bluuebunny/crossref_metadata_2025 huggingface dataset:
Telehealth Behavior Therapy for the Management of Type 1 Diabetes in Adolescents
Authors: Lehmkuhl Heather D. , Storch Eric A. , Cammarata Christina , Meyer Kara , Rahman Omar , Silverstein Janet , Malasanos Toree , Geffken Gary
Published: January 2014

Background:

Poor management of type 1 diabetes mellitus (T1DM) may result in serious medical complications. Psychological intervention may improve adherence to medical regimens; however, access to trained professionals is limited, particularly in rural communities. Telehealth interventions may address this by allowing families to access services at home; however, little is known about the efficacy of such services.

Method:

This study presents results from a pilot trial of a randomized waitlist controlled trial of Telehealth Behavioral Therapy (TBT) for youths with T1DM. Primary outcome measures were adherence to the diabetes regimen, glycemic control, and level of family discord. Thirty-two youths (23 female) with T1DM (aged 9 to 17 years) and one parent or caregiver participated. Telehealth Behavioral Therapy sessions were conducted thrice weekly for 12 weeks by phone and lasted an average of 15 min each.

Results:

Results indicated that youths in treatment decreased their hemoglobin A1c by 0.74 compared to 0.09 in the waitlist, though this was not statistically significant. Youths in treatment reported increased unsupportive and decreased caring parental behaviors.

Conclusion:

Telehealth Behavioral Therapy improves access to knowledgeable providers and results in a clinically significant improvement in glycemic control. Despite some youths experiencing an increase in unsupportive parental behaviors, TBT is a promising method of service delivery that warrants further investigation.
A Comparison of Dosing Accuracy: Visually Impaired and Sighted People Using Insulin Pens
Authors: Williams Ann S. , Schnarrenberger Patrick A.
Published: January 2014

Background:

In the United States, 18% of people with diagnosed diabetes have visual impairment. Insulin pens are widely used by both blind and sighted people. However, major manufacturers include a disclaimer in the instructions warning against use by visually impaired people, without giving a rationale. Published studies neither support nor refute the disclaimer.

Method:

The purpose of this study was to compare accuracy of dosing with insulin pens between visually impaired and sighted people. Inclusion criteria were self-reported diabetes and inability (visually impaired group) or ability (sighted group) to read regular print. The sole exclusion criterion was inability to pass a brief test of decisional capacity. Each participant received standardized instructions for insulin pen use, either in recorded (visually impaired group) or in printed (sighted group) format, and delivered 10 systematically varied doses into an injection ball, which was weighed on a precision laboratory balance.

Results:

No significant correlation with accuracy of insulin dosing was found for any of the analyzed variables: Visual status, age, gender, years of having diabetes mellitus (DM), or treatment of DM with or without insulin.

Conclusions:

This study provided preliminary evidence of the safety of use of insulin pens by visually impaired people and raised questions about the validity of the disclaimer. Further study of the safety of use of insulin pens by blind people is needed. Inclusion of people with disabilities in research on technology intended for patient use would ensure that people with disabilities can benefit from new technology.
Patients' Perception and Future Acceptance of an Artificial Pancreas
Authors: van Bon Arianne C. , Kohinor Miriam J. E. , Hoekstra Joost B. L. , von Basum Golo , DeVries J. Hans
Published: January 2014

Background:

Little is known of patient acceptance of an artificial pancreas (AP). The purpose of this study was to investigate future acceptance of an AP and its determinants.

Methods:

Patients with type 1 diabetes treated with insulin pump therapy were interviewed using questions based on the technology acceptance model and completed the diabetes treatment and satisfaction questionnaire (DTSQ).

Results:

Twenty-two adults with type 1 diabetes participated. Half of the patients were followed in a university hospital, and the others were under treatment in an affiliated teaching hospital. Half of the patients were male. The mean DTSQ score was 29 (range 23–33). The AP was perceived as likely to be useful. Perceived advantages were a stable glucose regulation, less need for self-monitoring of blood glucose, relief of daily concerns, and time saving. Participants were confident in their capability to use the system. Although many participants (58%) had been reluctant to start continuous subcutaneous insulin infusion, the majority (79%) felt they would have no barriers to start using the AP. Trust in the AP was related to the quality of glucose control it would provide. Almost everyone expressed the intention to use the new system when available, even if it would initially not cover 24/24 hours.

Conclusion:

The overall attitude on the AP was positive. Intention to use was dependent on trust in the AP, which was related to the quality of glucose control provided by the AP.
Development of an Internet-Based Obesity Prevention Program for Children
Authors: Gabriele Jeanne M. , Stewart Tiffany M. , Sample Alicia , Davis Allison B. , Allen Ray , Martin Corby K. , Newton Robert L. , Williamson Donald A.
Published: January 2014

Background:

Childhood obesity is a growing problem, particularly in rural, Louisiana school children. Traditionally, school-based obesity prevention programs have used a primary prevention approach. Finding methods to deliver secondary prevention programs to large numbers of students without singling out overweight students has been a challenge. An innovative approach to achieving this goal is through use of an Internet intervention targeted toward a student's weight status. This article describes the Louisiana (LA) Health Internet intervention, including the student Web site, the Internet counselor Web site, and the Internet counseling process.

