AUCTORES
Research Article
*Corresponding Author: ABID Mohamed, Diabetes Endocrinology Department, UHC Hospital Hédi CHAKER, Route El Ain, Sfax, Tunisia.
Citation: Mohamed Abid, Emna Ben Aissa (2023), Management of Diabetes in Tunisia: Results from a Cross-Sectional Study of the International Diabetes Management Practices Study (IDMPS) – Wave 7. J. General Medicine and Clinical Practice. 6(1); DOI:10.31579/2639-4162/081
Copyright: © 2023, ABID Mohamed. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 27 January 2023 | Accepted: 12 April 2023 | Published: 19 April 2023
Keywords: basal–prandial; cardiovascular risk; complications; diabetes; glycemic control; insulin; management
Aims/Background: Diabetes is a serious health condition requiring a range of interventions and self-management education to reduce the risk of complications. The aim of the present study was to assess the care management of people with diabetes in medical practice in Tunisia and its efficiency on HbA1c target.
Materials and methods: The International Diabetes Management Practices Study (IDMPS) is an international, multicentre, non-interventional observational study on care management of diabetes. The data collected from Tunisia in 2016 during the 7th wave was analysed, including 423 patients (people with type1: n=127, with type 2: n=296).
Results: The recommended target of HbA1c <7% was achieved by only 15.5% of type 1 diabetes patients and 24.7% of type 2 diabetes patients. The majority of type 2 diabetes patients (63.3%) received only OGLD (oral glycaemic lowering drug) therapy alone. For type 1 diabetes patients, receiving insulin treatment, more than two-thirds experienced symptomatic episodes of hypoglycemia in the past 3 months, against 24.6% for type 2 diabetes patients. Hospitalizations due to diabetes were reported during the past 12 months for 22.0% and 6.8% of type 1 and type 2 diabetes patients, respectively.
Conclusions/interpretation: The clinical burden of diabetes in Tunisia is unsettling, highlighting the need for more awareness of the disease and its complications. Clinicians probably need to be more careful about intensification of the treatment, even to some therapeutic inertia for type 2 diabetes patients, and global cardiovascular risk approach including the triple pooled targets as recommended in the last guidelines.
IDF: International Diabetes Federation
IDMPS: International Diabetes Management Practices Study
LDL-CS: Low-Density Lipoprotein-Cholesterol
MENA: Middle East and North Africa
OGLD: Oral Glycaemic Lowering Drug
SBP/DBP: Systolic Blood Pressure/Diastolic Blood Pressure
What is already known about this subject?
What is the key question?
What are the new findings?
How might this impact on clinical practice in the foreseeable future?
Diabetes is a major health issue that has shown alarming increases across the world, driven by increasing obesity, sedentary lifestyle, and population aging [1]. According to estimates, more than a half a billion people are living with diabetes worldwide and the prevalence of type 2 diabetes is set to increase from its present level of 537 million (2021) to 783 million by the year 2045 [2]. This rise is predicted to occur virtually in every nation, with the greatest increases expected in developing countries. Furthermore, the Middle East and North Africa (MENA) region has the second highest increase of all regions reviewed by the International Diabetes Federation (IDF), with a diabetes prevalence of 18.1% in 2021, the number of people with diabetes is expected to increase by 87% by 2045. However, the prevalence of diabetes in the MENA region may be underestimated, with a proportion of undiagnosed diabetes close to 37.6% (27.3 million) [3].
Diabetic patients are at risk of developing serious complications, which if not well managed, can result in hospitalizations and even premature death. It turns out that diabetes and its complications caused 428,600 deaths in adults aged less than 60 years in 2021 (24.5% of all-cause mortality) in MENA region [3].
In addition, diabetes also imposes a significant economic impact on countries, health systems and individuals with an estimated annual cost of diagnosed diabetes in 2017 of $327 billion, including $237 billion in direct medical costs and $90 billion in reduced productivity [4]. Indirect costs including loss of production (labour-force drop out from disability), mortality, absenteeism and presenteeism (reduced productivity when at work).
The Diabetes Control and Complications Trial (DCCT) in subjects with type 1 diabetes and the United Kingdom Prospective Diabetes Study (UKPDS) in subjects with type 2 diabetes have supported the position that early treatment of diabetes with tight glycemic control can reduce the morbidity and mortality of the disease by decreasing its chronic complications [5,6]. Therefore, the goal of treatment for patients with diabetes is to achieve metabolic goals, thus preventing or delaying complications and optimizing quality of life. Moreover, this should be personalized according to individual preferences, values, and goals [7].
International diabetes societies (ADA, EASD) have made global recommendations aiming to achieve optimal levels of glycemic control HbA1c lessthan 7% (53 mmol/mol) for nonpregnant adult without hypoglycemia. However, less stringent HbA1c goals lessthan 8% (64 mmol/mol) may be appropriate for patients with limited life expectancy, or where the harms of treatment are greater than the benefits [8,9]. However, it turns out that several patients are still not well controlled and do not achieve the HbA1c goal, a fact that seems to be related to all the insulin therapy issues, from initiation of insulin therapy to proper insulin titration [10]. Therefore, there is a need to better assess the current practices in diabetes management and put in place some actions to improve the quality of care of these patients.
The standardization of the data collection process and the data analysis will justify international comparisons. This very large database will provide supportive data for international recommendations in terms of insulin therapy, in order to improve quality of medicine usage. It will also support future exploratory research.
In this article, we focused on Tunisian data collected during the 7th wave of the IDMPS to assess the management of diabetic patients in medical practice in Tunisia and the predictive factors of reaching the target HbA1c for these patients.
