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1.  Telemedicine-Based KADIS® Combined with CGMS™ Has High Potential for Improving Outpatient Diabetes Care 
The Karlsburg Diabetes Management System (KADIS®) was developed over almost two decades by modeling physiological glucose–insulin interactions. When combined with the telemedicine-based communication system TeleDIAB® and a continuous glucose monitoring system (CGMS™), KADIS has the potential to provide effective, evidence-based support to doctors in their daily efforts to optimize glycemic control.
To demonstrate the feasibility of improving diabetes control with the KADIS system, an experimental version of a telemedicine-based diabetes care network was established, and an international, multicenter, pilot study of 44 insulin-treated patients with type 1 and 2 diabetes was performed. Patients were recruited from five outpatient settings where they were treated by general practitioners or diabetologists. Each patient underwent CGMS monitoring under daily life conditions by a mobile monitoring team of the Karlsburg diabetes center at baseline and 3 months following participation in the KADIS advisory system and telemedicine-based diabetes care network. The current metabolic status of each patient was estimated in the form of an individualized “metabolic fingerprint.” The fingerprint characterized glycemic status by KADIS-supported visualization of relationships between the monitored glucose profile and causal endogenous and exogenous factors and enabled evidence-based identification of “weak points” in glycemic control. Using KADIS-based simulations, physician recommendations were generated in the form of patient-centered decision support that enabled elimination of weak points. The analytical outcome was provided in a KADIS report that could be accessed at any time through TeleDIAB. The outcome of KADIS-based support was evaluated by comparing glycosylated hemoglobin (HbA1c) levels and 24-hour glucose profiles before and after the intervention.
Application of KADIS-based decision support reduced HbA1c by 0.62% within 3 months. The reduction was strongly related to the level of baseline HbA1c, diabetes type, and outpatient treatment setting. The greatest benefit was obtained in the group with baseline HbA1c levels >9% (1.22% reduction), and the smallest benefit was obtained in the group with baseline HbA1c levels of 6–7% (0.13% reduction). KADIS was more beneficial for patients with type 1 diabetes (0.79% vs 0.48% reduction) and patients treated by general practitioners (1.02% vs 0.26% reduction). Changes in HbA1c levels were paralleled by changes in mean daily 24-hour glucose profiles and fluctuations in daily glucose.
Application of KADIS in combination with CGMS and the telemedicine-based communication system TeleDIAB successfully improved outpatient diabetes care and management.
PMCID: PMC2769624  PMID: 19885114
advisory system; continuous glucose monitoring; decision support; HbA1c; KADIS; outpatient diabetes care; telemedicine
2.  Bluetooth Low Energy: Wireless Connectivity for Medical Monitoring 
Electronic wireless sensors could cut medical costs by enabling physicians to remotely monitor vital signs such as blood pressure, blood glucose, and blood oxygenation while patients remain at home.
According to the IDC report “Worldwide Bluetooth Semiconductor 2008-2012 Forecast,” published November 2008, a forthcoming radio frequency communication (“wireless connectivity”) standard, Bluetooth low energy, will link wireless sensors via radio signals to the 70% of cell phones and computers likely to be fitted with the next generation of Bluetooth wireless technology, leveraging a ready-built infrastructure for data transmission. Analysis of trends indicated by this data can help physicians better manage diseases such as diabetes.
The technology also addresses the concerns of cost, compatibility, and interoperability that have previously stalled widespread adoption of wireless technology in medical applications.
PMCID: PMC2864182  PMID: 20307407
Bluetooth low energy; diabetes; electronic sensors; low-power radio; medical monitoring; radio frequency
3.  The Diabetes Telemonitoring Study Extension: an exploratory randomized comparison of alternative interventions to maintain glycemic control after withdrawal of diabetes home telemonitoring 
Telemonitoring interventions featuring transmission of home glucose records to healthcare providers have resulted in improved glycemic control in patients with diabetes. No research has addressed the intensity or duration of telemonitoring required to sustain such improvements.
The DiaTel study (10 January 2005 to 1 November 2007) compared active care management (ACM) with home telemonitoring (n=73) to monthly care coordination (CC) telephone calls (n=77) among veterans with diabetes and suboptimal glycemic control. The purpose of the DiaTel Extension was to assess whether initial improvements could be sustained with interventions of the same or lower intensity among participants who re-enrolled in a 6-month extension of DiaTel.