Method:

The LA Health Internet intervention had separate interfaces for students and Internet counselors. The main features of the student site were behavioral weight loss lessons, lesson activities, chat with an Internet counselor, and email. The Internet counselor site contained these same features, plus a student directory and various means of obtaining student information to guide counseling. Based on their baseline weight status, students received lessons and counseling that promoted either weight loss or weight maintenance. Intervention was delivered during class time, and teachers scheduled Internet counseling sessions with intervention personnel.

Results:

The LA Health Internet intervention was initially implemented within 14 schools; 773 students were granted access to the site. From Fall 2007 to Spring 2009, 1174 hours of Internet counselor coverage was needed to implement the Internet counseling component of this intervention

Conclusion:

The LA Health Internet intervention is an innovative and feasible method of delivering a secondary prevention program within a school setting to large numbers of students.
The Secret to Health Information Technology's Success within the Diabetes Patient Population: A Comprehensive Privacy and Security Framework
Authors: Pandya Sheel M.
Published: January 2014

Congress made an unprecedented investment in health information technology (IT) when it passed the American Recovery and Reinvestment Act in February 2009. Health IT provides enormous opportunities to improve health care quality, reduce costs, and engage patients in their own care. But the potential payoff for use of health IT for diabetes care is magnified given the prevalence, cost, and complexity of the disease. However, without proper privacy and security protections in place, diabetes patient data are at risk of misuse, and patient trust in the system is undermined. We need a comprehensive privacy and security framework that articulates clear parameters for access, use, and disclosure of diabetes patient data for all entities storing and exchanging electronic data.
Conceptual Model for the Design of a Serious Video Game Promoting Self-Management among Youth with Type 1 Diabetes
Authors: Thompson Debbe , Baranowski Tom , Buday Richard
Published: January 2014

Video games are a popular form of entertainment. Serious video games for health attempt to use entertainment to promote health behavior change. When designed within a framework informed by behavioral science and supported by commercial game-design principles, serious video games for health have the potential to be an effective method for promoting self-management behaviors among youth with diabetes. This article presents a conceptual model of how this may be achieved. It concludes by identifying research needed to refine our knowledge regarding how to develop effective serious video games for health.
Thermal Imaging Today and Its Relevance to Diabetes
Authors: Ring Francis
Published: January 2014

From the historic and simple assessment of temperature by the clinical thermometer, modern infrared technology has opened up new perspectives, especially in the use of thermal imaging to map body surface temperature with a remote sensing camera. Since the 1960s, there is now a greater understanding of thermal physiology and the relationship between skin temperature and blood perfusion. Furthermore, the examination technique, and the advantages of computer-aided digital imaging has greatly improved the reliability of this technology in medicine. Studies in diabetology have shown the value of this new facility and its relevance to clinical assessment of peripheral perfusion and tissue viability.
An Analysis of Alternate Site Tests to Improve Patient Compliance with Self-Monitoring of Blood Glucose
Authors: Jacoby Jeanne M.
Published: January 2014

Background:

Multiple barriers stand in the way of patients performing self-monitoring of blood glucose (SMBG). Alternate-site testing (AST) has been introduced as one solution to reduce pain and improve compliance. In a study published in this issue of Journal of Diabetes Science and Technology, Ito and colleagues studied patients who exclusively used the traditional fingertip blood glucose testing (FBGT) and introduced these patients to the palm blood glucose testing (PBGT). These patients did not see much benefit in using PBGT over FBGT but did plan to use PBGT in the future (likely allowing for increased testing frequency). Future studies should consider populations of patients who may find more benefit to AST—minimizing barriers and improving compliance in diabetes self-management. Additionally, other barriers to SMBG should be explored and solutions studied to improve compliance in diabetes care.
The Health Implications of Sucrose, High-Fructose Corn Syrup, and Fructose: What Do We Really Know?
Authors: Rippe James M.
Published: January 2014

The epidemic of obesity and related metabolic diseases continues to extract an enormous health toll. Multiple potential causes for obesity have been suggested, including increased fat consumption, increased carbohydrate consumption, decreased physical activity, and, most recently, increased fructose consumption. Most literature cited in support of arguments suggesting a link between obesity and fructose consumption is epidemiologic and does not establish cause and effect. The causes of obesity are well-known and involve the overconsumption of calories from all sources. Research employing a pure fructose model distorts the real-world situation of fructose consumption, which predominantly comes from sweeteners containing roughly equal proportions of glucose and fructose. The fructose hypothesis has the potential to distract us from further exploration and amelioration of known causes of obesity. Randomized prospective trials of metabolic consequences of fructose consumption at normal population levels and from sources typically found in the human diet such as sucrose and high-fructose corn syrup are urgently needed.
Quantifying the Composition of Human Skin for Glucose Sensor Development
Authors: Groenendaal Willemijn , von Basum Golo , Schmidt Kristiane A. , Hilbers Peter A. J. , van Riel Natal A. W.
Published: January 2014

Background:

Glucose is heterogeneously distributed within human skin. In order to develop a glucose measurement method for human skin, both a good quantification of the different compartments of human skin and an understanding of glucose transport processes are essential. This study focused on the composition of human skin. In addition, the extent to which intersubject variability in skin composition alters glucose dynamics in human skin was investigated.

