Outcomes of telehealth in the management of Type 2 Diabetes — a systematic review and meta-analysis of randomised controlled trials

Background: The outcomes of telehealth in the management of type 2 diabetes (T2DM) have not been evaluated since the publication of recent clinical trials. Objective: To conduct a systematic review and meta-analysis of recently published randomized controlled trials (RCTs) to assess the biochemical, clinical and psychosocial outcomes of telehealth in subjects with T2DM. Methods: Electronic databases, MEDLINE, CINAHL, INFORMIT, SCOPUS and the Cochrane Central Register of Controlled Trials and reference lists of existing systematic reviews were searched until August 2017 to identify relevant studies. Study search and selection were performed by two independent reviewers. 4791 articles were retrieved of which 11 RCTs (n=3772) were included. A meta-analysis with random effects model was applied to estimate the pooled results. Results: Telehealth was associated with a statistically significant and clinically relevant absolute decline in glycosylated haemoglobin (HbA1c) compared to usual care (mean difference -0.17%; 95% CI -0.25 to -0.09%; p<0.0001), especially if participants had a mean baseline HbA1c≥8.0%; were less than sixty years of age or received telehealth for less than one year. There was no clinically significant reduction in LDL-cholesterol (LDL-c), body mass index (BMI), systolic (SBP) or diastolic blood pressure (DBP). Conclusion: Telehealth interventions were associated with improved glycaemic control (HbA1c) in T2DM diabetic patients. However, no clinically relevant impact was observed on lipid profile, blood pressure, body mass index and psychosocial well-being. Future studies should seek to evaluate the effect of intervention duration on HbA1c, psychosocial outcomes and the effectiveness of telehealth in rural and underserved populations

The effectiveness of mindfulness-based stress reduction (MBSR) on the mental health, HbA1C, and mindfulness of diabetes patients: A systematic review and meta-analysis of randomised controlled trials

The clinically standardised mindfulness-based stress reduction (MBSR) has been utilised as an intervention for improving mental health among diabetes patients The present study aimed to assess the effectiveness of mindfulness-based stress reduction (MBSR) on the mental health, haemoglobin A1c (HbA1C) and mindfulness of diabetes patients. A systematic review and meta-analysis approach was employed to review randomised controlled trials published in the English language between the inception of eight databases to July 2022. Eleven articles from 10 studies, with a combined sample size of 718 participants were included in the systematic review and nine studies were included in the meta-analysis. In the meta-analysis, outcomes at post-intervention and follow-up were compared between the MBSR intervention and control groups with an adjustment of the baseline values. The results showed that MBSR demonstrated effects at post-intervention and follow-up (in a period between one to 12 months with a mean length of 4.3 months) in reducing anxiety and depressive symptoms, and enhancing mindfulness, with large effect sizes. However, the effect of MBSR on reducing stress was observed at follow-up, but not at post-intervention. Effects of MBSR on HbA1C were not detected at post-intervention and follow-up. The findings suggest that MBSR appears to be an effective treatment for improving mental health conditions and mindfulness in people with diabetes. The measurement of cortisol is recommended to be used as a biological measure to evaluate the effectiveness of MBSR in diabetes patients in future research

Electromechanical therapy in diabetic foot ulcers patients: A systematic review and meta-analysis

Purpose: Diabetic foot ulcer (DFU) is one of the most devastating and troublesome consequences of diabetes. The current therapies are not always effective because of the complicated aetiology and interactions of local and systemic components in DFU. However, adjunctive therapy (electromechanical therapy) has become the latest modality in recent years, although there is a lack of significant research to support its utilization as a treatment standard. The purpose of this systematic research was to review the literature on the application of electromechanical therapies in the healing of DFUs. Methods: For this systematic review, we searched PubMed, Medline, EmBase, the Cochrane library, and Google Scholar for the most current research (1990–2022) on electromechanical therapies for DFUs. We used the PICO method (where P is population, I is intervention, C is comparator/control, and O is outcome for our study) to establish research question with the terms [Electromechanical therapy OR Laser therapy OR photo therapy OR Ultrasound therapy OR Shockwave therapy] AND [diabetic foot ulcers OR diabetes] were used as search criteria. Searches were restricted to English language articles only. Whereas, Cochrane handbook of “Systematic Reviews of Interventions” with critical appraisal for medical and health sciences checklist for systematic review was used for risk of bias assessment. There were 39 publications in this study that were deemed to be acceptable. All the suitably selected studies include 1779 patients. Results: The meta-analysis of 15 included research articles showed the overall effect was significant (P = 0.0002) thus supporting experimental groups have improvement in the DFUs healing in comparison to the control group. Conclusion: This systematic review and meta-analysis revealed electromechanical treatments are significantly viable options for patients with DFUs. Electromechanical therapy can considerably reduce treatment ineffectiveness, accelerate healing, and minimize the time it takes for complete ulcer healing

Cushing’s disease: does low-dose pasireotide offer a comparable efficacy and safety to high-dose?