DiaTel participants receiving ACM were re-assigned randomly to monthly CC calls with continued telemonitoring but no active medication management (ACM-to-CCHT, n=23) or monthly CC telephone calls (ACM-to-CC, n=21). DiaTel participants receiving CC were re-assigned randomly to continued CC (CC-to-CC, n=28) or usual care (UC, ie, CC-to-UC, n=29). Hemaglobin A1c (HbA1c) was assessed at 3 and 6 months following re-randomization.
Marked HbA1c improvements observed in DiaTel ACM participants were sustained 6 months after re-randomization in both ACM-to-CCHT and ACM-to-CC groups. Lesser HbA1c improvements observed in DiaTel CC participants were sustained in both CC-to-CC and CC-to-UC groups. No benefit was apparent for continued transmission of glucose data among DiaTel ACM participants or continued monthly telephone calls among DiaTel CC participants 6 months after re-randomization.
Significant improvements in HbA1c achieved using home telemonitoring and active medication management for 6 months were sustained 6 months later with interventions of decreased intensity in VA Health System-qualified veterans.
Clinical trial reg. no
PMCID: PMC3534460  PMID: 22610495
Clinical trials; diabetes; health services research; kidney disease; self-monitoring; telemedicine intervention studies; veterans
4.  Missed Opportunities in Diabetes Management: A Longitudinal Assessment of Factors Associated with Sub-optimal Quality 
Journal of General Internal Medicine  2008;23(11):1770-1777.
In diabetic adults, tight control of risk factors reduces complications.
To determine whether failure to make visits, monitor risk factors, or intensify therapy affects control of blood pressure, glucose, and lipids.
A non-concurrent, prospective study of data from electronic files and standardized abstraction of hard-copy medical records for the period 1/1/1999–12/31/2001.
Three hundred eighty-three adults with diabetes managed in an academically affiliated managed care program.
Main exposure variable: Intensification of therapy or failure to intensify, reckoned on a quarterly basis. Main outcome measure: Hemoglobin A1c (A1c), systolic blood pressure (SBP), and LDL-cholesterol at the end of the interval.
In this visit-adherent cohort, control of glycemia and lipids showed improvement over 24 months, but many patients did not achieve targets. Only those with the worst blood pressure control (SBP ≥160 mmHg) showed any improvement over 2 years. Failure to intensify treatment in patients who kept visits was the single strongest predictor of sub-optimal control. Compared to their counterparts with no failures of intensification, patients with failures in ≥3 quarters showed markedly worse control of blood glucose (A1c 1.4% higher: 95% CI: 0.7, 2.1); hypertension (SBP 22.2 mmHg higher: 95% CI: 16.6, 27.9) and LDL cholesterol (LDL 43.7 mg/dl higher: 95% CI: 24.1, 63.3). These relationships were strong, graded, and independent of socio-demographic factors, baseline risk factor values, and co-morbidities.
Failure to intensify therapy leads to suboptimal control, even with adequate visits and monitoring. Interventions designed to promote appropriate intensification should enhance diabetes care in primary practice.
PMCID: PMC2585658  PMID: 18787908
diabetes mellitus; treatment; outcomes; quality of care; cohort study
5.  Integrating Telehealth Technology into a Clinical Pharmacy Telephonic Diabetes Management Program 
Use of home monitoring technologies can enhance care coordination and improve clinical outcomes in patients with diabetes and other chronic diseases. This study was designed to explore the feasibility of incorporating a telehealth system into an existing telephonic diabetes management program utilizing clinical pharmacists.
This observational study was conducted at three Providence Medical Group primary care clinics. Adults with a diagnosis of diabetes and a recent hemoglobin A1c (HbA1c) >8% were referred by their primary care provider to participate in the study. Participants utilized the telehealth system developed by Intel Corporation and were followed by clinical pharmacists who provide telephonic diabetes management. The primary clinical outcome measure was change in mean HbA1c. Secondary outcomes included blood glucose levels, participant self-management knowledge, and the degree of participant engagement.
Mean HbA1c level decreased by 1.3% at the study end (p = .001). Based on participant satisfaction surveys and qualitative responses, participants were satisfied with the telehealth system. Mean blood glucose values decreased significantly over the 16-week study period from 178 mg/dl [standard deviation (SD) 67] at week 1 to 163 mg/dl (SD 64) at week 16 (p = .0002). Participants entered the study with moderate to good knowledge about managing their diabetes based on three questions, and no statistically significant improvement in knowledge was found post-study.
Telehealth technology can be a positive adjunct to the primary care team in managing diabetes or other chronic conditions to improve clinical outcomes.