Methods:

To quantify the composition of the three layers of human skin—epidermis, dermis, and adipose tissue—cell and blood vessel volumes were calculated from skin biopsies. These results were combined with data from the literature. The composition was applied as input for a previously developed computational model that calculates spatiotemporal glucose dynamics in human skin. The model was used to predict the physiological effects of intersubject variability in skin composition on glucose profiles in human skin.

Results:

According to the model, the lag time of glucose dynamics in the epidermis was sensitive to variation in the volumes of interstitial fluid, cells, and blood of all layers. Data showed most variation/uncertainty in the volume composition of the adipose tissue. This variability mainly influences the dynamics in the adipose tissue.

Conclusions:

This study identified the intersubject variability in human skin composition. The study shows that this variability has significant influence on the glucose dynamics in human skin. In addition, it was determined which volumes are most critical for the quantification and interpretation of measurements in the different layers.
Bioluminescence Imaging of Glucose in Tissue Surrounding Polyurethane and Glucose Sensor Implants
Authors: Prichard Heather L. , Schroeder Thies , Reichert William M. , Klitzman Bruce
Published: January 2014

Background:

The bioluminescence technique was used to quantify the local glucose concentration in the tissue surrounding subcutaneously implanted polyurethane material and surrounding glucose sensors. In addition, some implants were coated with a single layer of adipose-derived stromal cells (ASCs) because these cells improve the wound-healing response around biomaterials.

Methods:

Control and ASC-coated implants were implanted subcutaneously in rats for 1 or 8 weeks (polyurethane) or for 1 week only (glucose sensors). Tissue biopsies adjacent to the implant were immediately frozen at the time of explant. Cryosections were assayed for glucose concentration profile using the bioluminescence technique.

Results:

For the polyurethane samples, no significant differences in glucose concentration within 100 μm of the implant surface were found between bare and ASC-coated implants at 1 or 8 weeks. A glucose concentration gradient was demonstrated around the glucose sensors. For all sensors, the minimum glucose concentration of approximately 4 mM was found at the implant surface and increased with distance from the sensor surface until the glucose concentration peaked at approximately 7 mM at 100 μm. Then the glucose concentration decreased to 5.5–6.5 mM more than 100 μm from the surface.

Conclusions:

The ASC attachment to polyurethane and to glucose sensors did not change the glucose profiles in the tissue surrounding the implants. Although most glucose sensors incorporate a diffusion barrier to reduce the gradient of glucose and oxygen in the tissue, it is typically assumed that there is no steep glucose gradient around the sensors. However, a glucose gradient was observed around the sensors. A more complete understanding of glucose transport and concentration gradients around sensors is critical.
Importance of Interleukin-1 and Interleukin-1 Receptor Antagonist in Short-Term Glucose Sensor Function in Vivo
Authors: Klueh Ulrike , Liu Zenghe , Feldman Ben , Kreutzer Don
Published: January 2014

Background:

The importance of the interleukin (IL)-1 cytokine family in inflammation and immunity is well established as a result of extensive in vitro and in vivo studies. In fact, much of our understanding of the in vivo importance of interleukin-1beta (IL-1B) is the result of research utilizing transgenic mice, such as overexpression or deficiencies of the naturally occurring inhibitor of IL-1 known as interleukin-1 receptor antagonist (IL-1RA). For the present studies, we utilized these transgenic mice to determine the role of IL-1B in glucose sensor function in vivo.

Methods:

To investigate the role of IL-1B in glucose sensor function in vivo, we compared glucose sensor function in transgenic mice that (1) overexpressed IL-1RA [B6.Cg-Tg(II1rn)1Dih/J] and (2) are deficient in IL-1RA (B6.129S- Il1rntm1Dih/J), with mice that have normal levels of IL-1RA (C57BL/6).

Results:

Our studies demonstrated that, during the first 7 days post-sensor implantation (PSI), mice deficient in IL-1RA had extensive inflammation and decreased sensor function when compared to normal or IL-1RA-overexpressing mice.