Study design and recruitment of patients
This is an international, multicentre, non-interventional, observational on management care study of people with type 1 or type 2 diabetes mellitus. The study was composed of a cross-sectional study to assess current practices in the management of subjects with type 1 and type 2 diabetes mellitus. The cross-sectional phase was composed of yearly surveys of 2 weeks duration each.
The IDMPS study is composed of yearly surveys (cross-sectional studies and/or longitudinal studies). The first wave of the study was performed in 2005. Six waves have already been performed. This cross-sectional study has been implemented for the seventh wave, which was carried out in 24 countries. In total, 4 regions were defined: Africa (Algeria, Cameroon, Madagascar, Democratic Republic of Congo, Egypt, Tunisia, Morocco, South Africa, Senegal, Ivory Coast, Nigeria, Kenya), Eurasia (Ukraine, Russia), Middle East (Iran, Iraq, Jordan, Kuwait, Lebanon, Pakistan, UAE, Saudi Arabia), and South Asia (Bangladesh, India).
As variables collected during each study were analysed on a yearly basis, by country, and in an independent manner, the Statistical Analysis Plan (SAP) was updated before each analysis.
All the patients who met the eligibility criteria of the cross-sectional study were included. The eligible population considered is: treated with insulin (T1DM only), with type of diabetes recorded (Type1 or type 2), and without missing data concerning the treatment of diabetes (“Does the patient receive oral glycaemic lowering drug (Yes/No)” and “Is the patient currently treated with insulin (Yes/No)”).
Exclusion criteria were: patients enrolled in ongoing clinical trials, or those undergoing temporary insulin therapy (due to other medical issues including gestational diabetes, pancreatic cancer or surgery at baseline).
Survey data was collected by physicians on a standardized IDMPS case report form. The analysis population was constituted after database cleaning.
The sample size was determined on a country basis, based on the primary objective, which was to assess the management of care of T2DM patients, and on the relative precision that was expected.
Based on the assumption that insulin was the least prescribed therapy in terms of proportions, the sample size was determined in order to establish the frequency of insulin-treated patients. It was estimated to give an estimation of proportions with an absolute precision of 20% and a confidence interval of 95%.
n = p (1-p) x (εα/ e)²
with: n = the per country sample size, p = the estimated proportion of type 2 DM patients treated with insulin, εα = 1.96 for α = 5 %, e = the absolute precision (20%) x p = the relative precision.
Ethics
The IDMPS study protocol was approved, all followed procedures were compliant with the appropriate regulatory and ethical committees of the participating countries and centers, as well as those in Tunisia.
Study objectives
The purpose of this diabetes registry is to collect, analyse and disseminate data on people living with diabetes mellitus to improve the quality of care of these patients.
The primary objective of the study was to assess the management of care of people with type 2 diabetes in current medical practice.
The secondary study objectives were: to assess the management of care of patients with type 1 diabetes in current medical practice, and to evaluate the predictive factors for reaching target HbA1c in patients with type 1 and type 2 diabetes.
Statistical analysis
Quantitative variables are described by: the number of missing data, extreme values, mean, standard deviation, median and quartiles. Qualitative variables are described by: the number of missing data, the different modalities of the variable, the corresponding numbers and percentages, and the 95% confidence interval (95% CI).
The modality “Unknown” was considered as missing data regarding “Yes/No/Unknown” answers.
Several comparative analyses were performed. The relationship between categorical variables was investigated using the Chi2 test or Fisher's exact test, depending on the expected values. For categorical variables, comparisons of means were made using the Student t-test or the Wilcoxon/Mann-Whitney test, depending on the normality of the distribution.
Statistical analysis was carried out using SAS® software version 9-2. There was no intermediate analysis.
Study population
In Tunisia, 423 diabetes mellitus patients were recruited in the 7th wave of IDMPS. All of them met the eligibility criteria for analysis, distributed in 127 T1DM patients and 296 T2DM patients (Table 1).
Type 1 | Type 2 | Total | ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Diet and exercise alone | OGLD treatment | Insulin treatment | OGLD treatment + Insulin treatment | Total | ||||||||||
N=127 | N=1 | N=171 | N=25 | N=99 | N=296 | N=423 | ||||||||
Age (years) | 35.47 ± 12.16 | 45 ± . | 59.84 ± 10.15 | 61.40 ± 12.50 | 60.46 ± 9.50 | 60.13 ± 10.15 | 52.73 ± 15.63 | |||||||
Age in class (years) | ||||||||||||||
≤40 | 89 | (70.1%) | 0 | 5 | (2.9%) | 1 | (4.0%) | 2 | (2.0%) | 8 | (2.7%) | 97 | (22.9%) | |
]40;65] | 37 | (29.1%) | 1 | (100.0%) | 124 | (72.5%) | 13 | (52.0%) | 67 | (67.7%) | 205 | (69.3%) | 242 | (57.2%) |
]65;85] | 1 | (0.8%) | 0 | 41 | (24.0%) | 11 | (44.0%) | 30 | (30.3%) | 82 | (27.7%) | 83 | (19.6%) | |