PMCID: PMC3208888  PMID: 22027325
diabetes; disease management; home monitoring; pharmacy; primary care; telehealth
6.  International Forum for the Advancement of Diabetes Research and Care, April 29–30, 2011, Athens, Greece 
The International Forum for the Advancement of Diabetes Research and Care brought together distinguished international experts in diabetes to discuss diverse trends and emerging issues in diabetes therapy and management. The plenary sessions on the first day focused on trends in insulin therapy, the role of glucagon-like peptide-1 receptor agonists in diabetes treatment, the relationship between diabetes and cardiovascular risk, and the challenges associated with the development of clinically relevant treatment guidelines. Interactive breakout sessions addressed the following topics: microvascular complications of diabetes; the need for a team approach to patient education; optimal management of Asian people with diabetes; the role of continuous glucose monitoring in assessing glucose variability; and lessons learned from biosimilar drugs. The plenary sessions on the second day covered self-monitoring of blood glucose, treatment and prevention of type 1 diabetes, and future directions for diabetes therapy. The meeting represented an excellent forum for the presentation of new research and the exchange of ideas aimed at improving outcomes for people with diabetes.
PMCID: PMC3160268  PMID: 21864094
7.  Mobile Health Applications to Assist Patients with Diabetes: Lessons Learned and Design Implications 
Self-management is critical to achieving diabetes treatment goals. Mobile phones and Bluetooth® can supportself-management and lifestyle changes for chronic diseases such as diabetes. A mobile health (mHealth) research platform—the Few Touch Application (FTA)—is a tool designed to support the self-management of diabetes. The FTA consists of a mobile phone-based diabetes diary, which can be updated both manually from user input and automatically by wireless data transfer, and which provides personalized decision support for the achievement of personal health goals. Studies and applications (apps) based on FTAs have included: (1) automatic transfer of blood glucose (BG) data; (2) short message service (SMS)-based education for type 1diabetes (T1DM); (3) a diabetes diary for type 2 diabetes (T2DM); (4) integrating a patient diabetes diary with health care (HC) providers; (5) a diabetes diary for T1DM; (6) a food picture diary for T1DM; (7) physical activity monitoring for T2DM; (8) nutrition information for T2DM; (9) context sensitivity in mobile self-help tools; and (10) modeling of BG using mobile phones.
We have analyzed the performance of these 10 FTA-based apps to identify lessons for designing the most effective mHealth apps. From each of the 10 apps of FTA, respectively, we conclude: (1) automatic BG data transfer is easy to use and provides reassurance; (2) SMS-based education facilitates parent-child communication in T1DM; (3) the T2DM mobile phone diary encourages reflection; (4) the mobile phone diary enhances discussion between patients and HC professionals; (5) the T1DM mobile phone diary is useful and motivational; (6) the T1DM mobile phone picture diary is useful in identifying treatment obstacles; (7) the step counter with automatic data transfer promotes motivation and increases physical activity in T2DM; (8) food information on a phone for T2DM should not be at a detailed level; (9) context sensitivity has good prospects and is possible to implement on today’s phones; and (10) BG modeling on mobile phones is promising for motivated T1DM users.
We expect that the following elements will be important in future FTA designs: (A) automatic data transfer when possible; (B) motivational and visual user interfaces; (C) apps with considerable health benefits in relation to the effort required; (D) dynamic usage, e.g., both personal and together with HC personnel, long-/short-term perspective; and (E) inclusion of context sensitivity in apps. We conclude that mHealth apps will empower patients to take a more active role in managing their own health.
PMCID: PMC3570855  PMID: 23063047
blood glucose; diabetes; mobile health; self-management; type 1 diabetes; type 2 diabetes
8.  Continuous Glucose Monitoring Versus Self-monitoring of Blood Glucose in Children with Type 1 Diabetes- Are there Pros and Cons for Both? 
US endocrinology  2012;8(1):27-29.
Glucose monitoring is essential for modern diabetes treatment and the achievement of near-normal glycemic control. Monitoring provides the data necessary for patients to make daily management decisions related to food intake, insulin dose, and physical exercise and can enable patients to avoid potentially dangerous episodes of hypo- and hyperglycemia. Additionally, monitoring can provide health care providers with the information needed to identify glycemic patterns, educate patients, and adjust insulin. Presently, youth with type 1 diabetes can self-monitor blood glucose via home blood glucose meters or monitor glucose concentrations nearly continuously using a continuous glucose monitor. There are advantages and disadvantages to the use of either of these technologies. This review describes the two technologies and the research supporting their use in the management of youth with type 1 diabetes in order to weigh their relative costs and benefits.
