the bionic pancreas in cystic fibrosis-related diabetes: A pilot study. J Cyst Fibros 2019; 19:159-161. [PMID: 31420176 DOI: 10.1016/j.jcf.2019.08.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 07/26/2019] [Accepted: 08/04/2019] [Indexed: 11/16/2022]
Abstract
Cystic fibrosis-related diabetes (CFRD) is the most common extrapulmonary manifestation of cystic fibrosis. The current standard of care for CFRD involves treatment with insulin, typically via multiple daily injections. We conducted a small pilot study comparing usual care with automated glycemic control using the bihormonal (insulin and glucagon) and insulin-only configurations of the bionic pancreas. Both configurations of the bionic pancreas achieved good glycemic control, with mean glucose levels <150 mg/dl and minimal hypoglycemia. Subjects reported improved treatment satisfaction and reduced burden of diabetes management with the bionic pancreas. Further investigation of automated glycemic control in the treatment of CFRD is warranted.
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Affiliation(s)
- Jordan S Sherwood
- Diabetes Research Unit, Massachusetts General Hospital, Boston, MA, United States of America
| | - Rabab Z Jafri
- Diabetes Research Unit, Massachusetts General Hospital, Boston, MA, United States of America
| | - Courtney A Balliro
- Diabetes Research Unit, Massachusetts General Hospital, Boston, MA, United States of America
| | - Hui Zheng
- Biostatics Center, Massachusetts General Hospital, Boston, MA, United States of America
| | | | | | - Steven J Russell
- Diabetes Research Unit, Massachusetts General Hospital, Boston, MA, United States of America
| | - Melissa S Putman
- Diabetes Research Unit, Massachusetts General Hospital, Boston, MA, United States of America; Department of Endocrinology, Boston Children's Hospital, Boston, MA, United States of America.
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Mongraw-Chaffin M, Beavers DP, McClain DA. Hypoglycemic symptoms in the absence of diabetes: Pilot evidence of clinical hypoglycemia in young women. J Clin Transl Endocrinol 2019; 18:100202. [PMID: 31428564 PMCID: PMC6695274 DOI: 10.1016/j.jcte.2019.100202] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 07/10/2019] [Accepted: 07/23/2019] [Indexed: 02/09/2023]
Abstract
Aims Clinical visits of non-diabetic patients reporting hypoglycemic symptoms are common in endocrinology practices, but remain understudied and lack clinical definition and evidence-based recommendations for diagnosis or treatment. Our goal was to pilot test the concordance of hypoglycemic symptoms with low glucose values in young non-diabetic individuals. Methods We recruited eight individuals who reported regularly experiencing symptoms consistent with hypoglycemia to wear a blinded Dexcom continuous glucose monitor and report symptoms for seven days. We excluded individuals with diabetes or other known causes of hypoglycemia or similar symptoms. Results Participants were all women with an average age of 29 years. 25% were African American and 25% had obesity. All participants experienced glucose values ≤ 70 mg/dL and half (4/8) experienced glucose ≤ 54 mg/dL for at least 15 min or 3 consecutive readings. Average time between last meal and reported symptoms was 4.4 h. Lower glucose values were significantly associated with higher odds of experiencing hypoglycemic symptoms 1.15 (CI: 1.07-1.24) for every -5mg/dL, (p < 0.001) from mixed effects models for repeated measures adjusted for age, race, and body mass index. All participants also reported engaging in potentially obesogenic behaviors in order to avoid symptoms. Conclusions Individuals with hypoglycemic symptoms in the absence of diabetes experience clinical hypoglycemia, indicating the need to understand the etiology, behavioral responses, and other health risks that might be associated with this understudied condition.