>85 | 0 | 0 | 1 | (0.6%) | 0 | 0 | 1 | (0.3%) | 1 | (0.2%) | ||||
Gender | ||||||||||||||
Male | 68 | (53.5%) | 1 | (100.0%) | 94 | (55.0%) | 14 | (56.0%) | 57 | (57.6%) | 166 | (56.1%) | 234 | (55.3%) |
Female | 59 | (46.5%) | 0 | 77 | (45.0%) | 11 | (44.0%) | 42 | (42.4%) | 130 | (43.9%) | 189 | (44.7%) | |
Ethnicity | ||||||||||||||
Caucasian | 105 | (82.7%) | 1 | (100.0%) | 135 | (78.9%) | 22 | (88.0%) | 80 | (80.8%) | 238 | (80.4%) | 343 | (81.1%) |
Black | 1 | (0.8%) | 0 | 0 | 0 | 0 | 0 | 1 | (0.2%) | |||||
Oriental, Arab, Persian | 21 | (16.5%) | 0 | 36 | (21.1%) | 3 | (12.0%) | 19 | (19.2%) | 58 | (19.6%) | 79 | (18.7%) | |
Living area | ||||||||||||||
Urban area | 107 | (84.3%) | 0 | 159 | (93.0%) | 19 | (76.0%) | 83 | (83.8%) | 261 | (88.2%) | 368 | (87.0%) | |
Rural area | 12 | (9.4%) | 1 | (100.0%) | 5 | (2.9%) | 4 | (16.0%) | 6 | (6.1%) | 16 | (5.4%) | 28 | (6.6%) |
Sub-urban area | 8 | (6.3%) | 0 | 7 | (4.1%) | 2 | (8.0%) | 10 | (10.1%) | 19 | (6.4%) | 27 | (6.4%) | |
Education level | ||||||||||||||
Missing | 1 | 0 | 0 | 0 | 0 | 0 | 1 | |||||||
Illiterate | 2 | (1.6%) | 0 | 11 | (6.4%) | 4 | (16.0%) | 7 | (7.1%) | 22 | (7.4%) | 24 | (5.7%) | |
Primary | 16 | (12.7%) | 0 | 47 | (27.5%) | 6 | (24.0%) | 25 | (25.3%) | 78 | (26.4%) | 94 | (22.3%) | |
Secondary | 57 | (45.2%) | 1 | (100.0%) | 70 | (40.9%) | 12 | (48.0%) | 53 | (53.5%) | 136 | (45.9%) | 193 | (45.7%) |
University/Higher education | 51 | (40.5%) | 0 | 43 | (25.1%) | 3 | (12.0%) | 14 | (14.1%) | 60 | (20.3%) | 111 | (26.3%) | |
Health Insurance * | 117 | (92.1%) | 1 | (100.0%) | 161 | (94.2%) | 23 | (92.0%) | 95 | (96.0%) | 280 | (94.6%) | 397 | (93.9%) |
Type of health insurance | ||||||||||||||
Public | 102 | (87.2%) | 1 | (100.0%) | 138 | (85.7%) | 23 | (100.0%) | 89 | (93.7%) | 251 | (89.6%) | 353 | (88.9%) |
Private | 5 | (4.3%) | 0 | 10 | (6.2%) | 0 | 1 | (1.1%) | 11 | (3.9%) | 16 | (4.0%) | ||
Public + Private | 10 | (8.5%) | 0 | 13 | (8.1%) | 0 | 5 | (5.3%) | 18 | (6.4%) | 28 | (7.1%) |
* Health insurance is defined as National Public Health Insurance and/or Private Health Insurance.
Table 1: Patient demography by type of diabetes
30 physicians included at least one patient in the study: 21 (70%) were specialists (endocrinologists or diabetologists) and 9 were non-specialists (4 (13.3%) General practitioners and 5 (16.7%) internists/cardiologists). All patients met the eligibility criteria for analysis (inclusion/exclusion criteria met, without any other reason of exclusion), distributed in 127 T1DM patients and 296 T2DM patients. All patients were included in the eligible population for analysis.
Characteristics of people with type 1 diabetes
Demographic and clinical features of the T1DM cohort (N = 127) are presented in Tables 1 and 2. The average duration of diabetes was 15.29 ± 10.17 years.
Hospitalizations due to diabetes were reported for 22% of patients during the past 12 months.
Treatment of people with T1DM, attainment of targets and self-care
Most people with T1DM (95.3%) were treated with insulin while only 6.3% received OGLD therapy (Table 3). 85.8% received either basal + prandial insulin (Table 4); while 9.4% received basal alone and 3.9% premix alone. The average duration of insulin therapy was approximately 15.18 ± 10.16 years. 85.7% of T1DM patients had a glucose meter.
HbA1c mean was 8.94%. 15.5% of them achieved the glycaemic target HbA1c lessthan 7 %. Glycaemic goals as targeted by the treating physician were achieved in 15.9% of patients. Comparing the last HbA1c measurement with the HbA1c target value considered by the physician, 9.5% of patients had an HbA1c below the targeted value.
Characteristics of people with type 2 diabetes
Demographic and clinical features of the T2DM cohort (N = 296) are exposed in Tables 1 and 2. The average duration of diabetes was 11.74 ± 8.17 years. Diabetes-related complications were experienced by 49.1% of patients: microvascular complications in 41.6% and macrovascular complications in 14.8%. 6.8% had been hospitalized due to their diabetes in the previous 12 months.
Treatment of people with T2DM, attainment of targets and self-care
Regarding lifestyle, 38.6% of the people with T2DM followed healthy diet and exercise plan. Concerning treatment, 171 (63.3%) patients received only OGLD therapy alone, while 99 (36.66%) patients received a combination of OGLD with insulin, and 25 (9.25%) patients received insulin treatment alone.
For those treated with OGLD drugs only, 56.2% were treated with Metformin + sulfonylureas (+/- others), and 27.8% with Metformin alone. For those who received insulin therapy, basal prandial combination was the most frequently (52.0%) used regimen. Basal alone (32.0%) and Premix alone (12.0%) were the following most preferred regimens respectively. For those who received insulin and OGLD drugs, basal alone was the most frequently (52.5%) used regimen, followed by basal prandial combination (36.4%) and premix alone (10.1%).
In T2DM, the premixed insulin dose was higher than basal/ basal+ prandial regimen, mean basal insulin dose was 34.01 IU (0.41 IU/kg), the mean prandial insulin dose was 18.42 IU (0.21 IU/kg) and the mean premixed insulin dose was 54.43 IU (0.67 IU/kg). Self-adjustment of insulin was performed in 23.6% of patients.