PMCID: PMC3848052  PMID: 24312136
diabetes; type 1; children; monitoring; glycemic control
9.  Diabetes Management Using Modern Information and Communication Technologies and New Care Models 
Diabetes, a metabolic disorder, has reached epidemic proportions in developed countries. The disease has two main forms: type 1 and type 2. Disease management entails administration of insulin in combination with careful blood glucose monitoring (type 1) or involves the adjustment of diet and exercise level, the use of oral anti-diabetic drugs, and insulin administration to control blood sugar (type 2).
State-of-the-art technologies have the potential to assist healthcare professionals, patients, and informal carers to better manage diabetes insulin therapy, help patients understand their disease, support self-management, and provide a safe environment by monitoring adverse and potentially life-threatening situations with appropriate crisis management.
New care models incorporating advanced information and communication technologies have the potential to provide service platforms able to improve health care, personalization, inclusion, and empowerment of the patient, and to support diverse user preferences and needs in different countries. The REACTION project proposes to create a service-oriented architectural platform based on numerous individual services and implementing novel care models that can be deployed in different settings to perform patient monitoring, distributed decision support, health care workflow management, and clinical feedback provision.
This paper presents the work performed in the context of the REACTION project focusing on the development of a health care service platform able to support diabetes management in different healthcare regimes, through clinical applications, such as monitoring of vital signs, feedback provision to the point of care, integrative risk assessment, and event and alarm handling. While moving towards the full implementation of the platform, three major areas of research and development have been identified and consequently approached: the first one is related to the glucose sensor technology and wearability, the second is related to the platform architecture, and the third to the implementation of the end-user services. The Glucose Management System, already developed within the REACTION project, is able to monitor a range of parameters from various sources including glucose levels, nutritional intakes, administered drugs, and patient’s insulin sensitivity, offering decision support for insulin dosing to professional caregivers on a mobile tablet platform that fulfills the need of the users and supports medical workflow procedures in compliance with the Medical Device Directive requirements.
Good control of diabetes, as well as increased emphasis on control of lifestyle factors, may reduce the risk profile of most complications and contribute to health improvement. The REACTION project aims to respond to these challenges by providing integrated, professional, management, and therapy services to diabetic patients in different health care regimes across Europe in an interoperable communication platform.
PMCID: PMC3626139  PMID: 23612026
Medical Information Systems; Medical Expert Systems; Biomedical Engineering; Biomedical Informatics; Biomedical Computing; Telemedicine; Diabetes
10.  An excursion into self-monitoring of blood glucose in children 
Postgraduate Medical Journal  1982;58(677):156-159.
Ten adolescent diabetic children monitored blood glucose (BG) concentrations during a British Diabetic Association holiday camp in Denmark. The range of results was wide but revealed a mean pre-breakfast (fasting) BG of 9·8 mmol/l and a mean BG before the main evening meal of 13·2 mmol/l. Before the evening meal eight of ten children had BG concentrations in excess of 13 mmol/l. There was a significant correlation between mean BG concentrations and glycosylated haemoglobin.
The procedure was well accepted and proved to be of considerable educational value. It clearly revealed the children whose diabetes was satisfactorily controlled and those in whom adjustments of management were required. It is suggested that similar phases of self-measurement of BG in their homes will clarify the diabetic control of many children and thus help to improve it.
PMCID: PMC2426366  PMID: 7100038
11.  Automated Glycemic Pattern Analysis: Overcoming Diabetes Clinical Inertia 
The OneTouch® Verio™ IQ Meter with PatternAlert™ Technology has been approved by the U.S. Food and Drug Administration as the first self-glucose monitor that can automatically determine glycemic patterns [high and low pre-meal blood glucose (BG)] for health care providers (HCPs) and patients. In this issue of Journal of Diabetes Science and Technology, Katz and coauthors demonstrate that this device was more accurate and quicker in detecting abnormal glucose patterns than the review by HCPs of 30-day handwritten BG logs and that its interpretations were positively accepted by the HCPs. Continued development of automated pattern analysis and decision-support software to overcome the “data-overload” associated with intensive glucose monitoring and diabetes management will reduce clinical inertia and could dramatically improve diabetes outcomes.
PMCID: PMC3692230  PMID: 23439174
automated glucose pattern detection; diabetes management decision support
12.  Integration of Remote Blood Glucose Meter Upload Technology into a Clinical Pharmacist Medication Therapy Management Service 
A pharmacist-delivered, outpatient-focused medication therapy management (MTM) program is using a remote blood glucose (BG) meter upload device to provide better care and to improve outcomes for its patients with diabetes. Sharing uploaded BG meter data, presented in easily comprehensible graphs and charts, enables patients, caregivers, and the medical team to better understand how the patients’ diabetes care is progressing.