Conclusion:

These data directly support our hypothesis that the IL-1 family of cytokines and antagonists play a critical role in controlling tissue reactions and thereby sensor function in vivo during the first 7 days PSI.
Hyperspectral Imaging in Diabetic Foot Wound Care
Authors: Yudovsky Dmitry , Nouvong Aksone , Pilon Laurent
Published: January 2014

Diabetic foot ulceration is a major complication of diabetes and afflicts as many as 15 to 25% of type 1 and 2 diabetes patients during their lifetime. If untreated, diabetic foot ulcers may become infected and require total or partial amputation of the affected limb. Early identification of tissue at risk of ulcerating could enable proper preventive care, thereby reducing the incidence of foot ulceration. Furthermore, noninvasive assessment of tissue viability around already formed ulcers could inform the diabetes caregiver about the severity of the wound and help assess the need for amputation. This article reviews how hyperspectral imaging between 450 and 700 nm can be used to assess the risk of diabetic foot ulcer development and to predict the likelihood of healing noninvasively. Two methods are described to analyze the in vivo hyperspectral measurements. The first method is based on the modified Beer-Lambert law and produces a map of oxyhemoglobin and deoxyhemoglobin concentrations in the dermis of the foot. The second is based on a two-layer optical model of skin and can retrieve not only oxyhemoglobin and deoxyhemoglobin concentrations but also epidermal thickness and melanin concentration along with skin scattering properties. It can detect changes in the diabetic foot and help predict and understand ulceration mechanisms
Pharmacokinetic Characterization of the Novel Pulmonary Delivery Excipient Fumaryl Diketopiperazine
Authors: Potocka Elizabeth , Cassidy James P. , Haworth Pamela , Heuman Douglas , van Marle Sjoerd , Baughman Robert A.
Published: January 2014

Background:

Technosphere® [Bis-3, 6(4-fumarylaminobutyl)-2, 5-diketopiperazine (FDKP)] microparticles, the integral component of the Technosphere inhalation system, deliver drugs to the deep lung and have been used to administer insulin and glucagon-like peptide-1 via inhalation in clinical studies. Three studies were conducted to characterize FDKP pharmacokinetics, including assessments in subjects with diabetic nephropathy (DNP), in subjects with chronic liver disease (CLD), and in healthy subjects.

Methods:

An open-label, nonrandomized, two-period, fixed-sequence crossover absorption, distribution, metabolism, and excretion (ADME) study was conducted in six healthy nonsmoking men who received single intravenous and oral doses of [14C]FDKP solution, with serial sampling of blood, urine, feces, and expired air. Additionally, two single-dose, open-label, parallel-design studies with 20 mg of inhaled FDKP were conducted in (1) 12 diabetic subjects with normal renal function and 24 DNP subjects and (2) 12 healthy subjects and 21 CLD subjects.

Results:

In the ADME study, >95% of the intravenous dose and <3% of the oral dose were recovered in urine, with no evidence of metabolism. No significant pharmacokinetic differences were observed between healthy subjects and CLD subjects [geometric mean (% coefficient of variation) area under the curve from time 0 to 480 minutes (AUC0-480): 26,710 (34.8) and 31,477 (28.8) ng/ml·min, respectively]. Maximum observed drug concentration ( Cmax) and AUC0-480 were higher in DNP subjects than in subjects with normal renal function [ Cmax: 159.9 (59.4) ng/ml versus 147.0 (44.3) ng/ml; AUC0-480: 36,869 (47.2) ng/ml·min versus 30,474 (31.8) ng/ml·min]. None of the differences observed were considered clinically significant.

Conclusions:

Fumaryl diketopiperazine is predominantly cleared unchanged by the kidney with essentially no oral bioavailability. Technosphere is a safe delivery vehicle for medications administered via inhalation.
Glucose Information for Tight Glycemic Control: Different Methods with Different Challenges
Authors: Weber Christian , Neeser Kurt
Published: January 2014

Rigorous glucose control is essential for prevention of diabetes-related complications in diabetes patients. Even without diabetes, tight glucose control is beneficial in hospitalized, critically ill patients.

Actually, three different glucose measurement methods are used: (1) hand held devices, (2) blood-gas analyzers, and (3) laboratory analyzers in core laboratories. Each method is subject to specific challenges and limitations that can affect the overall system performance.

In this article, we aim to demonstrate that even glucose measurement results from core laboratories (professional laboratory systems) do not necessarily reflect the absolute “true” glucose level of a patient.
The Physiology of Glucagon
Authors: Taborsky Gerald J.
Published: January 2014

This short review outlines the physiology of glucagon in vivo, with an emphasis on its neural control, the author's area of interest. Glucagon is secreted from alpha cells, which are a minority of the pancreatic islet. Anatomically, they are down stream from the majority islet beta cells. Beta-cell secretory products restrain glucagon secretion. Activation of the autonomic nerves, which innervate the islet, increases glucagon secretion.

Glucagon is secreted into the portal vein and thus has its major physiologic action at the liver to break down glycogen. Glucagon thereby maintains hepatic glucose production during fasting and increases hepatic glucose production during stress, including the clinically important stress of hypoglycemia. Three different mechanisms proposed to stimulate glucagon secreted during hypoglycemia are discussed: (1) a stimulatory effect of low glucose directly on the alpha cell, (2) withdrawal of an inhibitory effect of adjacent beta cells, and (3) a stimulatory effect of autonomic activation.

