Journal Watch

Prepared for IDDT by Jim Young

March 2017

The use of mobile health to deliver self-management support to young people with type 1 diabetes
Rosie Dobson et al. JMIR. DOI: 10.2196/diabetes.7221
Increasingly, mobile health (mHealth) interventions are being developed and evaluated as a means of improving glycemic control. This cross-sectional survey was conducted to investigate the current and perceived roles of mHealth in supporting young people to manage their diabetes, and to understand young people’s preferences for this mode of delivery. It looked at 115 young adults (16-24 years) with type 1 diabetes in Auckland, New Zealand. It found that current engagement with mHealth in this population appears low, although the findings from this study provide support for the use of mHealth in this group because of the ubiquity and convenience of mobile devices. The most commonly reported reason for not using apps was a lack of awareness that they existed. The researchers add that mHealth has the potential to provide information and support to this population, utilizing mediums commonplace for this group and with greater reach than traditional methods.


Association of T1D v T2D diagnosed during childhood and adolescence with complications during teenage years and young adulthood
Dana Dabelea et al. JAMA. DOI:10.1001/jama.2017.0686

This observational study from the USA included 2,018 participants with type 1 and type 2 diabetes diagnosed at younger than 20 years. The main outcomes measured were diabetic kidney disease, retinopathy, peripheral neuropathy, cardiovascular autonomic neuropathy, arterial stiffness, and hypertension. It found that the prevalence of complications and comorbidities was higher among those with type 2 diabetes compared with type 1, but frequent in both groups. The authors suggest that their findings support early monitoring of youth with diabetes for development of complications.


Diabetic foot care in England: an economic study
Insight Health Economics

This 52-page paper estimated the number of people with diabetes experiencing ulcers or amputations in England each year, and of the cost of their care. It estimated that there are around 7,000 lower limb amputations in people with diabetes in England each year, and the likelihood that someone with diabetes will have a leg, foot or toe amputation is around 23 times that of a person without diabetes. The estimate is that the NHS in England spent £972m – £1.13bn on healthcare related to foot ulceration and amputation in diabetes in 2014-15; equivalent to 0.72-0.83% of the entire NHS budget. For ulceration around two thirds of this expenditure was in primary, community and outpatient settings. Available data suggested that care for the diabetic foot could be improved in many areas. The paper points put that the 2015 National Diabetes Foot Care Audit found that many patients experienced long waits for specialist foot care. Delays in access to specialist care are associated with increased ulcer severity, slower healing, increased risk of amputation and higher NHS costs. The annual saving from averted bed days was more than 20 times the cost of the improvement programme, and savings from averted amputations and bed-days were almost 5 times the cost of the service improvement.,%20An%20economic%20case%20study%20(January%202017).pdf


A large difference in dose timing of basal insulin introduces risk of hypoglycemia and overweight
Akiko Nishimura et al. Diabetes Therapy. DOI: 10.1007/s13300-017-0238-7

This report evaluated the effects of deviations from a regular dosing schedule on glycemic control and hypoglycemia on patients treated with long-acting insulin (insulin glargine U100). It also considered the effects of ultra-long-acting insulin (insulin degludec) in this context. Nineteen individuals with type 1 diabetes and 58 with type 2 diabetes were enrolled in the study. Glargine U100 was switched to degludec in those individuals with type 2 diabetes who achieved inadequate glycemic control or suffered from frequent hypoglycemic episodes or who required two injections per day, and changes in HbA1c level and frequency of hypoglycemic episodes during the 12-week period were compared. It was found that a greater difference in dose timing was related to a higher frequency of hypoglycemic episodes and overweight in persons with type 2 diabetes. Smoking, drinking and living alone were independently associated with a greater difference in dose timing. Insulin degludec decreased the frequency of hypoglycemia and improved glycemic control in participants whose dose mistiming was greater than 120 min. The authors advise that fixed dose timing should be employed for basal insulin, because a larger difference in dose timing worsens diabetes-related factors.


The English National Screening Programme for diabetic retinopathy 2003–2016
Peter H. Scanlon. Acta Diabetologica. DOI: 10.1007/s00592-017-0974-1
This is an interesting, detailed, and illustrative discourse. It is a very informative read.
Here is the abstract: The aim of the English NHS Diabetic Eye Screening Programme is to reduce the risk of sight loss amongst people with diabetes by the prompt identification and effective treatment if necessary of sight-threatening diabetic retinopathy, at the appropriate stage during the disease process. In order to achieve the delivery of evidence-based, population-based screening programmes, it was recognised that certain key components were required. It is necessary to identify the eligible population in order to deliver the programme to the maximum number of people with diabetes. The programme is delivered and supported by suitably trained, competent, and qualified, clinical and non-clinical staff who participate in recognised ongoing Continuous Professional Development and Quality Assurance schemes. There is an appropriate referral route for those with screen-positive disease for ophthalmology treatment and for assessment of the retinal status in those with poor-quality images. Appropriate assessment of control of their diabetes is also important in those who are screen positive. Audit and internal and external quality assurance schemes are embedded in the service. In England, two-field mydriatic digital photographic screening is offered annually to all people with diabetes aged 12 years and over. The programme commenced in 2003 and reached population coverage across the whole of England by 2008. Increasing uptake has been achieved and the current annual uptake of the programme in 2015–16 is 82.8% when 2.59 million people with diabetes were offered screening and 2.14 million were screened. The benefit of the programme is that, in England, diabetic retinopathy/maculopathy is no longer the leading cause of certifiable blindness in the working age group.