56.1% patients had a glucose meter. Self-management of both blood glucose and insulin was performed in 20.0% of patients. 82.4% of T2DM patients ever received diabetes education and 77.2% were involved in an educational program provided by the physician or his/her clinical staff.
HbA1c mean was 8.16%. Only 24.7% of the T2DM patients achieved the glycemic target HbA1c lassthan 7%, and 26.6% the glycemic goals as targeted by the treating physician. Table 5 summarizes the glycemic control according to insulin regimen. The mean value at the last measurement of HbA1c for patients with insulin therapy was lower with the basal regimen or basal+ postprandial regimen than with the premix regimen: 8.73, 8.62 and 9.44 respectively. Among the patients who did not achieve glycemic goals as targeted, the reasons for non-achievement were mostly the lack of titration of insulin (57.1%) and the lack of diabetes education (49.5%).
Type 1 | Type 2 | Total | ||||||||||||
Diet and exercise alone | OGLD treatment | Insulin treatment | OGLD treatment + Insulin treatment | Total | ||||||||||
N=127 | N=1 | N=171 | N=25 | N=99 | N=296 | N=423 | ||||||||
Time since diabetes diagnosis (years) | 15.29 ± 10.17 | 2 ± .
| 8.96 ± 6.77
| 15.40 ± 9.66
| 15.76 ± 8.03
| 11.74 ± 8.17
| 12.81 ± 8.95
| |||||||
Time since diabetes diagnosis in class (years) |
| |||||||||||||
≤ 1 | 6 | (4.7%) | 0 | 8 | (4.7%) | 2 | (8.0%) | 0 | 10 | (3.4%) | 16 | (3.8%) | ||
]1;5] | 19 | (15.0%) | 1 | (100.0%) | 59 | (34.5%) | 2 | (8.0%) | 7 | (7.1%) | 69 | (23.4%) | 88 | (20.9%) |
]5;10] | 25 | (19.7%) | 0 | 50 | (29.2%) | 3 | (12.0%) | 17 | (17.3%) | 70 | (23.7%) | 95 | (22.5%) | |
]10;20] | 37 | (29.1%) | 0 | 42 | (24.6%) | 11 | (44.0%) | 55 | (56.1%) | 108 | (36.6%) | 145 | (34.4%) | |
> 20 | 40 | (31.5%) | 0 | 12 | (7.0%) | 7 | (28.0%) | 19 | (19.4%) | 38 | (12.9%) | 78 | (18.5%) | |
Family history of diabetes | 75 | (60.0%) | 0 | 110 | (71.4%) | 18 | (81.8%) | 76 | (80.0%) | 204 | (75.0%) | 279 | (70.3%) | |
Family members diabetes-diagnosed before the age of 40 years | 35 | (51.5%) | 20 | (21.1%) | 1 | (6.3%) | 6 | (10.7%) | 27 | (16.2%) | 62 | (26.4%) | ||
Weight at diagnosis of diabetes (kg) | 63.71 ± 14.78
| 95 ± . | 84.57 ± 15.23 | 76.46 ± 13.02 | 82.05 ± 14.60 | 83.30 ± 14.97
| 78.08 ± 17.23
| |||||||
Weight (kg) | 70.94 ± 13.72 | 96 ± . | 80.03 ± 13.79 | 75.10 ± 12.63 | 85.22 ± 16.82 | 81.40 ± 15.05 | 78.26 ± 15.42 | |||||||
BMI at diagnosis (kg/m²)* | 23 ± 3.89 | 33.70 ± . | 30.35 ± 5.71 | 27.23 ± 4.79 | 30.72 ± 4.79 | 30.23 ± 5.43 | 28.55 ± 5.95 | |||||||
BMI at diagnosis in class (kg/m²)* | ||||||||||||||
≤ 18.5 | 8 | (15.7%) | 0 | 1 | (0.9%) | 1 | (7.7%) | 0 | 2 | (1.2%) | 10 | (4.6%) | ||
]18.5;25] | 30 | (58.8%) | 0 | 19 | (17.8%) | 1 | (7.7%) | 6 | (12.8%) | 26 | (15.5%) | 56 | (25.6%) | |
]25;30] | 11 | (21.6%) | 0 | 32 | (29.9%) | 8 | (61.5%) | 15 | (31.9%) | 55 | (32.7%) | 66 | (30.1%) | |
]30;35] | 2 | (3.9%) | 1 | (100.0%) | 35 | (32.7%) | 3 | (23.1%) | 16 | (34.0%) | 55 | (32.7%) | 57 | (26.0%) |
> 35 | 0 | 0 | 20 | (18.7%) | 0 | 10 | (21.3%) | 30 | (17.9%) | 30 | (13.7%) | |||
BMI at inclusion (kg/m²) | 25.04 ± 4.20 | 34 ± . | 29.03 ± 4.73 | 27.54 ± 4.74 | 31.07 ± 5.66 | 29.60 ± 5.16 | 28.24 ± 5.32 | |||||||
Tendinous xanthomata | 0 | 0 | 0 | 0 | 2 | (2.0%) | 2 | (0.7%) | 2 | (0.5%) | ||||
Arcus cornealis | 1 | (0.8%) | 0 | 2 | (1.2%) | 0 | 5 | (5.2%) | 7 | (2.4%) | 8 | (1.9%) | ||
Systolic Blood Pressure (mmHg) | 120.57 ± 14.82 | 120 ± . | 129.74 ± 14.64 | 132.60 ± 10.42 | 134.20 ± 14.93 | 131.44 ± 14.53 | 128.18 ± 15.43 | |||||||
SBP in class | ||||||||||||||
SBP < 130> | 92 | (72.4%) | 1 | (100.0%) | 77 | (45.0%) | 7 | (28.0%) | 31 | (31.3%) | 116 | (39.2%) | 208 | (49.2%) |
SBP ≥ 130 mmHg | 35 | (27.6%) | 0 | 94 | (55.0%) | 18 | (72.0%) | 68 | (68.7%) | 180 | (60.8%) | 215 | (50.8%) | |
Screening for any diabetes-related complications | 121 | (96.0%) | 1 | (100.0%) | 164 | (96.5%) | 23 | (92.0%) | 98 | (99.0%) | 286 | (96.9%) | 407 | (96.7%) |