In type 1 diabetes (T1DM), increased glucagon secretion contributes to the elevated ketones and acidosis present in diabetic ketoacidosis (DKA). It also contributes to the hyperglycemia seen with or without DKA. The glucagon response to insulin-induced hypoglycemia is impaired soon after the development of T1DM. The mediators of this impairment include loss of beta cells and loss of sympathetic nerves from the autoimmune diabetic islet.
Benchmarking Glucose Results through Automation: The 2009 Remote Automated Laboratory System Report
Authors: Anderson Marcy , Zito Denise , Kongable Gail
Published: January 2014

Background:

Hyperglycemia in the adult inpatient population remains a topic of intense study in U.S. hospitals. Most hospitals have established glycemic control programs but are unable to determine their impact. The 2009 Remote Automated Laboratory System (RALS) Report provides trends in glycemic control over 4 years to 576 U.S. hospitals to support their effort to manage inpatient hyperglycemia.

Methods:

A proprietary software application feeds de-identified patient point-of-care blood glucose (POC-BG) data from the Medical Automation Systems RALS-Plus data management system to a central server. Analyses include the number of tests and the mean and median BG results for intensive care unit (ICU), non-ICU, and each hospital compared to the aggregate of the other hospitals.

Results:

More than 175 million BG results were extracted from 2006–2009; 25% were from the ICU. Mean range of BG results for all inpatients in 2006, 2007, 2008, and 2009 was 142.2–201.9, 145.6–201.2, 140.6–205.7, and 140.7–202.4 mg/dl, respectively. The range for ICU patients was 128–226.5, 119.5–219.8, 121.6–226.0, and 121.1–217 mg/dl, respectively. The range for non-ICU patients was 143.4–195.5, 148.6–199.8, 145.2–201.9, and 140.7–203.6 mg/dl, respectively. Hyperglycemia rates of >180 mg/dl in 2008 and 2009 were examined, and hypoglycemia rates of <40 mg/dl (severe) and <70 mg/dl (moderate) in both 2008 and 2009 were calculated.

Conclusions:

From these data, hospitals can determine the current state of glycemic control in their hospital and in comparison to other hospitals. For many, glycemic control has improved. Automated POC-BG data management software can assist in this effort.
No Relevant Relationship between Glucose Variability and Oxidative Stress in Well-Regulated Type 2 Diabetes Patients
Authors: Siegelaar Sarah E. , Barwari Temo , Kulik Wim , Hoekstra Joost B. , DeVries J. Hans
Published: January 2014

Background:

A strong relationship between glycemic variability and oxidative stress in poorly regulated type 2 diabetes (T2DM) on oral medication has been reported. However, this relationship was not seen in type 1 diabetes. The purpose of this study is to reexamine the relation between glycemic variability and oxidative stress in a cohort of T2DM patients on oral medication.

Methods:

Twenty-four patients with T2DM on oral glucose lowering treatment underwent 48 hours of continuous glucose monitoring (CGMS® System Gold™, Medtronic MiniMed) and simultaneous collection of two consecutive 24-hour urine samples for determination of 15( S)-8-iso-prostaglandin F2α (PGF2α) using high-performance liquid chromatography tandem mass spectrometry. Standard deviation (SD) and mean amplitude of glycemic excursions (MAGE) were calculated as markers of glycemic variability.

Results:

Included in the study were 66.7% males with a mean age (range) of 59 (36–76) years and a mean (SD) HbA1c of 6.9% (0.7). Median [interquartile range (IQR)] urinary 15( S)-8-iso-PGF2α excretion was 176.1 (113.6–235.8) pg/mg creatinine. Median (IQR) SD was 31 (23–40) mg/dl and MAGE 85 (56–106) mg/dl. Spearman correlation did not show a significant relation for SD (ρ = 0.15, p = .49) or MAGE (ρ = 0.23, p = .29) with 15( S)-8-iso-PGF2α excretion. Multivariate regression analysis adjusted for age, sex, HbA1c, and exercise did not alter this observation.

Conclusions:

We did not find a relevant relationship between glucose variability and 15( S)-8-iso-PGF2α excretions in T2DM patients well-regulated with oral medication that would support an interaction between hyperglycemia and glucose variability with respect to the formation of reactive oxygen species.
FreeStyle Navigator Continuous Glucose Monitoring System with TRUstart Algorithm, a 1-Hour Warm-up Time
Authors: McGarraugh Geoffrey , Brazg Ronald , Weinstein Richard
Published: January 2014

Background:

The first-generation FreeStyle Navigator® Continuous Glucose Monitoring System (FreeStyle Navigator CGM) requires a 10 h warm-up period to avoid inaccurate glucose readings caused by sensor insertion trauma and wound-healing processes. The performance of a second-generation FreeStyle Navigator CGM that begins reporting glucose 1 h after sensor insertion is described.

Methods:

Second-generation FreeStyle Navigator CGM performance was evaluated in an in-clinic study using the YSI Model 2300 STATPlus Glucose Analyzer as reference with 47 subjects with type 1 diabetes. The reference readings were taken at 15 min intervals, and the study was designed to emphasize the first 10 h of use.