Whilst literature is expanding on pasireotide use in the management of Cushing’s disease (CD), there is still currently much unknown about long-term and low-dose pasireotide use in CD. We present a 60-year-old female with residual CD after transphenoidal surgery (TSS), being successfully managed with S.C. pasireotide for over 10 years. For 6 years, her S.C. pasireotide was inadvertently administered at 360 µg twice daily (BID), almost half the recommended dose of 600 µg BID. Despite the low-dose, her urinary free cortisol (UFC) normalised within 6 months and Cushingoid features resolved. She remained in biochemical and clinical remission on the same low-dose for 6 years, before a medication audit discovered her mistaken dose and directed her to take 600 µg BID. With the higher dose 600 µg BID for the next 5 years, her glycaemia worsened without any changes in her UFC and residual tumour volume. Our case showed the continuing effectiveness and safety of treatment with S.C. pasireotide for more than 10 years, and that a low-dose regimen may be considered an option for responders by its safety profile

High rate of diabetes in the Asia-Pacific Island: possible role of rapid urbanization: a hospital based study

Asia-Pacific countries are experiencing lifestyle-related non-communicable disease crises. Kimbe, one of Papua New Guinea's provincial capitals is noted as the fastest growing city in the South Pacific subcontinent yet its impact on diabetes mellitus (DM) is not known. To determine pattern of newly diagnosed DM, we conducted a retrospective review of Kimbe General Hospital medical admissions from January 2009 to December 2012. 125 patients were diagnosed with diabetes with male: female ratio of 1.1: 1. Overall, number of patients diagnosed with DM at the hospital increased rapidly from 16 in 2009 to 49 in 2012; p <0.05. Majority of the patients were of young population aged <50 years representing 72 % of the cohort and predominantly of coastal province of origin. Almost 3/4th of the study population was based in Kimbe town and its suburb with only 32 subjects (25.6%) identified as rural residents; p<0.05. This study suggests that subjects living in Asia-Pacific area of rapid urbanization are at higher risk of diabetes compared to residents of rural areas. It highlights the need for adequate health planning and education as part of urbanization program in the DM-prone Asia-Pacific population. Further prospective studies are needed to verify our findings

Response to: comment on “prevalence and risk factors for siabetic lower limb amputation: a clinic-based case control study”

[Extract] The observations by Bakhtiyari and Mansournia on our study [1] were received with great interest. We believe our study was consistent with a case-control format [2]. In particular, our target population was selected from subjects diagnosed with diabetic foot ulcer (DFU) at the local high-risk foot clinic, effectively fulfilling the criteria of control (DFU without amputations) and case (DFU with amputation), as previously described [3]

Lower extremity amputations and long-term outcomes in diabetic foot ulcers: a systematic review

Background: Diabetes mellitus causes a large majority of non-traumatic major and minor amputations globally. Patients with diabetes are clinically complex with a multifactorial association between diabetic foot ulcers (DFU) and subsequent lower extremity amputations (LEA). Few studies show the long-term outcomes within the cohort of DFU-associated LEA. Aim: To highlight the long-term outcomes of LEA as a result of DFU. Methods: PubMed/MEDLINE and Google Scholar were searched for key terms, "diabetes", "foot ulcers", "amputations" and "outcomes". Outcomes such as mortality, re-amputation, re-ulceration and functional impact were recorded. Peer-reviewed studies with adult patients who had DFU, subsequent amputation and follow up of at least 1 year were included. Non-English language articles or studies involving children were excluded. Results: A total of 22 publications with a total of 2334 patients were selected against the inclusion criteria for review. The weighted mean of re-amputation was 20.14%, 29.63% and 45.72% at 1, 3 and 5 years respectively. The weighted mean of mortality at 1, 3 and 5 years were 13.62%, 30.25% and 50.55% respectively with significantly higher rates associated with major amputation, re-amputation and ischemic cardiomyopathy. Conclusion: Previous LEA, level of the LEA and patient comorbidities were significant risk factors contributing to re-ulceration, re-amputation, mortality and depreciated functional status