Cardiovascular disease | 57 | (45.6%) | 1 | (100.0%) | 117 | (68.4%) | 21 | (84.0%) | 69 | (71.9%) | 208 | (71.0%) | 265 | (63.4%) |
Retinopathy | 85 | (68.0%) | 0 | 124 | (72.5%) | 20 | (80.0%) | 80 | (80.8%) | 224 | (75.7%) | 309 | (73.4%) | |
Neuropathy | 82 | (65.6%) | 0 | 111 | (65.3%) | 17 | (68.0%) | 67 | (69.1%) | 195 | (66.6%) | 277 | (66.3%) | |
Kidney damage (renal function) | 106 | (84.8%) | 0 | 152 | (89.9%) | 21 | (84.0%) | 91 | (92.9%) | 264 | (90.1%) | 370 | (88.5%) | |
Kidney damage (microalbumin/proteinuria) | 83 | (66.4%) | 0 | 121 | (71.6%) | 20 | (80.0%) | 81 | (83.5%) | 222 | (76.0%) | 305 | (73.1%) | |
Diabetic foot | 86 | (69.4%) | 0 | 114 | (66.7%) | 19 | (76.0%) | 75 | (77.3%) | 208 | (70.7%) | 294 | (70.3%) | |
Lipid abnormalities | 94 | (75.2%) | 1 | (100.0%) | 153 | (90.0%) | 22 | (88.0%) | 94 | (95.9%) | 270 | (91.8%) | 364 | (86.9%) |
Blood pressure control | 111 | (88.8%) | 1 | (100.0%) | 158 | (93.5%) | 22 | (88.0%) | 96 | (98.0%) | 277 | (94.5%) | 388 | (92.8%) |
Table 2: Clinical profile of patients by type of diabetes
Type 1 N=127 | Type 2 N=296 | Total N=423 | ||||||||
OGLD treatment | OGLD treatment + Insulin treatment | Total | ||||||||
N=171 | N=99 | N=270 | N=397 | |||||||
Patient received Oral Glycaemic Lowering Drug | 8 | (6.3%) | 171 | (100.0%) | 99 | (100.0%) | 270 | (100.0%) | 278 | (70.0%) |
OGLD therapy | ||||||||||
1 OGLD | 7 | (5.5%) | 58 | (34.3%) | 63 | (63.6%) | 121 | (45.1%) | 128 | (32.4%) |
Duration of treatment for 1 OGLD (months) | 24.86 ± 32.67 | 57.36 ± 72.87 | 154.40 ± 122.82 | 107.88 ± 112.63 | 103.34 ± 111.34 | |||||
2 OGLDs | 1 | (0.8%) | 87 | (51.5%) | 24 | (24.2%) | 111 | (41.4%) | 112 | (28.4%) |
Duration of treatment for 2 OGLDs (months) | 12.00 (.) | 83.66 ± 71.97 | 122.88 ± 86.02 | 92.21 ± 76.58 | 91.49 ± 76.61 | |||||
More than 2 OGLDs | 0 | 24 | (14.2%) | 12 | (12.1%) | 36 | (13.4%) | 36 | (9.1%) | |
Duration of treatment for more than 2 OGLDs (months) | 121.88 ± 89.63 | 112.83 ± 71.76 | 118.86 ± 83.16 | 118.86 ± 83.16 | ||||||
Class of OGLDs | ||||||||||
Metformin alone | 4 | (3.1%) | 47 | (27.8%) | 56 | (56.6%) | 103 | (38.4%) | 107 | (27.1%) |
Sulphonylureas alone | 0 | 8 | (4.7%) | 1 | (1.0%) | 9 | (3.4%) | 9 | (2.3%) | |
Metformin + Sulphonylureas (+/- others) | 1 | (0.8%) | 95 | (56.2%) | 29 | (29.3%) | 124 | (46.3%) | 125 | (31.6%) |
Other | 3 | (2.4%) | 19 | (11.2%) | 13 | (13.1%) | 32 | (11.9%) | 35 | (8.9%) |
Table 3: Oral glucose-lowering drugs treatment by type of diabetes
Type 1 N=127 | Type 2 N=296 | Total N=423 | ||||||||
Insulin treatment alone | OGLD treatment + Insulin treatment | Total | ||||||||
N=25 | N=99 | N=124 | N=251 | |||||||
Patient currently treated with insulin | 127 | (100.0%) | 25 | (100.0%) | 99 | (100.0%) | 124 | (100.0%) | 251 | (100.0%) |
Duration of insulin treatment (years) | 15.18 ± 10.16 | 6.88 ± 6.36 | 4.51 ± 4.49 | 4.99 ± 4.99 | 10.17 ± 9.51 | |||||
Basal insulin | 121 | (95.3%) | 21 | (84.0%) | 89 | (89.9%) | 110 | (88.7%) | 231 | (92.0%) |
Type of basal insulin* | ||||||||||
Long acting insulin analog | 70 | (58.3%) | 15 | (71.4%) | 51 | (57.3%) | 66 | (60.0%) | 136 | (59.1%) |
Intermediate human insulin | 50 | (41.7%) | 6 | (28.6%) | 38 | (42.7%) | 44 | (40.0%) | 94 | (40.9%) |
Basal insulin daily dose (IU) | 36.10 ± 18.16 | 30.76 ± 12.48 | 34.78 ± 19.28 | 34.01 ± 18.20 | 35.10 ± 18.17 | |||||
Basal insulin daily dose (IU/kg) | 0.52 ± 0.26 | 0.41 ± 0.16 | 0.41 ± 0.23 | 0.41 ± 0.22 | 0.47 ± 0.25 | |||||
Basal insulin number of injections | 1.58 ± 0.50 | 1.35 ± 0.49 | 1.42 ± 0.50 | 1.41 ± 0.49 | 1.50 ± 0.50 | |||||
Prandial insulin | 110 | (86.6%) | 14 | (56.0%) | 36 | (36.4%) | 50 | (40.3%) | 160 | (63.7%) |
Type of prandial insulin* | ||||||||||
Short acting insulin analog | 68 | (61.8%) | 8 | (57.1%) | 19 | (52.8%) | 27 | (54.0%) | 95 | (59.4%) |
Rapid acting human insulin | 42 | (38.2%) | 6 | (42.9%) | 17 | (47.2%) | 23 | (46.0%) | 65 | (40.6%) |
Biosimilar insulin | 1 | (0.9%) | 0 | 0 | 0 | 1 | (0.6%) | |||