Pharmacists are becoming increasingly more active in helping to manage patients’ complex medication regimens in an effort to help detect and avoid medication-related problems. Working together with patients and their physicians as part of an interdisciplinary health care team, pharmacists are helping to improve medication outcomes. This article focuses on two case studies highlighting the Diabetes Monitoring Program, one component of the Meridian Pharmacology Institute MTM service, and discusses the clinical application of a unique BG meter upload device.
PMCID: PMC3045227  PMID: 21303643
blood glucose meter upload device; clinical pharmacist; diabetes monitoring program; medication compliance; medication therapy management; Metriklink; pharmacist
13.  Web-based Care Management in Patients with Poorly Controlled Diabetes Mellitus 
Diabetes care  2005;28(7):1624-1629.
To assess the effects of web-based care management on glucose and blood pressure control over 12 months in patients with poorly controlled diabetes mellitus.
Research Design and Methods
104 patients with diabetes mellitus and hemoglobin A1c ≥ 9.0% who received their care at a VA medical center were recruited. All participants completed a diabetes education class and were randomized to continue with usual care (n = 52) or receive web-based care management (n = 52). The care management group received a notebook computer, glucose and blood pressure monitoring devices and access to a care management website. The website provided educational modules, accepted uploads from monitoring devices, and had an internal messaging system for patients to communicate with the care manager.
Participants receiving web-based care management had lower hemoglobin A1c over 12 months (P<0.05) when compared to education and usual care. Persistent website users had greater improvement in hemoglobin A1c when compared to intermittent users (−1.9% vs. −1.2%, P=0.051) or education and usual care (−1.4%, P<0.05). Greater numbers of website data uploads were associated with larger declines in hemoglobin A1c (highest tertile −2.1%, lowest tertile: −1.0%, P<0.02). Hypertensive participants in the web-based care management group had a greater reduction in systolic blood pressure (P<0.01). HDL cholesterol rose and triglycerides fell in the web-based care management group (P<0.05).
Web-based care management may be a useful adjunct in the care of patients with poorly controlled diabetes mellitus.
PMCID: PMC1262644  PMID: 15983311
14.  Comparison of Glycemic Excursion in Patients with New Onset Type 2 Diabetes Mellitus before and after Treatment with Repaglinide 
Due to industrialization and sedentary life, incidence of type 2 diabetes (DM2) is increasing seriously. Repaglinide is a glucose reducing agent that predominantly reduces post-prandial glucose. Continuous glucose monitoring system (CGMS) monitors blood glucose excursions over a 3-day period. CGMS can be used as a therapeutic and diagnostic instrument in diabetics. There are not enough studies about using CGMS in DM2. The aim of this study was to determine the blood glucose excursions in patients with new onset of DM2. 10 patients with new onset of DM2 were entered to this study. As the first therapeutic management, patients received diabetic diet and moderate exercise for 3-weeks, if they did not achieve blood glucose goal (Fasting blood glucoser (FBG) <120mg/dl, 2-hour postprandial blood glucose (2hpp) <180mg/dl), were considered to undergo 3-days CGMS at baseline and after 4-weeks on Repaglinide (0.5mg three times before meals). Mean excursions of blood glucose were not different at the onset and at the end of treatment (6±4.05 VS 7.6±5.2 episodes, P=0.49). There were also no significant differences between mean duration of hypoglycemic episodes (zero VS 5.1±14.1 hours, P =0.28) and hyperglycemic episodes before and after therapy (7.6±5.2 VS 5.7±4.1, P=0.42), but mean hyperglycemia duration was significantly reduced at the end of therapy (21±26.17 VS 57.7±35.3, P=0.001). Patients experienced a mean of 0.3±0.67 episodes of hypoglycemia after therapy showed no significant difference before it (P =0.19). Mean FBG (with CGMS) was significantly lower after therapy than before it (142.9±54.31 VS 222.9±82.6, P <0.001).
This study showed the usefulness of CGMS not only as a diagnostic but also as an educational and therapeutic tool that in combination with Repaglinide (with the lowest effective dose and duration) can significantly reduce FBG and glycemic excursions in DM2 patients and hypoglycemic events are low.
PMCID: PMC3601336  PMID: 23526382
Repaglinide; Glycemic excursions; Type 2 diabetes; Continuous glucose monitoring system.
15.  Metabolic rhythms in adolescents with diabetes. 
Archives of Disease in Childhood  1986;61(2):124-129.
