Lipohypertrophy has been suggested as an outcome of lipogenic action of insulin and/or injection-related tissue trauma. In a cross-sectional study, we evaluated the predictors of lipohypertrophy in 372 type 1 diabetes patients (mean age 17.1 years) receiving subcutaneous insulin with pen and/or syringes for ≥3 months. On examining injection sites with inspection and palpation technique, 62.1% patients demonstrated lipohypertrophy. Univariate analysis showed that gender, BMI, HbA1c, injection device, rotation, injection area, needle length, insulin regimen, and total daily dose of insulin were associated with lipohypertrophy (p < 0.05). Notably, the mean needle reuse was comparable in patients with or without lipohypertrophy (8.1 vs. 7.2, p = 0.534). In multivariate logistic regression, gender, HbA1c, TDD, injection devices, and needle length lost its significance. Further, injections over smaller area (≤8.5 × 5.5 cm) and non-rotation of sites were found to be strongest independent predictor of lipohypertrophy (p < 0.0005 for both) with increased odds of 23.2 (95% CI 9.1–59.2) and 6.3 (95% CI 3.4–11.9) times, respectively. Being underweight was also a significant independent predictor (odds ratio [OR] 13.0 [95% CI 2.2–75.2], p = 0.004). Compared to rapid plus long-acting analogs, regular insulin plus long-acting analogs and conventional premixed insulin users had 3.2 (95% CI 1.5–6.8, p = 0.003) and 4.6 (95% CI 1.4–15.7, p = 0.014) fold higher risk of lipohypertrophy (mean injection frequency 4.01 vs. 4.01 vs. 2.09, respectively). Sub-group analysis showed that lipohypertrophy was 79% less likely in patients with multiple daily injections (≥4) than twice-daily regimen (OR 0.21, p < 0.0005). Moreover, lipohypertrophy was reduced to half with bolus doses of rapid-acting insulin analogs than regular insulin (p = 0.003), even though mean injection frequency was comparable (4.01 vs. 3.93, p = 0.229). This difference was statistically insignificant for basal doses with NPH or long-acting analogs (p = 0.069). Therefore, injection area, rotation, BMI, and insulin regimen are the best predictors of lipohypertrophy and together could correctly identify lipohypertrophy status in 84.4% patients with excellent discrimination capability (AUC = 0.906, p < 0.0005). In conclusion, findings of our study suggest that delivering rapidly absorbed insulin analogs over large injection area along with greater split of total daily doses reduce insulin-induced lipogenesis and outplay tissue trauma added through frequent injections and needle reuse.

Background No validated measures exist for evaluating diabetes self‐management in Indian type 1 diabetes (T1D) patients. Objective To cross culturally adapt and evaluate the psychometric properties of Hindi version of Diabetes Self‐Management Profile‐Self Report (DSMP‐SR‐Hindi) in Indian T1D patients. Methods Total 160 T1D patients and their parents participated in the study. The mean age of patients was 13.5 ± 2.5 years and HbA1c was 8.6 ± 2.2%. Results Exploratory factor analysis employing principle axis factoring with promax rotation was conducted. Monte Carlo parallel analysis identified three sub‐scales instead of five sub‐scales proposed in original version. Because of underlying ceiling and floor effects and insufficient loadings, five items were eliminated. Consequently, final Hindi version of DSMP‐SR contained 19 items from DSMP‐SR‐24. Internal consistencies were adequate for overall scale (Cronbach's α = 0.835), identified sub‐scales (Cronbach's α = 0.702‐0.802) and comparable between genders. DSMP‐19 total scores (r = −0.74) and three subscales correlated significantly with HbA1c (SMBG and Corrective Adjustments [r = −0.58], Exercise [r = −0.48], and Conformity to Diet and Insulin Routine [r = −0.64]). For every one SD improvement (11.2 marks) in DSMP‐SR‐Hindi score, odds of falling into poor glycaemic group (HbA1c > 7.5%) dropped to 0.242 times (95% CI 0.144‐0.405; P < .001). Conclusions DSMP‐SR‐Hindi is a reliable and valid self‐report measure of diabetes self‐management behavior in Indian T1D patients. The revealed three subscales are reliable to use in isolation and across the genders. It will help in monitoring patient's progress in stepwise manner, ranging from their basic understanding of prescribed regimen to taking advance corrective actions in face of altered needs.

A301treatment option(s), or filtration surgery. Treatment strategy change probabilities were identified by a clinician panel. Direct costs were included for drugs, procedures,

DescriptionA 15-year-old boy with a 3-year history of type 1 diabetes mellitus was referred to endocrinology clinic for the management of uncontrolled blood glucose levels. His present treatment plan comprised subcutaneous basal-bolus insulin regimen. He was taking regular insulin before the three major meals and insulin glargine at the bedtime. His body mass index (BMI) was 14.8 kg/m 2 and HbA1c level 14.9%, suggesting uncontrolled hyperglycaemia for a long time.On examination, he was found to have remarkably prominent bilateral lipohypertrophic areas on the lower abdomen (figure 1), large enough to be noticeable even through the clothing.His injection practices revealed that he was self-administering insulin over the abdomen with the syringe of needle size 6 mm, apparently leading to intramuscular injection in a thin-built person. 1 Furthermore, he was drawing his recommended dose of basal insulin with the 40 IU/mL syringe out of a vial of 100 IU/mL strength resulting into 2.5 times of the prescribed amount. However, the match between insulin syringe and strength was appropriate for the bolus doses.He was injecting in the area measured to be around 8.5×5.5 cm on either side of the lower abdomen approximating the size of a credit card. He preferred this area, as injections at this site were painless. In addition, he was not performing systematic site rotation within a quadrant of abdominal area by leaving a space of 1 cm for the subsequent injections. Moreover, one syringe was reportedly used on an average six times. Missing the doses of insulin along with the habit of injecting into lipohypertrophic lesions caused one episode of diabetic ketoacidosis requiring hospitalisation 2 weeks prior to this visit.Patient was managed using talk, inspect and educate strategy followed by our endocrinology clinic considering the high prevalence of insulin-related lipohypertrophy in Indian patients. 2Readdressing correct injection technique is very important to curb lipohypertrophy and its consequences. Therefore, the systematic rotation (figure 2) and practice of injections in larger area were explained to the patient. He was also directed to discontinue injections into lipohypertrophic lesions and advised to inject into the normal tissue. It was further recommended to reduce the dose of insulin, guided by self-monitoring of blood glucose, for avoiding hypoglycaemia while shifting to normal site. Patient was educated about the importance of adhering to Insulin-mediated lipohypertrophy: an uncommon cause of diabetic ketoacidosis Learning pointsCreate TIE (Talk, Inspect and Educate) with the patient ► Talk to the patients and their families regarding diabetes management to understand the ongoing challenges faced by them. ► Inspect the injection sites on regular basis for the early detection of lipohypertrophy. ► Educate the patients and their families about importance of proper insulin injection practice.

P< 0.001). ConClusions: Despite limitations of our study especially related to reasons for prescribing different drugs, we note that a large proportion of older patients are still prescribed with medications that potentially cause hypoglycaemia, in particular, sulphonylureas and beta-blockers. This finding is to remind doctors to proceed with caution in treating the elderly when treating the elderly with certain medications.