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Affiliation(s)
- Morgana Mongraw-Chaffin
- Department of Epidemiology & Prevention, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Daniel P Beavers
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Donald A McClain
- Department of Endocrinology and Metabolism, Wake Forest School of Medicine, Winston-Salem, NC, United States
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Abstract
PURPOSE OF REVIEW In this article, we consider advanced technologies for the management of diabetes. RECENT FINDINGS Specifically, we pose the question of which should come first: an insulin pump (CSII) or a continuous glucose monitor (CGM)? Historical perspective on both insulin delivery and glucose measurement is provided. Recently published clinical trials are reviewed. Practical issues including quality of life, patient education, and out-of-pocket cost are discussed. Based on available evidence and clinical experience, we favor CGM as a first-line technology recommendation for the treatment of type 1 diabetes (T1D).
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Affiliation(s)
| | - Amy B. Criego
- International Diabetes Center, Park Nicollet Pediatric Endocrine, Minneapolis, MN 55416 USA
| | - Anders L. Carlson
- International Diabetes Center, HealthPartners Endocrinology, Minneapolis, MN 55416 USA
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Knopp JL, Signal M, Harris DL, Marics G, Weston P, Harding J, Tóth-Heyn P, Hómlok J, Benyó B, Chase JG. Modelling intestinal glucose absorption in premature infants using continuous glucose monitoring data. Comput Methods Programs Biomed 2019; 171:41-51. [PMID: 30344050 DOI: 10.1016/j.cmpb.2018.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 09/11/2018] [Accepted: 10/01/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND Model-based glycaemic control protocols have shown promise in neonatal intensive care units (NICUs) for reducing both hyperglycaemia and insulin-therapy driven hypoglycaemia. However, current models for the appearance of glucose from enteral feeding are based on values from adult intensive care cohorts. This study aims to determine enteral glucose appearance model parameters more reflective of premature infant physiology. METHODS Peaks in CGM data associated with enteral milk feeds in preterm and term infants are used to fit a two compartment gut model. The first compartment describes glucose in the stomach, and the half life of gastric emptying is estimated as 20 min from literature. The second compartment describes glucose in the small intestine, and absorption of glucose into the blood is fit to CGM data. Two infant cohorts from two NICUs are used, and results are compared to appearances derived from data in highly controlled studies in literature. RESULTS The average half life across all infants for glucose absorption from the gut to the blood was 50 min. This result was slightly slower than, but of similar magnitude to, results derived from literature. No trends were found with gestational or postnatal age. Breast milk fed infants were found to have a higher absorption constant than formula fed infants, a result which may reflect known differences in gastric emptying for different feed types. CONCLUSIONS This paper presents a methodology for estimation of glucose appearance due to enteral feeding, and model parameters suitable for a NICU model-based glycaemic control context.
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Affiliation(s)
- J L Knopp
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand.
| | - M Signal
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand.
| | - D L Harris
- Newborn Intensive Care Unit, Waikato District Health Board, Hamilton, New Zealand; Liggins Institute, University of Auckland, Auckland, New Zealand.
| | - G Marics
- First Department of Paediatrics, Intensive Care Unit, Semmelweis University, Budapest, Hungary
| | - P Weston
- Newborn Intensive Care Unit, Waikato District Health Board, Hamilton, New Zealand.
| | - J Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand.
| | - P Tóth-Heyn
- First Department of Paediatrics, Intensive Care Unit, Semmelweis University, Budapest, Hungary.
| | - J Hómlok
- Budapest University of Technology and Economics, Budapest, Hungary
| | - B Benyó
- Budapest University of Technology and Economics, Budapest, Hungary.
| | - J G Chase
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand.