Metabolic rhythms were studied over 24 hours in eight adolescents with insulin dependent diabetes before and two months after attempting to improve diabetic control with home blood glucose monitoring. A significant improvement in blood glucose concentration was observed, although 24 hour mean concentrations remained grossly abnormal. This improvement was accompanied by significant falls in blood glycerol and total ketone bodies concentrations and a significant rise in blood lactate concentration. Without attention to other factors affecting diabetic control, the introduction of home blood glucose monitoring produces only a small improvement in control.
PMCID: PMC1777582  PMID: 3954437
16.  Health and social services integration in the Veneto Region 
Veneto Region is currently achieving the integration of health and social services by integrating the tele-surveillance (detection of emergencies) already provided to ‘socially frail’ people with tele-monitoring, addressed to patients affected by chronic diseases.
This strategy is guided by the idea that a better integration between the different levels of assistance is capable of improving the quality and continuity of care and generating synergies that benefit the healthcare system both by enhancing coordination of efforts and by reducing costs.
The strategy employs a unique call center at Regional level, that currently performs tele-surveillance services (a social service) originally targeted to ‘socially frail’ people and a more complete tele-monitoring service for chronic patients, thus integrating health and social services. Tele-monitoring consists in the remote measurement of vital parameters (controlled by physicians), and the management of emergencies.
Results and conclusions
This approach to the integration of different assistance levels is being put to the test in the context of the RENEWING HEALTH European Project. The project will assess the services using a multidisciplinary HTA methodology thus providing reliable evidence on the effectiveness and cost-effectiveness on the large-scale implementation of this kind of service.
PMCID: PMC3617744
telemonitoring; chronic diseases; frail people; social and health services integration
17.  Effect of Diabetes Mellitus on Outcomes of Hyperglycemia in a Mixed Medical Surgical Intensive Care Unit 
Intensive insulin therapy and degree of glycemic control in critically ill patients remains controversial, particularly in patients with diabetes mellitus. We hypothesized that diabetic patients who achieved tight glucose control with continuous insulin therapy would have less morbidity and lower mortality than diabetic patients with uncontrolled blood glucose.
A retrospective chart review was performed on 395 intensive care unit (ICU) patients that included 235 diabetic patients. All patients received an intravenous insulin protocol targeted to a blood glucose (BG) level of 80–140mg/dl. Outcomes were compared between (a) nondiabetic and diabetic patients, (b) diabetic patients with controlled BG levels (80–140mg/dl) versus uncontrolled levels (>140 mg/dl), and (c) diabetic survivors and nonsurvivors.
Diabetic patients had a shorter ICU stay compared to nondiabetic patients (10 ± 0.7 vs 13 ± 1.1, p = .01). The mean BG of the diabetic patients was 25% higher on average in the uncontrolled group than in the controlled (166 ± 26 vs 130 ± 9.4 mg/dl, p < .01). There was no difference in ICU and hospital length of stay (LOS) between diabetic patients who were well controlled compared to those who were uncontrolled. Diabetic nonsurvivors had a significantly higher incidence of hypoglycemia (BG <60 mg/dl) compared to diabetic survivors.
The results showed that a diagnosis of diabetes was not an independent predictor of mortality, and that diabetic patients who were uncontrolled did not have worse outcomes. Diabetic nonsurvivors were associated with a greater amount of hypoglycemic episodes, suggesting these patients may benefit from a more lenient blood glucose protocol.
PMCID: PMC3192640  PMID: 21722589
blood glucose; diabetes; hyperglycemia; intensive insulin therapy
18.  Twenty years of a multidisciplinary paediatric diabetes home care unit 
Archives of Disease in Childhood  2005;90(4):342-345.
As only a minority of patients with type 1 diabetes are unwell at diagnosis, these patients could be managed at home if appropriate facilities were available. A multidisciplinary diabetes home care service was established over 20 years ago at Birmingham Children's Hospital, to support children with diabetes mellitus within the home environment from diagnosis, reducing emotional upset and separation. Despite increase in the size and distribution of the unit over this time (from 230 to 400 patients (now spread over two hospitals)), the proportion of newly diagnosed children managed wholly at home (median 43%; range 31–67%), and the reduction in number and duration of admissions has been sustained (readmission rate with diabetic ketoacidosis 4.1 bed-days per 100 patients/year; range 2.9–7.1), with no deterioration in overall blood glucose control. In this way the savings achieved by reductions in expensive hospital bed occupancy have more than offset the costs of maintaining the unit.