Prandial insulin daily dose (IU) | 23.30 ± 13.89 | 19.14 ± 12.75 | 18.42 ± 11.51 | 18.62 ± 11.74 | 21.84 ± 13.40 | |||||
Prandial insulin daily dose (IU/kg) | 0.33 ± 0.20 | 0.25 ± 0.16 | 0.21 ± 0.13 | 0.22 ± 0.14 | 0.30 ± 0.19 | |||||
Prandial insulin number of injections | 2.46 ± 0.67 | 2.14 ± 0.66 | 2.26 ± 0.71 | 2.23 ± 0.69 | 2.39 ± 0.69 | |||||
Premix insulin | 6 | (4.7%) | 3 | (12.0%) | 11 | (11.1%) | 14 | (11.3%) | 20 | (8.0%) |
Type of Premix insulin* | ||||||||||
Premixed analog insulin | 5 | (83.3%) | 2 | (66.7%) | 8 | (80.0%) | 10 | (76.9%) | 15 | (78.9%) |
Premixed human insulin | 1 | (16.7%) | 1 | (33.3%) | 2 | (20.0%) | 3 | (23.1%) | 4 | (21.1%) |
Premix insulin daily dose (IU) | 62.33 ± 15.87 | 62.00 ± 7.21 | 52.36 ± 18.44 | 54.43 ± 16.92 | 56.80 ± 16.61 | |||||
Premix insulin daily dose (IU/kg) | 0.95 ± 0.29 | 0.88 ± 0.16 | 0.62 ± 0.23 | 0.67 ± 0.24 | 0.76 ± 0.28 | |||||
Premix insulin number of injections | 2.33 ± 0.52 | 2.00 | 2.00 ± 0.45 | 2.00 ± 0.39 | 2.10 ± 0.45 | |||||
Devices used by the patient** | ||||||||||
Reusable pen | 7 | (5.5%) | 1 | (4.0%) | 3 | (3.0%) | 4 | (3.2%) | 11 | (4.4%) |
Disposable pen | 69 | (54.3%) | 14 | (56.0%) | 55 | (55.6%) | 69 | (55.6%) | 138 | (55.0%) |
Vials | 54 | (42.5%) | 11 | (44.0%) | 42 | (42.4%) | 53 | (42.7%) | 107 | (42.6%) |
Pump | 1 | (0.8%) | 0 | 0 | 0 | 1 | (0.4%) | |||
Patient self-adjust insulin dose | 76 | (59.8%) | 5 | (20.0%) | 24 | (24.5%) | 29 | (23.6%) | 105 | (42.0%) |
Combination of insulin treatment | ||||||||||
Basal alone | 12 | (9.4%) | 8 | (32.0%) | 52 | (52.5%) | 60 | (48.4%) | 72 | (28.7%) |
Prandial alone | 0 | 1 | (4.0%) | 0 | 1 | (0.8%) | 1 | (0.4%) | ||
Premix alone | 5 | (3.9%) | 3 | (12.0%) | 10 | (10.1%) | 13 | (10.5%) | 18 | (7.2%) |
Basal + Prandial | 109 | (85.8%) | 13 | (52.0%) | 36 | (36.4%) | 49 | (39.5%) | 158 | (62.9%) |
Basal + Premix | 0 | 0 | 1 | (1.0%) | 1 | (0.8%) | 1 | (0.4%) |
Table 4: Current insulin treatment by type of diabetes
Type 1 N=127 | Type 2 N=296 | Total N=423 | |||||||||||
Insulin treatment alone | OGLD treatment + Insulin treatment | Total | |||||||||||
N=127 | N=25 | N=99 | N=124 | N=251 | |||||||||
Basal alone (N) | 12 | 8 | 52 | 60 | 72 | ||||||||
Value of last HbA1c measurement (%) – Mean (SD) | 9.34 (1.87) | 9.24 (3.59) | 8.65 (1.43) | 8.73 (1.83) | 8.81 (1.83) | ||||||||
HbA1c < 7> | 1 | (12.5%) | 2 | (25.0%) | 4 | (7.8%) | 6 | (10.2%) | 7 | (10.4%) | |||
Basal + Prandial (N) | 109 | 13 | 36 | 49 | 158 | ||||||||
Value of last HbA1c measurement (%) – Mean (SD) | 8.88 (1.81) | 8.57 (2.05) | 8.64 (1.59) | 8.62 (1.70) | 8.79 (1.78) | ||||||||
HbA1c < 7> | 15 | (14.7%) | 2 | (15.4%) | 4 | (11.8%) | 6 | (12.8%) | 21 | (14.1%) | |||
Premix alone (N) | 5 | 3 | 10 | 13 | 18 | ||||||||
Value of last HbA1c measurement (%) – Mean (SD) | 9.62 (2.91) | 9.90 (2.72) | 9.30 (1.42) | 9.44 (1.68) | 9.49 (2.00) | ||||||||
HbA1c < 7> | 2 | (40.0%) | 1 | (33.3%) | 1 | (10.0%) | 2 | (15.4%) | 4 | (22.2%) | |||
Table 5: Glycaemic control per current insulin treatment by type of diabetes
Hypoglycemia
More than one out of three people living with diabetes mellitus has shown signs of hypoglycemia during the last three months, mainly in patients treated with insulin, 67.7% for T1DM, 24.6% for T2DM (33.3% in patients treated with insulins and 41.8% in patients treated with OGLD plus insulin treatment). One in ten patients experienced severe hypoglycemia in the past of 12 months, mainly in patients treated with insulin, 27.2% for T1DM and 12.5% for T2DM (Table 6). In 95.2% of cases, one of the causes is an inappropriate management of insulin therapy, whether it is the timing of the injection or the adaptation of doses: in case of physical exercise in 42.5% of cases, or relative to food intake, particularly for T2DM patients, in whom it is overestimated by one patient in three (33.3%). Thus, 11.4% required hospitalization due to the diabetes during last 12 months and in 14.6% of cases reason of hospitalization was hypoglycemia.