Is insulin a satiety signal? Insulin treatment antagonises starvation-induced increases in neuropeptide Y concentrations in the arcuate nucleus of the rat

Neuropeptide Y (NPY), the most powerful appetite stimulant known, is synthesised in hypothalamic arcuate nucleus (ARC). NPY levels rise in the ARC and in appetite-regulating hypothalamic nuclei in food-deprived rats, and may drive compensatory hyperphagia in starvation. Circulating insulin levels fall in starvation and insulin deficiency has been postulated to stimulate hypothalamic NPY; this supports the suggestion that insulin acts on the brain to inhibit feeding. We tested this hypothesis by determining whether the increase in NPY in the ARC of starved rats was suppressed by insulin treatment. Adult male Wistar rats were studied. Controls (n=8) were freely-fed and two other groups were food-deprived for 72 hours, both losing 20% of initial weight (p<O.OOI vs controls). One food·deprived group n=10) received insulin (5 U/kg/day) injected subcutaneously twice daily and both other groups recieved saline. Mean blood glucose values (measured in tail-prick samples) were 5.9± 0.1 mmoVI in controls, 4.6± 0.3 mmol/l in food-deprived (p<O.OOI. vs controls) and in insulin·treated 4.4± 0.3 mmol/I (p<O.OOI vs controls; NS vs food-deprived group). Final plasma insulin levels in insulin·treated rats were higher than in saline-treated food-deprived rats (46.6± 8.9 vs 28.9± 4.5 pmol/l; p<O.OOI) and comparable with controls (52.6± 16.2 pmol/l; p=NS). ARC NPY concentrations rose significantly above controls in food·deprived rats (14.18± 1.79 vs 8.4± 2.16 fmol/ug protein; p<O.OOI) and were intermediate in the insulin-treated food-deprived group (11.19± 1.36 fmol/ug protein: p<O.OI vs controls and p<O.OOI vs saline-treated, food deprived). Other hypothalamic regions showed no differences between groups. Insulin therefore antagonises fasting·induced increases in NPY concentrations in the ARC. This is consistent with the hypotheses that insulin deficiency stimulates hypothalamic NPY synthesis, and that peripheral insulin acts as a satiety factor by inhibiting hypothalamic NPY

Prevalence and risk factors for diabetic lower limb amputation: a clinic-based case control study

Objective: The aim of the study was to evaluate the prevalence of and risk factors for lower limb amputation in a specialist foot clinic-based setting. Methods: A retrospective quantitative study was conducted, using clinical and biochemical profiles of diabetic foot patients attending the High Risk Foot Clinic at The Townsville Hospital, Australia, between January 1, 2011, and December 31, 2013. Results: The total study sample included 129 subjects, comprising 81 males and 48 females with M : F ratio of 1.7 : 1. Twenty-three subjects were Indigenous Australians, representing 17.8% of the study population. The average age of the cohort was 63.4 years ± 14.1 years [CI 90.98–65.89]. Lower limb amputation was identified as a common and significant outcome (n = 44), occurring in 34.1%, more commonly amongst the Indigenous Australians (56.5% versus 29.2%; p = 0.94, OR 0.94). Risk factors most closely associated with amputation included diabetic retinopathy (p = 0.00, OR 4.4), coronary artery bypass graft (CABG) surgery (p = 0.01, OR 4.1), Charcot's arthropathy (p = 0.01, OR 2.9), and Indigenous ethnicity (p = 0.01, OR 3.4). Although average serum creatinine, corrected calcium, and glycosylated haemoglobin A1c (Hba1c) levels were higher amongst amputees they were statistically insignificant. Conclusions: Lower limb amputation is a common outcome and linked to ethnicity and neurovascular diabetic complications amongst subjects with diabetic foot ulcer. Further research is needed to identify why risk of lower limb amputation seems to differ according to ethnicity

Blockade of mini-TrpRS for treatment of diabetic foot syndrome

Diabetic foot syndrome demonstrates wound chronicity due to impaired tissue perfusion in lower limbs. Previous studies showed interferon-gamma (IFN-γ), a central inflammatory mediator in diabetic foot syndrome, to induce the truncated form of tryptophanyl-tRNA synthetase (mini-TrpRS) that has strong angiostatic properties. Recently we reported that mini-TrpRS signalling could be blocked in the presence of IFN-γ with D-tryptophan in vitro. Here we discuss the IFN-γ/mini-TrpRS axis in the pathology of diabetic foot syndrome and emerging therapeutic options