Classification and differential diagnosis of diabetic nephropathy
Chenyang Qi et al. Journal of Diabetes Research. DOI:

This open access paper is another detailed read. Please click your preferred reading option on the right (PDF or HTML).
Diabetic nephropathy (DN) is a major cause of end-stage renal disease throughout the world in both developed and developing countries. This review briefly introduces the characteristic pathological changes of DN and Tervaert pathological classification, which divides DN into four classifications according to glomerular lesions, along with a separate scoring system for tubular, interstitial, and vascular lesions. Given the heterogeneity of the renal lesions and the complex mechanism underlying diabetic nephropathy, Tervaert classification has both significance and controversies in the guidance of diagnosis and prognosis. Applications and evaluations using Tervaert classification and indications for renal biopsy are summarized in this review according to recent studies. Meanwhile, differential diagnosis with another nodular glomerulopathy and the situation that a typical DN superimposed with a nondiabetic renal disease (NDRD) are discussed and concluded in this review.


Deficiencies in postgraduate training for healthcare professionals who provide diabetes education and support
J. L. Byrne et al. Diabetic Medicine. DOI: 10.1111/dme.13334

This research surveyed 4,785 healthcare professionals caring for people with diabetes in 17 countries to assess diabetes healthcare provision, self-management support and training. It found that of the healthcare professionals surveyed, 33.5% received formal postgraduate training in self-management and 62.9% received training for medical management of diabetes. 20.4% had received no postgraduate training. Overall, the greatest training need was in the management of psychological aspects of diabetes. In conclusion, the study shows that healthcare professionals report being insufficiently equipped to provide diabetes self-management education, including emotional and psychological aspects of diabetes, and many are not receiving postgraduate training in any part (including medical care) of the management of diabetes. The authors stress that it is paramount that those responsible for the continuing professional development of healthcare professionals address this skills gap.


Hypofibrinolysis in diabetes: a therapeutic target for the reduction of cardiovascular risk
Katherine Kearney et al. Cardiovascular Diabetology. DOI: 10.1186/s12933-017-0515-9

An enhanced thrombotic environment and premature atherosclerosis are key factors for the increased cardiovascular risk in diabetes. The occlusive vascular thrombus, formed secondary to interactions between platelets and coagulation proteins, is composed of a skeleton of fibrin fibres with cellular elements embedded in this network. Diabetes is characterised by quantitative and qualitative changes in coagulation proteins, which collectively increase resistance to fibrinolysis, consequently augmenting thrombosis risk.
[Fibrinolysis is a process that prevents blood clots from growing and becoming problematic].
Current long-term therapies to prevent arterial occlusion in diabetes are focused on anti-platelet agents, a strategy that fails to address the contribution of coagulation proteins to the enhanced thrombotic milieu. Moreover, antiplatelet treatment is associated with bleeding complications, particularly with newer agents and more aggressive combination therapies, questioning the safety of this approach. Therefore, to safely control thrombosis risk in diabetes, an alternative approach is required with the fibrin network representing a credible therapeutic target. This review addressed diabetes-specific mechanistic pathways responsible for hypofibrinolysis including the role of clot structure, defects in the fibrinolytic system and increased incorporation of anti-fibrinolytic proteins into the clot. Future anti-thrombotic therapeutic options are discussed with special emphasis on the potential advantages of modulating incorporation of the anti-fibrinolytic proteins into fibrin networks. This latter approach carries theoretical advantages, including specificity for diabetes, ability to target a particular protein with a possible favourable risk of bleeding. The development of alternative treatment strategies to better control residual thrombosis risk in diabetes will help to reduce vascular events, which remain the main cause of mortality in this condition.


Supporting insulin initiation in type 2 diabetes in primary care
John Furler et al. BMJ. DOI:

This trial from Australia compared the effectiveness of a novel model of care (“Stepping Up”) with usual primary care in normalising insulin initiation for type 2 diabetes, leading to improved HbA1c levels. The Stepping Up model of care intervention involved theory based change in practice systems and reorientation of the roles of health professionals in the primary care diabetes team. The core components were an enhanced role for the practice nurse in leading insulin initiation and mentoring by a registered nurse with diabetes educator credentials. The findings were that the Stepping Up model of care was associated with increased insulin initiation rates in primary care, and improvements in glycated haemoglobin without worsening emotional wellbeing.


Management of hyperglycemia and diabetes in orthopedic surgery
Funke Akiboye and Gerry Rayman. Current Diabetes Reports. DOI: 10.1007/s11892-017-0839-6

An increasing number of orthopedic operations are being carried out in an older population in whom the prevalence of diabetes is dramatically increasing. People having surgery with diabetes and hyperglycemia are at increased risk of post-operative complications. The peri-operative risks have been well demonstrated for cardiac surgery and, more recently, for orthopedic surgery. This paper considers the issues surrounding orthopaedic surgery in patients with diabetes and the significance and management of hyperglycemia in the peri-operative period. This paper concludes that specialist in-patient teams who can examine local processes, along with design and implementation of clear local pathways across the surgical process are key in minimizing the harm to this vulnerable group of patients