Results:

The second-generation FreeStyle Navigator CGM exhibited continuous glucose error grid analysis ratings of 93.7% “clinically accurate”, 3.6% “benign errors”, and 2.8% “clinical errors” and a mean and median absolute relative difference of 14.5% and 10.7%, respectively. The second-generation algorithm detected signal instability in the first 10 h of use and suspended the reporting of 14.1% of first day continuous glucose readings. The clinical accuracy of the second-generation FreeStyle Navigator CGM was similar for the first 10 h versus subsequent hours, with 92.6% and 94.2% “clinically accurate” readings, respectively.

Conclusion:

The warm-up period for the second-generation FreeStyle Navigator CGM was reduced from 10 to 1 h, with minimal interruption of glucose reporting and without sacrificing clinical performance.
H.E.A.L.T.H.: Efficacy of an Internet/Population-Based Behavioral Weight Management Program for the U.S. Army
Authors: Stewart Tiffany , Han Hongmei , Allen H. Raymond , Bathalon Gaston , Ryan Donna H. , Newton Robert L. , Williamson Donald A.
Published: January 2014

Background:

A Significant number of soldiers exceed the maximum allowable weight standards or have body weights approaching the maximum allowable weight standards. This mandates development of scalable approaches to improve compliance with military weight standards.

Methods:

We developed an intervention that included two components: (1) an Internet-based weight management program (Web site) and (2) a promotion program designed to promote and sustain usage of the Web site. The Web site remained online for 37 months, with the Web site promotion program ending after 25 months.

Results:

Soldiers' demographics were as follows: Mean age, 32 years; body mass index (BMI), 28 kg/m2; 31% female; and 58% Caucasian. Civilian demographics were as follows: Mean age, 38 years; BMI, 30 kg/m2; 84% female; and 55% Caucasian. Results indicated that 2417 soldiers and 2147 civilians ( N = 4564) registered on the Web site. In the first 25 months (phase 1) of the study, new participants enrolled on the Web site at a rate of 88 (soldiers) and 80 (civilians) per month. After the promotion program was removed (phase 2), new participants enrolled at a rate of 18 (soldiers) and 13 (civilians) per month. Utilization of the Web site was associated with self-reported weight loss ( p < .0001). Participants who utilized the Web site more frequently lost more weight ( p < .0001). Participants reported satisfaction with the Web site.

Conclusions:

The Web site and accompanying promotion program, when implemented at a military base, received satisfactory ratings and benefited a subset of participants in promoting weight loss. This justifies further examination of effectiveness in a randomized trial setting.
Behavioral Challenges in the Management of Childhood Diabetes
Authors: Clarke William L.
Published: January 2014

For many individuals, the diagnosis of diabetes is accompanied by the need for significant lifestyle changes, many of which seem difficult or impossible to implement. When diabetes is diagnosed in a child, those lifestyle changes may involve radical alterations in family life and significantly impact the child's normal growth and development as well as the family's social and economic status. This article describes some of the behavioral challenges associated with childhood diabetes and the importance of identifying strong, developmentally appropriate family support. Specific emphases are given to the complexity of the treatment regimens, the physiologic and emotional challenges associated with normal growth and development, and the family's role in ensuring successful diabetes management. Challenges inherent in both type 1 and type 2 diabetes mellitus are discussed as are factors important to ensuring adherence to the treatment plan.
New Directions in Virtual Environments and Gaming to Address Obesity and Diabetes: Industry Perspective
Authors: Ruppert Barb
Published: January 2014

Virtual reality is increasingly used for education and treatment in the fields of health and medicine. What is the health potential of virtual reality technology from the software development industry perspective? This article presents interviews with Ben Sawyer of Games for Health, Dr. Walter Greenleaf of InWorld Solutions, and Dr. Ernie Medina of MedPlay Technologies. Games for Health brings together researchers, medical professionals, and game developers to share information on the impact that game technologies can have on health, health care, and policy. InWorld is an Internet-based virtual environment designed specifically for behavioral health care. MedPlay Technologies develops wellness training programs that include exergaming technology. The interviewees share their views on software development and other issues that must be addressed to advance the field of virtual reality for health applications.
Integrative Gaming: A Framework for Sustainable Game-Based Diabetes Management
Authors: Kahol Kanav
Published: January 2014

Obesity and diabetes have reached epidemic proportions in both developing and developed nations. While doctors and caregivers stress the importance of physical exercise in maintaining a healthy lifestyle, many people have difficulty subscribing to a healthy lifestyle. Virtual reality games offer a potentially exciting aid in accelerating and sustaining behavior change. However, care needs to be taken to develop sustainable models of employing games for the management of diabetes and obesity. In this article, we propose an integrative gaming paradigm designed to combine multiple activities involving physical exercises and cognitive skills through a game-based storyline. The persuasive story acts as a motivational binder that enables a user to perform multiple activities such as running, cycling, and problem solving. These activities guide a virtual character through different stages of the game. While performing the activities in the games, users wear sensors that can measure movement (accelerometers, gyrometers, magnetometers) and sense physiological measures (heart rate, pulse oximeter oxygen saturation). These measures drive the game and are stored and analyzed on a cloud computing platform. A prototype integrative gaming system is described and design considerations are discussed. The system is highly configurable and allows researchers to build games for the system with ease and drive the games with different types of activities. The capabilities of the system allow for engaging and motivating the user in the long term. Clinicians can employ the system to collect clinically relevant data in a seamless manner.
Cost-Effectiveness of Implementing the Chronic Care Model for Diabetes Care in a Military Population
Authors: Kuo Shihchen , Bryce Cindy L. , Zgibor Janice C. , Wolf Donna L. , Roberts Mark S. , Smith Kenneth J.
Published: January 2014