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Marks BE, Wolfsdorf JI, Waldman G, Stafford DE, Garvey KC. Pediatric Endocrinology Trainees' Education and Knowledge About Insulin Pumps and Continuous Glucose Monitors. Diabetes Technol Ther 2019; 21:105-109. [PMID: 30681363 PMCID: PMC6434593 DOI: 10.1089/dia.2018.0331] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Recent data demonstrating a lack of improvement in average hemoglobin A1c levels despite the increased use of insulin pumps and continuous glucose monitors (CGMs) suggest that patients are not using these technologies optimally. Suboptimal provider understanding of these devices may be a contributing factor. METHODS We sought to assess fellows' knowledge, attitudes, and practices regarding insulin pumps and CGMs using a mixed-methods survey. We polled 42 pediatric endocrinology fellows and 69 attending physicians in pediatric endocrinology using items on a five-point Likert scale. RESULTS Perceived fellow knowledge of insulin pumps and CGMs was only 3.6 ± 1.0 and 3.6 ± 0.9, respectively. Despite consensus about the need for pediatric endocrinologists to understand these technologies, only 14.7% of fellows reported the presence of a formal curriculum about these technologies at their institutions. Potential gaps identified in fellows' knowledge include general use and troubleshooting, advanced insulin pump features, infusion sets and dermatological complications, systematic approach to data, interpretation and application of CGM data, and keeping pace with technological advances. CONCLUSIONS Our data suggest suboptimal fellow knowledge and understanding of insulin pumps and CGMs in pediatric type 1 diabetes management, which is likely attributable to inadequate education in fellowship training programs. The development of formal educational curricula targeting areas of weakness identified in this survey may improve clinician knowledge of these technologies and ultimately impact patient education and care.
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Affiliation(s)
- Brynn E. Marks
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts
- Address correspondence to: Brynn E. Marks, MD, Division of Endocrinology, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115
| | - Joseph I. Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts
| | - Gretchen Waldman
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts
| | - Diane E. Stafford
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts
| | - Katharine C. Garvey
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts
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Szymońska I, Jagła M, Starzec K, Kwinta P. Glycemic variability in continuous glucose monitoring negatively correlates with gestational age in very low birth weight infants. J Matern Fetal Neonatal Med 2019; 33:3041-3043. [PMID: 30614329 DOI: 10.1080/14767058.2019.1566313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Introduction: High glycemic variability is commonly observed in intensive care patients, both in pediatrics and adults. The aim of the study was to evaluate the correlation between gestational age and glycemic variability in cohort of very low birth infants.Patients and methods: A prospective, single-center, open cohort study enrolled 74 very low birth weight infants with a mean birth weight of 1066 g. Continuous glucose monitoring system (Guardian Real-Time CGM®, Medtronic, Northridge, CA, USA) was used to measure glucose levels. Spearman's rank correlation coefficients were calculated for glycemic variability indices and gestational age. Multiple linear regression analyses were used to assess the adjusted effect of multiple glycemic variability variables.Results: The correlations between all calculated glycemic variability indices and gestational age were negative. In multiple regression analysis, all glycemic variability indices negatively correlated with gestational age and positively correlated with mean interstitial fluid glucose concentration.Conclusions: Glycemic variability in very low birth weight infants correlates with gestational age and mean glucose concentrations.
