What we can really expect from telemedicine in intensive diabetes treatment: 10 years later.

During the last 10 years many new telematic systems aiming at support of diabetes treatment have been designed and developed. Most systems that were applied in clinical randomized trials used the classical approach, with data transfers from patients performed usually once every few days. In the few available meta-analyses of these trials, a significant improvement of the mean hemoglobin A1c was demonstrated in patients using telematic systems. However, the magnitude of this improvement in comparison with the control groups was lower than expected. This conclusion was confirmed by results of the IDEATel study involving more than 1,600 patients over a period of 5 years. It might by hypothesized that in some groups of patients continuous telecare with frequent contacts between patients and the care provider during each day should be required. This hypothesis is confirmed by the results of the clinical trials applying real-time diabetes monitoring systems. However, the increased frequency of the data transfers and checkups requires a new model for technology-supported care. The new model should connect together the ubiquitous data transfer with an automatically selected optimal frequency, the automatic assessment of the data coupled with quicker feedback from the decision support system or from the provider, and selection of the optimal time for the patient's face-to-face visit in the clinic. All this new future implementations together with already confirmed advantages of the telematic support, such as the increase of self-confidence of the patient, will hopefully give real benefits for the patients.

Area of the diabetic ulcers estimated applying a foot scanner-based home telecare system and three reference methods.

BACKGROUND: Diabetic foot ulcer area is a basic parameter used for monitoring the wound healing and effectiveness of the treatment applied. TeleDiaFoS (developed earlier in collaboration with the Department and Clinic of Gastroenterology and Metabolic Diseases, Medical University of Warsaw, Warsaw, Poland) is one of just a few systems available that make possible monitoring of the wound size remotely based on the foot scans transmitted to the physician from a patient's home. The aim of this study was to compare the diabetic foot ulcer areas measured using TeleDiaFoS with the results obtained using three reference methods. METHODS: The reference measurements were conducted using the elliptical method with a ruler, the wound tracing method and planimetrics with the Visitrak (Smith & Nephew, London, UK) system, and the pattern-coded structured light method with the Silhouette (ARANZ Medical, Christchurch, New Zealand) system. Regression and Bland-Altman analyses were performed. The study group consisted of 23 diabetes patients with plantar foot ulcers. RESULTS: Thirty-three wounds were successfully examined. The measurement method influenced the measured area significantly (P=0.00005). The correlation coefficients between TeleDiaFoS and the ruler, Visitrak, and Silhouette methods were 0.949, 0.985, and 0.987, and the limits of agreement equaled -1.3±5.5 cm(2), -0.4±2.2 cm(2), and -0.6±2.1 cm(2), respectively. The strong linear relationships obtained can be used to convert the wound area measured with TeleDiaFoS to the corresponding value of each of the reference methods. CONCLUSIONS: The results indicate that the wound area of plantar ulcers in diabetes might be monitored effectively using the TeleDiaFoS system based on the foot scans that the patient can produce at home with no assistance of other persons.

Toward the improvement of diabetes treatment: recent developments in technical support.

Diabetes is recognized as one of the most severe health problem in the world. It spares no one, attacking men, women, children, and the elderly. Diabetes is the leading cause of kidney failure, blindness in adults, nervous system damage, and amputations. It is a major risk factor for heart disease, stroke, and birth defects. Diabetes is currently one of the most costly diseases in both human and economic terms. Diabetes is a metabolic disorder resulting from insulin deficiency, insulin resistance, or both. There are several possible realizations of the so-called artificial or bio-artificial pancreas (AP, BAP), systems which should automatically and efficiently substitute for the lost function of the # cells. Any types of AP/BAP are routinely used for the treatment of diabetes. Currently, for ambulatory insulin-treated diabetics, only application of intensive therapy can effectively delay the development and progression of the above-mentioned life-threatening late complications of diabetes. Ideal intensive insulin treatment should mimic as closely as possible the secretion of insulin by # cells in healthy people. The crucial factors that determine the efficiency of this type of treatment are the effective monitoring of the patient's glycemic control (monitoring phase) and the accurate delivery of insulin according to established algorithms (treatment phase). The monitoring phase includes blood glucose measurements, the transfer of all parameters measured and noted by the patient to a physician, and clear registration of the data. The treatment phase concerns selection of the optimal insulin regimen and effective insulin delivery to the patient. Delivery of insulin is most commonly realized either intermittently using multiinjection techniques or continuously by portable pumps. However, several others methods of delivery are under development. The main objective of this article is to discuss in detail recent technical developments in intensive insulin treatment, stressing the existing problems and reviewing the best applied solutions.