Telemedicine and type 1 diabetes: is technology per se sufficient to improve glycaemic control?

AIM: In the TELEDIAB-1 study, the Diabeo system (a smartphone coupled to a website) improved HbA1c by 0.9% vs controls in patients with chronic, poorly controlled type 1 diabetes. The system provided two main functions: automated advice on the insulin doses required; and remote monitoring by teleconsultation. The question is: how much did each function contribute to the improvement in HbA1c? METHODS: Each patient received a smartphone with an insulin dose advisor (IDA) and with (G3 group) or without (G2 group) the telemonitoring/teleconsultation function. Patients were classified as "high users" if the proportion of "informed" meals using the IDA exceeded 67% (median) and as "low users" if not. Also analyzed was the respective impact of the IDA function and teleconsultations on the final HbA1c levels. RESULTS: Among the high users, the proportion of informed meals remained stable from baseline to the end of the study 6months later (from 78.1±21.5% to 73.8±25.1%; P=0.107), but decreased in the low users (from 36.6±29.4% to 26.7±28.4%; P=0.005). As expected, HbA1c improved in high users from 8.7% [range: 8.3-9.2%] to 8.2% [range: 7.8-8.7%] in patients with (n=26) vs without (n=30) the benefit of telemonitoring/teleconsultation (-0.49±0.60% vs -0.52±0.73%, respectively; P=0.879). However, although HbA1c also improved in low users from 9.0% [8.5-10.1] to 8.5% [7.9-9.6], those receiving support via teleconsultation tended to show greater improvement than the others (-0.93±0.97 vs -0.46±1.05, respectively; P=0.084). CONCLUSION: The Diabeo system improved glycaemic control in both high and low users who avidly used the IDA function, while the greatest improvement was seen in the low users who had the motivational support of teleconsultations.

Advanced glycation end products assessed by skin autofluorescence in type 1 diabetics are associated with nephropathy, but not retinopathy.

AIMS: Advanced glycation end products (AGEs) are thought to play a central role in the pathogenesis of diabetes complications. For this reason, a non-invasive tool using skin autofluorescence (AF) quantification that correlates with levels of tissue AGEs has been developed. The present study aimed to assess whether or not skin AF is associated with microvascular complications in patients with type 1 diabetes (T1D). METHODS: All consecutive patients with T1D (n=133) had three AF measures taken on the forearm, using illumination with a fluorescent tube, all on the same day after breakfast or lunch. Potential associations between skin AF levels and microvascular complications, age, diabetes duration and health status were then assessed using a multivariate linear-regression model. RESULTS: On age-adjusted analyses, diabetes duration, retinopathy, nephropathy and neuropathy were significantly associated with skin AF levels (all P<0.001). AF levels increased significantly with severity in both retinopathy and nephropathy (P<0.001). After adjusting for age, diabetes duration, HbA(1c), smoking, retinopathy, nephropathy and neuropathy, the association of AF levels remained significant with nephropathy and neuropathy, but not with retinopathy and diabetes duration. CONCLUSION: This study suggests an independent association between skin AF levels and diabetic nephropathy and neuropathy, but not retinopathy, in T1D patients. Prospective studies are needed to confirm the ability of skin AF levels to predict microangiopathy.

Immunology of pancreatic islet transplantation.

Clinical protocols in type 1 diabetic patients to optimize islet survival and function post-transplantation improved dramatically in the last decade, but it is clear that this approach still has potential limitations to provide long term insulin independency. Islet allografts administered in the liver via the portal vein are exposed to several factors contributing to a rapid loss of function that may reach 50% of the initial beta cell mass. Allo- and auto-immune reactions - an unique situation in clinical transplantation - are partially overcome with immunosuppressive regimen. Serological markers and T cell reactivities may correlate with graft failure. Most of the drugs that are used, including rapamycin (sirolimus) or the calcineurin inhibitor tacrolimus (FK506), have deleterious effects on beta function and/or insulin sensitivity. Immediate factors that limit initial islet engraftment have been elucidated, including instant blood mediated inflammatory reaction and angiogenesis. Newer interventions designed to promote islet survival, to prevent apoptosis, to promote islet growth and to protect islets in the long run from immunological injury are rapidly approaching clinical trials.