PMCID: PMC1720334  PMID: 15781919
19.  Conservative management of pregnancy in diabetic women. 
In 1979 the obstetric management of pregnancies in diabetic women in Cardiff was changed from elective delivery at 37-38 weeks to delivery at term. This change was facilitated by home monitoring of blood glucose concentrations and improved techniques for assessing fetal wellbeing. There were 35 pregnancies in insulin dependent diabetics in 1972-8 and 45 in 1979-82. The quality of diabetic control during pregnancy was equally good in both periods. The average gestation at final admission to hospital increased from 30 to 37 weeks. Amniocentesis to assess fetal pulmonary maturity was necessary in 26 patients (74%) in the first period of study and in only four (9%) in the second. Gestational age at delivery increased from 37.4 to 39.4 weeks after the change in policy. The proportion of mothers entering spontaneous term labour and delivering vaginally increased from 14.3% to 37.8%. The mean birth weight of live born, singleton infants increased from 3090 g to 3650 g, the feeding pattern improved, and respiratory problems were less common. Morbidity was reduced and perinatal mortality was not increased with conservative management of pregnancy in diabetic women.
PMCID: PMC1441319  PMID: 6424790
20.  The Effect of Tele-Monitoring on Exercise Training Adherence, Functional Capacity, Quality of Life and Glycemic Control in Patients With Type II Diabetes 
We used tele-monitoring to attempt to improve exercise adherence (number of hours of exercise completed), peak VO2, HbA1c% and quality of life in an unsupervised, home based exercise program in people with type II diabetes, a cost analysis was also conducted. Thirty-nine patients with type II diabetes were randomized to tele-monitoring (TELE) or control (CON) groups. All patients were asked to complete 6 months exercise training and complete an exercise activity diary. The TELE group was instructed to record their exercise heart rates using a monitor and received weekly telephone calls from an exercise physiologist. Six TELE patients and seven CON patients did not complete the 6 month testing. TELE patients completed a mean weekly volume of 138 minutes, moderate intensity exercise, while CON patients completed 58 minutes weekly (p < 0.02). Neither group achieved the American Heart Association statement guideline for weekly exercise volume of 150 minutes. TELE patients improved peak VO2 (5.5 %), but neither group improved HbA1c% or quality of life. The CON group showed a 4.9% reduction in peak VO2. While tele-monitored patients completed more hours of exercise and demonstrated improved peak VO2 compared to controls, the exercise volume completed was insufficient to improve glycemic control. There is the potential via tele-monitoring to enable people with diabetes to meet exercise training guidelines.
Key points
Weekly telephone calls from a health professional providing encouragement, increases the amount of exercise completed by people with diabetes
Weekly telephone calls will result in improved fitness
At least 150 minutes weekly exercise is required to improve diabetes control
The cost of home exercise with telephone monitoring is cheaper (and more convenient for the patient) than delivering an exercise program at the hospital
Longer term research is needed to examine whether telephone supervised exercise will prevent serious events such as heart attack, strokes and death
PMCID: PMC3737832  PMID: 24137063
Diabetes mellitus; telemedicine; exercise therapy; outpatient; cost analysis.
21.  An Analysis of the Assessment of Glycated Hemoglobin Using A1cNow+™ Point-of-Care Device Compared to Central Laboratory Testing—an Important Addition to Pharmacist-Managed Diabetes Programs? 
The diabetes epidemic is accelerating rapidly. If no progress is made in early detection, then early intervention and treatment-to-goal diabetes care will become an overwhelming burden on our health care system. Better utilization of self-monitoring of blood glucose in patients with type 2 diabetes not on insulin could be achieved with regular review of hemoglobin A1c (A1C) values. Educating patients about the importance of diet, exercise, and medication compliance is enhanced when evidence of average blood glucose control can be presented to the patient directly. Affordable, accurate point-of-care testing of A1C with A1cNow+™ (Bayer HealthCare, Terrytown, NY) utilized in pharmacist-managed outpatient diabetes programs may prove to be an important clinical tool for improving patient outcomes and reducing the cost of the expanding diabetes epidemic.
PMCID: PMC2769787  PMID: 19885268
cost; diabetes; fitness; hemoglobin A1c; nutrition; pharmacist; point of care; type 2 diabetes
22.  The effects of medicinal plants on renal function and blood pressure in diabetes mellitus 
Cardiovascular Journal of Africa  2012;23(8):462-468.