Type 1
| Type 2 | Total
| |||||||||
OGLD treatment alone | Insulin treatment alone | OGLD treatment + Insulin treatment | Total | ||||||||
N = 127 | N=171 | N=25 | N=99 | N=295 | N=422 | ||||||
Patient experienced any symptomatic episodes of hypoglycemia in the past 3 months | |||||||||||
N | 124 | 170 | 24 | 98 | 292 | 416 | |||||
Yes (n, %) | 84 | (67.7%) | 23 (13.5%) | 8 | (33.3%) | 41 | (41.8%) | 72 | (24.6%) | 156 | (37.4%) |
Patient experienced any severe episodes of hypoglycemia (requiring assistance) in the past 12 months | |||||||||||
N | 125 | 170 | 24 | 99 | 293 | 418 | |||||
Yes (n, %) | 34 (27.2%) | 4 (2.4%) | 3 (12,5%) | 4 (4.0%) | 11 (3,7%) | 45 (10.7%) |
Table 6: Symptomatic episodes of hypoglycemia
Adherence to insulin therapy and support programs
11.1% of diabetic patients interrupted their insulin treatment, for durations ranging from 2 to 20 months, with an average of 1.68 months for T1DM patients and 4.36 months for T2DM patients with OGLD plus insulin treatment. The main causes for this non-adherence were impact on social life for 58.6% of patients, the fear of hypoglycemia for 27.6%, episodes of hypoglycemia for 24.1%, lack of experience in insulin management for 31% and lack of support for 24.1% of patients (Table 7).
Type 1 | Type 2 | Total | ||||||||
OGLD treatment | OGLD treatment + Insulin treatment | Total | ||||||||
N=127 | N=171 | N=99 | N=270 | N=397 | ||||||
Reason of discontinuation* (N) | 20 | 2 | 7 | 9 | 29 | |||||
Lack of efficacy | 0 | 1 | (50.0%) | 0 | 1 | (11.1%) | 1 | (3.4%) | ||
Fear of hypoglycaemia | 6 | (30.0%) | 0 | 2 | (28.6%) | 2 | (22.2%) | 8 | (27.6%)
| |
Episodes of hypoglycaemia | 7 | (35.0%) | 0 | 0 | 0 | 7 | (24.1%) | |||
Occurrence of side effects | 3 | (15.0%) | 0 | 1 | (14.3%) | 1 | (11.1%) | 4 | (13.8%) | |
Impact on social life | 12 | (60.0%) | 2 | (100.0%) | 3 | (42.9%) | 5 | (55.6%) | 17 | (58.6%) |
Lack of experience in the management of insulin dosing or insulin administration | 6 | (30.0%) | 2 | (100.0%) | 1 | (14.3%) | 3 | (33.3%) | 9 | (31,0%) |
Cost of medications / strips | 6 | (30.0%) | 0 | 2 | (28.6%) | 2 | (22.2%) | 8 | (27.6%) | |
Absence of dose flexibility | 3 | (15.0%) | 0 | 0 | 0 | 3 | (10.3%) | |||
Weight gain | 3 | (15.0%) | 0 | 0 | 0 | 3 | (10.3%) | |||
Lack of support | 5 | (25.0%) | 1 | (50.0%) | 1 | (14.3%) | 2 | (22.2%) | 7 | (24.1%) |
Other reason(s) for discontinuation of insulin therapy | 4 | (20.0%) | 1 | (50.0%) | 1 | (14.3%) | 2 | (22.2%) | 6 | (20.7%) |
* A patient may have several reasons of discontinuation.
Table 7: Adherence to insulin therapy by type of diabetes
While 81.2% of clinicians consider patients may benefit from any support and that support programs exist, reaching 83.9% of diabetic people, the impact on insulin therapy management remains insufficient, as well as on dietary habits and physical activity level: 61.4% of patients did not modify them.
63.4% of people with type 2 diabetes had associated hypertension and 60.8% dyslipidemia.
A positive point to note: Tunisians seems to be little smokers. 65% have never smoked, 16.8% have stopped when the diagnosis was announced and therefore 18.2% continue to smoke despite knowing their diabetes.