Background:

Applying the chronic care model (CCM) for diabetes management helps improve health outcomes and patient care. The CCM was implemented at U.S. Air Force Wilford Hall Medical Center through the Diabetes Outreach Clinic (DOC) in 2006, but its cost-effectiveness in this setting is unknown.

Methods:

We constructed a Markov decision model to estimate DOC cost-effectiveness compared with usual care (UC) over a 20-year period. Based on empirical, post-intervention demographic and clinical data, we applied United Kingdom Prospective Diabetes Study risk equations to predict long-term probabilities of developing microvascular or macrovascular complications. Health care system and societal perspectives were considered, discounting costs and benefits at 3% annually. Intervention costs and outcomes were obtained from military data, while other costs, disease progression data, and utilities were drawn from published literature.

Results:

From a health care system perspective, the DOC cost $45,495 per quality-adjusted life-year (QALY) compared with UC; from a societal perspective, the DOC compared with UC cost $42,051/QALY (when the model started with the uncomplicated diabetes cohort), $61,243/QALY (when starting with the DOC cohort), or $61,813/QALY (when starting with the UC cohort). In one-way sensitivity analyses, results were most sensitive to yearly costs for specialty care visits. In probabilistic sensitivity analysis, the DOC was favored in 51% of model iterations using an acceptability threshold of $50,000/QALY and in 72% at a threshold of $100,000/QALY.

Conclusions:

The DOC strategy for diabetes care, performed with the CCM methodology in a military population, appears to be economically reasonable compared with UC.
Implant Healing in Experimental Animal Models of Diabetes
Authors: Le Nga N. , Rose Michael B. , Levinson Howard , Klitzman Bruce
Published: January 2014

Diabetes mellitus is becoming increasingly prevalent worldwide. Additionally, there is an increasing number of patients receiving implantable devices such as glucose sensors and orthopedic implants. Thus, it is likely that the number of diabetic patients receiving these devices will also increase. Even though implantable medical devices are considered biocompatible by the Food and Drug Administration, the adverse tissue healing that occurs adjacent to these foreign objects is a leading cause of their failure. This foreign body response leads to fibrosis, encapsulation of the device, and a reduction or cessation of device performance. A second adverse event is microbial infection of implanted devices, which can lead to persistent local and systemic infections and also exacerbates the fibrotic response. Nearly half of all nosocomial infections are associated with the presence of an indwelling medical device. Events associated with both the foreign body response and implant infection can necessitate device removal and may lead to amputation, which is associated with significant morbidity and cost. Diabetes mellitus is generally indicated as a risk factor for the infection of a variety of implants such as prosthetic joints, pacemakers, implantable cardioverter defibrillators, penile implants, and urinary catheters. Implant infection rates in diabetic patients vary depending upon the implant and the microorganism, however, for example, diabetes was found to be a significant variable associated with a nearly 7.2% infection rate for implantable cardioverter defibrillators by the microorganism Candida albicans. While research has elucidated many of the altered mechanisms of diabetic cutaneous wound healing, the internal healing adjacent to indwelling medical devices in a diabetic model has rarely been studied. Understanding this healing process is crucial to facilitating improved device design. The purpose of this article is to summarize the physiologic factors that Influence wound healing and infection in diabetic patients, to review research concerning diabetes and biomedical implants and device infection, and to critically analyze which diabetic animal model might be advantageous for assessing internal healing adjacent to implanted devices.
The Effect of Type-2-Diabetes-Related Vascular Endothelial Dysfunction on Skin Physiology and Activities of Daily Living
Authors: Petrofsky Jerrold Scott
Published: January 2014

A common factor contributing to organ damage in type 2 diabetes mellitus (T2DM) is impaired tissue blood flow caused by damage to vascular endothelial cells (VECs). Damage can occur even before the clinical diagnosis of diabetes. It can be caused by both a high average blood glucose concentration and/or large daily spikes in blood glucose. While much of the present literature focuses on the damage to VECs and organs from these large glucose excursions, this review will focus on the consequence of this damage, that is, how endothelial cell damage in diabetes affects normal daily activities (e.g., exercise, reaction to typical stimuli) and various treatment modalities (e.g. contrast baths and electrical stimulation therapy). It is important to understand the effects of VEC damage such as poor skin blood flow, compromised thermoregulation, and altered response to skin pressure in designing diabetes technologies as simple as heating pads and as complex as continuous glucose monitors. At the simplest level, people with diabetes have poor circulation to the skin and other organs. In the skin, even the blood flow response to locally applied pressure, such as during standing, is different than for people who do not have T2DM. Simple weight bearing on the foot can occlude the skin circulation. This makes the skin more susceptible to damage. In addition, endothelial damage has far-reaching effects on the whole body during normal activities of daily living, including an impaired response to local heat, such as hot packs and contrast baths, and higher body temperatures during whole body heating due to impaired blood flow and a reduced ability to sweat. Finally, because of multiple organ damage, people with T2DM have poor balance and gait and impaired exercise performance.
Telemedicine Security: A Systematic Review
Authors: Garg Vaibhav , Brewer Jeffrey
Published: January 2014