Diabetes mellitus is one of the most common chronic global diseases affecting children and adolescents in both the developed and developing nations. The major types of diabetes mellitus are type 1 and type 2, the former arising from inadequate production of insulin due to pancreatic β-cell dysfunction, and the latter from reduced sensitivity to insulin in the target tissues and/or inadequate insulin secretion. Sustained hyperglycaemia is a common result of uncontrolled diabetes and, over time, can damage the heart, eyes, kidneys and nerves, mainly through deteriorating blood vessels supplying the organs. Microvascular (retinopathy and nephropathy) and macrovascular (atherosclerotic) disorders are the leading causes of morbidity and mortality in diabetic patients. Therefore, emphasis on diabetes care and management is on optimal blood glucose control to avert these adverse outcomes.
Studies have demonstrated that diabetic nephropathy is associated with increased cardiovascular mortality. In general, about one in three patients with diabetes develops end-stage renal disease (ESRD) which proceeds to diabetic nephropathy (DN), the principal cause of significant morbidity and mortality in diabetes. Hypertension, a well-established major risk factor for cardiovascular disease contributes to ESRD in diabetes. Clinical evidence suggests that there is no effective treatment for diabetic nephropathy and prevention of the progression of diabetic nephropathy. However, biomedical evidence indicates that some plant extracts have beneficial effects on certain processes associated with reduced renal function in diabetes mellitus. On the other hand, other plant extracts may be hazardous in diabetes, as reports indicate impairment of renal function. This article outlines therapeutic and pharmacological evidence supporting the potential of some medicinal plants to control or compensate for diabetes-associated complications, with particular emphasis on kidney function and hypertension.
PMCID: PMC3721953  PMID: 23044503
diabetes mellitus; diabetic nephropathy; medicinal plants; hypertension
23.  Detection and remediation of medically urgent situations using telemedicine case management for older patients with diabetes mellitus 
Detection and response to medically urgent situations in patients with diabetes mellitus can improve the process and outcomes of care and potentially decrease morbidity and mortality. We examined the detection and remediation of medically urgent situations among older patients receiving telemedicine case management for diabetes.
In the setting of a randomized trial, 338 patients in the intervention group and living in upstate New York received a home telemedicine unit to transmit blood glucose and blood pressure values to a nurse case manager, videoconference with a nurse or dietitian every 4–6 weeks and access educational websites. The educators met with a supervising endocrinologist 4–5 times weekly and clinical recommendations were proposed to the primary care providers via mail, fax, or phone.
Over a 36 month period, 67 medically urgent situations were identified and addressed (1.9 events/month). Some of these situations were potentially life-threatening, including major drug contraindications (N = 24), other medically urgent situations (N = 19), and medical urgent conditions (ie, unstable angina) (N = 24).
The interaction via telemedicine in rural upstate New York between patients with diabetes mellitus, a diabetes care team, and primary care providers can successfully identify and remediate medically urgent situations.
PMCID: PMC2386361  PMID: 18488079
telemedicine; diabetes mellitus; medically urgent situations
24.  Establishing a Continuous Glucose Monitoring Program 
Real-time continuous glucose monitoring (RT-CGM) devices provide detailed information on glucose patterns and trends, and alarms that alert the patient to both hyper- and hypoglycemia. This technology can dramatically improve the day-to-day management of patients with diabetes and promises to be a major advance in diabetes care. The safe and effective use of RT-CGM in diabetes management rests on an understanding of several physiological as well as technological issues. This article outlines the key issues that should be addressed in the training curriculum for patients starting on RT-CGM: (1) physiologic lag between interstitial and blood glucose levels and the implications for device calibration, and interpretation and use of data in diabetes management; (2) practical considerations with the use of sensor alarms and caveats in the setting of alarm thresholds; and (3) potential risk for hypoglycemia related to excessive postprandial bolusing by RT-CGM users, and the practical implications for patient training.
PMCID: PMC2771501  PMID: 19885361
continuous glucose monitoring
25.  Glucose Biosensors: An Overview of Use in Clinical Practice 
Sensors (Basel, Switzerland)  2010;10(5):4558-4576.
Blood glucose monitoring has been established as a valuable tool in the management of diabetes. Since maintaining normal blood glucose levels is recommended, a series of suitable glucose biosensors have been developed. During the last 50 years, glucose biosensor technology including point-of-care devices, continuous glucose monitoring systems and noninvasive glucose monitoring systems has been significantly improved. However, there continues to be several challenges related to the achievement of accurate and reliable glucose monitoring. Further technical improvements in glucose biosensors, standardization of the analytical goals for their performance, and continuously assessing and training lay users are required. This article reviews the brief history, basic principles, analytical performance, and the present status of glucose biosensors in the clinical practice.
PMCID: PMC3292132  PMID: 22399892
diabetes mellitus; glucose biosensor; point-of-care testing; performance; self-monitoring of blood glucose

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