Regarding the high cardiovascular risk, the triple targets pooled together HbA1c lessthan 7%, and normal blood pressure (SBP/DBP: 130/80mmHg) and LDL‐CS lessthan 100 mg/dL is strongly recommended. In Tunisia, these triple targets were reached by only 2.4% of the people T2DM. The non-achievement of the triple targets was due to HbA1c level ≥ 7% in 78.8%, abnormal blood pressure for 76.4% and LDL level ≥ 100 mg/dL for 50.8%.
According to the IDF 2021 estimates, the prevalence of diabetes in Tunisia reaches 10.8% among adults aged 20 to 79 years. However, this percentage does not reflect the real situation in the country with a proportion of 40.2% of undiagnosed diabetes [3]. Diabetic patients are at risk of developing complications that reduce quality of life, undue stress on families, and can even be life-threatening if not well managed, thus the need for stringent disease management and individualized medical care [11].
The findings of the present IDMPS wave 7 reveal a worrying clinical burden of diabetes in Tunisia, with the presence of a high cardiovascular risk in diabetic patients, particularly related to the non-achievement of the recommended target value of HbA1c, of blood pressure and of LDL by most of diabetic patients. These outcomes are consistent with the reports of the Tunisian national coronary heart disease registry, where diabetes is significantly associated with coronary heart disease, mostly in women: 50.5% vs 28.7% in men [12].
In Tunisia, according to IDMPS wave 7 results, only 24.7% of the people with T2DM reached the recommended target value of HbA1c < 7>
In the people with T2DM, those treated with insulin alone or with OGLD alone were more likely to have an HbA1c < HbA1c>
In insulin-treated patients, the glycaemic goals as targeted by the treating physician were achieved in 26.6% of the people with T2DM. Among the patients who do not achieve glycaemic goals as targeted, the reasons for non-achievement were mostly first the lack of titration of insulin (57.1%), probably due to fear from hypoglycemia more than one in three patients with diabetes mellitus has shown signs of hypoglycemia during the last three months (37.4%), mainly in patients treated with insulin, one of the causes expressed by the patients is an inappropriate management of insulin therapy. In another local registry (Hypo G study) [16] whose objective was to assess the proportion of the people with T2MD with hypoglycemia in inadequately controlled with basal insulin with high risk of hypoglycemia, 73% of them presented a hypoglycaemia event during the last month.
The results of Hypo G study may join IDMPS wave 7 results regarding hypoglycaemia as main issue for optimisation of insulin treatment and achievement of glycemic control. Although more than 8 out of 10 patients with diabetes mellitus participated in support programs, it seems that the level of knowledge and acquisition of self-care skills is still insufficient. These data should raise questions about the quality of these programs. Moreover, we must note that the majority of these programs are carried out in less than 2 hours.
Consequently, physicians should ask their patients about hypoglycemia at each visit to try to find the principal reasons involved and implement a therapeutic strategy to decrease this risk. Also, there is a need to provide more patient support and patient education to improve patient knowledge in diabetes complication and self-care skills in insulin management [17,18].
Conclusion
After comparison with the international recommendations (EASD, ADA, and IDF), it appeared that the clinical burden of diabetes in Tunisia is unsettling especially because of the non-achievement of the recommended target value of HbA1c by most patients, highlighting the need for better education of patients and more awareness of the disease particularly its complications. Moreover, clinicians probably also need to explain to them that reaching glycemic targets requires adaptation of treatment, often leading to treatment intensification and insulin optimization taking account minimisation of hypoglycemia risk. Furthermore, the high cardiovascular risk of Tunisian diabetic patients, glycemic targets need to be extended to a more global approach, including the control of any associated hypertension or dyslipidemia.
Limitations
The information presented in the study is reflective of patients accessing healthcare at the selected study site and may not be representative of the general diabetes population. Due to the descriptive nature of the data, it was not possible to determine the specific impact of variables such as medication change over time. Nevertheless, the data provide some valuable insights into diabetes management in Tunisia.
Declarations
Acknowledgement
The authors would like to thank Charfi Nadia, Professor in endocrinology university of Sfax Tunisia and Ramzy Hala, employee of Sanofi and potential shareholder of Sanofi for their great support and contribution to the study.
The authors would like to thank all the physicians and People who participated in this study.
Editorial assistance and medical writing were provided by Better Being Health SARL, Marrakech, Morocco, and was funded by Sanofi.
Availability of data and materials
"Qualified researchers may request access to patient level data and related study documents including the clinical study report, study protocol with any amendments, blank case report form, statistical analysis plan, and dataset specifications. Patient level data will be anonymized, and study documents will be redacted to protect the privacy of trial participants. Further details on Sanofi’s data sharing criteria, eligible studies, and process for requesting access can be found at: https://www.vivli.org/.
The IDMPS study protocol was approved, all followed procedures were compliant with the appropriate regulatory and ethical committees of the participating countries and centers, as well as those in Tunisia.
The study was sponsored and funded by Sanofi.
All participants provided written informed consent before entering the study.
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Abid Mohamed declares that there is no conflict of interest. Ben Aissa Emna is an employee of Sanofi and potential shareholder of Sanofi.
Both authors Professor Mohamed ABID and Emna BEN AISSA have enssured the study concept, design, data analysis and interpretation of the current manuscript.
Drafting and critical revision of the manuscript was provided by scientific writing agency Better Being Health SARL based in Morocco.
The authors assume full responsibility for the present study, and state having approved the latest version of the manuscript for publication.
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
My Testimonial Covering as fellowing: Lin-Show Chin. The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews.
My experience publishing in Psychology and Mental Health Care was exceptional. The peer review process was rigorous and constructive, with reviewers providing valuable insights that helped enhance the quality of our work. The editorial team was highly supportive and responsive, making the submission process smooth and efficient. The journal's commitment to high standards and academic rigor makes it a respected platform for quality research. I am grateful for the opportunity to publish in such a reputable journal.
My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.