Telemedicine is a technology-based alternative to traditional health care delivery. However, poor security measures in telemedicine services can have an adverse impact on the quality of care provided, regardless of the chronic condition being studied. We undertook a systematic review of 58 journal articles pertaining to telemedicine security. These articles were selected based on a keyword search on 14 relevant journals. The articles were coded to evaluate the methodology and to identify the key areas of research in security that are being reviewed. Seventy-six percent of the articles defined the security problem they were addressing, and only 47% formulated a research question pertaining to security. Sixty-one percent proposed a solution, and 20% of these tested the security solutions that they proposed. Prior research indicates inadequate reporting of methodology in telemedicine research. We found that to be true for security research as well. We also identified other issues such as using outdated security standards.
The Scope of Cell Phones in Diabetes Management in Developing Country Health Care Settings
Authors: Ajay Vamadevan S. , Prabhakaran Dorairaj
Published: January 2014

Diabetes has emerged as a major public health concern in developing nations. Health systems in most developing countries are yet to integrate effective prevention and control programs for diabetes into routine health care services. Given the inadequate human resources and underfunctioning health systems, we need novel and innovative approaches to combat diabetes in developing-country settings. In this regard, the tremendous advances in telecommunication technology, particularly cell phones, can be harnessed to improve diabetes care. Cell phones could serve as a tool for collecting information on surveillance, service delivery, evidence-based care, management, and supply systems pertaining to diabetes from primary care settings in addition to providing health messages as part of diabetes education. As a screening/diagnostic tool for diabetes, cell phones can aid the health workers in undertaking screening and diagnostic and follow-up care for diabetes in the community. Cell phones are also capable of acting as a vehicle for continuing medical education; a decision support system for evidence-based management; and a tool for patient education, self-management, and compliance. However, for widespread use, we need robust evaluations of cell phone applications in existing practices and appropriate interventions in diabetes.
Characterizing Blood Glucose Variability Using New Metrics with Continuous Glucose Monitoring Data
Authors: Marling Cynthia R. , Shubrook Jay H. , Vernier Stanley J. , Wiley Matthew T. , Schwartz Frank L.
Published: January 2014

Objective:

Glycemic variability contributes to oxidative stress, which has been linked to the pathogenesis of the long-term complications of diabetes. Currently, the best metric for assessing glycemic variability is mean amplitude of glycemic excursion (MAGE); however, MAGE is not in routine clinical use. A glycemic variability metric in routine clinical use could potentially be an important measure of overall glucose control and a predictor of diabetes complication risk not detected by glycosylated hemoglobin (A1C) levels. This study aimed to develop and evaluate new automated metrics of glycemic variability that could be routinely applied to continuous glucose monitoring (CGM) data to assess and enhance glucose control.

Method:

Individual 24 h CGM tracings from our clinical diabetes research database were scored for MAGE and two additional metrics designed to compensate for aspects of variability not captured by MAGE: (1) number of daily glucose fluctuations >75 mg/dl that leave the normal range (70–175 mg/dl), or excursion frequency, and (2) total daily fluctuation, or distance traveled. These scores were used to train machine learning algorithms to recognize excessive variability based on physician ratings of daily CGM charts, producing a third metric of glycemic variability: perceived variability. Finger stick A1C (average) and serum 1,5-anhydroglucitol (postprandial) levels were used as clinical markers of overall glucose control for comparison.

Results:

Mean amplitude of glycemic excursion, excursion frequency, and distance traveled did not adequately quantify the glycemic variability visualized by physicians who evaluated the daily CGM plots. A naive Bayes classifier was developed that characterizes CGM tracings based on physician interpretations of tracings. Preliminary results suggest that the number of excessively variable days, as determined by this naive Bayes classifier, may be an effective way to automatically assess glycemic variability of CGM data. This metric more closely reflects 90-day changes in serum 1,5-anhydroglucitol levels than does MAGE.

Conclusion:

We have developed a new automated metric to assess overall glycemic variability in people with diabetes using CGM, which could easily be incorporated into commercially available CGM software. Additional work to validate and refine this metric is underway. Future studies are planned to correlate the metric with both urinary 8-iso-prostaglandin F2 alpha excretion and serum 1,5-anhydroglucitol levels to see how well it identifies patients with high glycemic variability and increased markers of oxidative stress to assess risk for long-term complications of diabetes.