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Affiliation(s)
- Izabela Szymońska
- Department of Pediatrics, Jagiellonian University Collegium Medicum, Poland, Kraków
| | - Mateusz Jagła
- Department of Pediatrics, Jagiellonian University Collegium Medicum, Poland, Kraków
| | - Katarzyna Starzec
- Department of Pediatrics, Jagiellonian University Collegium Medicum, Poland, Kraków
| | - Przemko Kwinta
- Department of Pediatrics, Jagiellonian University Collegium Medicum, Poland, Kraków
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Rayannavar A, Elci OU, Mitteer L, De Leon DD. Continuous Glucose Monitoring Systems: Are They Useful for Evaluating Glycemic Control in Children with Hyperinsulinism? Horm Res Paediatr 2019; 92:319-327. [PMID: 32208390 PMCID: PMC7192768 DOI: 10.1159/000506230] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 01/28/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Effective treatment and close monitoring in children with congenital hyperinsulinism (HI) are important to prevent hypoglycemic-associated brain damage. The current monitoring approach involves measuring plasma glucose intermittently, but this does not provide a comprehensive assessment of glycemic control and may fail to detect episodes of hypoglycemia. OBJECTIVE To determine whether Dexcom G5®, a continuous glucose monitoring system (CGMS), is an accurate and effective method for monitoring glycemic control in children with HI. METHODS Cross-sectional, observational study in 15 children with HI. Participants wore a blinded Dexcom G5® device for 2 weeks. At the end of 2 weeks, data from the Dexcom G5® and home glucose meter were downloaded and analyzed. RESULTS Fourteen children (15-67 months) completed the study. Using Bland-Altman analysis, the mean (SD) difference between 1,155 paired CGM and glucose meter readings was -8.09 (53.76). The sensitivity and specificity of CGM to detect hypoglycemia (<70 mg/dL) were 86 and 81.4%, respectively. The positive predictive values for hypoglycemia and severe hypoglycemia (<54 mg/dL) detected by CGM were low (50.3 and 14.8%, respectively), while the negative predictive values were high (96.4% for glucose <70 mg/dL and 99.1% for glucose <54 mg/dL). CONCLUSION Our study showed that CGM is not a reliable method to monitor for hypoglycemia, given the high number of false positive hypoglycemia readings. However, CGM can be useful in preventing unnecessary checks by glucose meter during times of normoglycemia. Therefore, the benefits of using CGM in patients with HI would be in guiding the need to check plasma glucose by glucose meter rather than point accuracy.
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Affiliation(s)
- Arpana Rayannavar
- Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Okan U. Elci
- Westat, Rockville MD,Biostatistics and Data Management Core, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Lauren Mitteer
- Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Diva D. De Leon
- Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, PA,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Zekarias K, Kumar A, Moheet A, Seaquist E. Real life evidence that impaired awareness of hypoglycemia persists for years in patients with type 1 diabetes. J Diabetes Complications 2018; 32:1097-1099. [PMID: 30301594 PMCID: PMC6289863 DOI: 10.1016/j.jdiacomp.2018.08.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 07/27/2018] [Accepted: 08/28/2018] [Indexed: 01/06/2023]
Abstract
AIMS To determine if impaired awareness of hypoglycemia in patients with type 1 diabetes persists over time and to assess if continuous glucose monitoring use was associated with improved awareness of hypoglycemia in our population. METHODS Thirty-six with type 1 diabetes and impaired awareness of hypoglycemia who participated in studies on impaired awareness of hypoglycemia between 2009 and 2015 were contacted to complete an online survey. The survey included the Cox/Clarke and Gold hypoglycemia questionnaires and questions about continuous glucose monitoring use. RESULTS 23 of 36 (63%) subjects contacted completed the survey. (12 M, 11 F; median age 51 years, median diabetes duration 34 years). One had had an islet cell transplant and was excluded. Persistent impaired awareness of hypoglycemia was found in 19/22 (86%) using the Cox questionnaire and 18/22 (82%) using the Gold questionnaire. Consistent use of continuous glucose monitoring over the last six months defined as using a device ≥75% of time over the last 6 months was reported by 67% (12/18) and 68% (13/19) of participants with persistent impaired awareness of hypoglycemia as measured by Gold and Cox; respectively. Nineteen of the 22 participants (86%) reported severe hypoglycemia over the last six months. CONCLUSION Impaired awareness of hypoglycemia persisted in >80% of the subjects with type 1 diabetes we studied between 2009 and 2015. While the consistent use of continuous glucose monitoring among our participants was high; it did not translate into restoration of hypoglycemia awareness in this population. This real world data shows that severe hypoglycemia continues to be a frequent problem in this patient population.
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Affiliation(s)
- K Zekarias
- University of Minnesota, Minneapolis, MN, United States of America
| | - A Kumar
- University of Minnesota, Minneapolis, MN, United States of America
| | - A Moheet
- University of Minnesota, Minneapolis, MN, United States of America
| | - E Seaquist
- University of Minnesota, Minneapolis, MN, United States of America.
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