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Arnqvist HJ, Ludvigsson J, Nordwall M. Early increase in HbA1c trajectory predicts development of severe microangiopathy in patients with type 1 diabetes: the VISS study. BMJ Open Diabetes Res Care 2024; 12:e003917. [PMID: 38719508 PMCID: PMC11085680 DOI: 10.1136/bmjdrc-2023-003917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 04/18/2024] [Indexed: 05/12/2024] Open
Abstract
INTRODUCTION To study the HbA1c trajectory from the time of diagnosis to examine if patients at the greatest risk for severe microangiopathy can be identified early allowing clinicians to intervene as soon as possible to avoid complications. RESEARCH DESIGN AND METHODS In a population-based observational study, 447 patients diagnosed with type 1 diabetes before 35 years of age, 1983-1987, were followed from diagnosis until 2019. Mean HbA1c was calculated each year for each patient. Severe diabetic microangiopathy was defined as proliferative diabetic retinopathy (PDR) or macroalbuminuria (nephropathy). RESULTS After 32 years, 27% had developed PDR and 8% macroalbuminuria. Patients with weighted HbA1c (wHbA1c); <57 mmol/mol; <7.4% did not develop PDR or macroalbuminuria. The HbA1c trajectories for patients developing PDR and macroalbuminuria follow separate courses early on and stay separated for 32 years during the follow-up. Patients without severe complications show an initial dip, after which HbA1c slowly increases. HbA1c in patients with severe complications directly rises to a high level within a few years. Mean HbA1c calculated for the period 5-8 years after diabetes onset strongly predicts the development of severe complications. Females with childhood-onset diabetes exhibit a high peak in HbA1c during adolescence associated with higher wHbA1c and higher prevalence of PDR. CONCLUSIONS The HbA1c trajectory from diabetes onset shows that mean HbA1c for the period 5-8 years after diagnosis strongly predicts severe microangiopathy. Females with childhood-onset diabetes exhibit a high peak in HbA1c during adolescence associated with higher wHbA1c and a higher prevalence of PDR.
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Affiliation(s)
- Hans J Arnqvist
- Division of Endocrinology, Department of Biomedical and Clinical Sciences, Linköping University, Linkoping, Sweden
| | - Johnny Ludvigsson
- Division of Pediatrics, Department of Biomedical and Clinical Sciences, Linköping University, Linkoping, Sweden
- Crown Princess Victoria Childrens Hospital, Linköping, Sweden
| | - Maria Nordwall
- Division of Pediatrics, Department of Biomedical and Clinical Sciences, Linköping University, Linkoping, Sweden
- Division of Pediatrics, Vrinnevi Hospital in Norrköping, Norrkoping, Sweden
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2
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Prahalad P, Scheinker D, Desai M, Ding VY, Bishop FK, Lee MY, Ferstad J, Zaharieva DP, Addala A, Johari R, Hood K, Maahs DM. Equitable implementation of a precision digital health program for glucose management in individuals with newly diagnosed type 1 diabetes. Nat Med 2024:10.1038/s41591-024-02975-y. [PMID: 38702523 DOI: 10.1038/s41591-024-02975-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 04/03/2024] [Indexed: 05/06/2024]
Abstract
Few young people with type 1 diabetes (T1D) meet glucose targets. Continuous glucose monitoring improves glycemia, but access is not equitable. We prospectively assessed the impact of a systematic and equitable digital-health-team-based care program implementing tighter glucose targets (HbA1c < 7%), early technology use (continuous glucose monitoring starts <1 month after diagnosis) and remote patient monitoring on glycemia in young people with newly diagnosed T1D enrolled in the Teamwork, Targets, Technology, and Tight Control (4T Study 1). Primary outcome was HbA1c change from 4 to 12 months after diagnosis; the secondary outcome was achieving the HbA1c targets. The 4T Study 1 cohort (36.8% Hispanic and 35.3% publicly insured) had a mean HbA1c of 6.58%, 64% with HbA1c < 7% and mean time in the range (70-180 mg dl-1) of 68% at 1 year after diagnosis. Clinical implementation of the 4T Study 1 met the prespecified primary outcome and improved glycemia without unexpected serious adverse events. The strategies in the 4T Study 1 can be used to implement systematic and equitable care for individuals with T1D and translate to care for other chronic diseases. ClinicalTrials.gov registration: NCT04336969 .
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Affiliation(s)
- Priya Prahalad
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA, USA.
- Stanford Diabetes Research Center, Stanford University, Stanford, CA, USA.
| | - David Scheinker
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA, USA
- Stanford Diabetes Research Center, Stanford University, Stanford, CA, USA
- Department of Management Science and Engineering, Stanford University, Stanford, CA, USA
- Clinical Excellence Research Center, Stanford University, Stanford, CA, USA
| | - Manisha Desai
- Department of Medicine, Quantitative Sciences Unit, Stanford University, Stanford, CA, USA
| | - Victoria Y Ding
- Department of Medicine, Quantitative Sciences Unit, Stanford University, Stanford, CA, USA
| | - Franziska K Bishop
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA, USA
- Stanford Diabetes Research Center, Stanford University, Stanford, CA, USA
| | - Ming Yeh Lee
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA, USA
| | - Johannes Ferstad
- Department of Management Science and Engineering, Stanford University, Stanford, CA, USA
| | - Dessi P Zaharieva
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA, USA
| | - Ananta Addala
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA, USA
- Stanford Diabetes Research Center, Stanford University, Stanford, CA, USA
| | - Ramesh Johari
- Stanford Diabetes Research Center, Stanford University, Stanford, CA, USA
- Department of Management Science and Engineering, Stanford University, Stanford, CA, USA
| | - Korey Hood
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA, USA
- Stanford Diabetes Research Center, Stanford University, Stanford, CA, USA
| | - David M Maahs
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA, USA
- Stanford Diabetes Research Center, Stanford University, Stanford, CA, USA
- Department of Health Research and Policy (Epidemiology), Stanford University, Stanford, CA, USA
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Straton E, Bryant BL, Kang L, Wang C, Barber J, Perkins A, Gallant L, Marks B, Agarwal S, Majidi S, Monaghan M, Streisand R. ROUTE-T1D: A behavioral intervention to promote optimal continuous glucose monitor use among racially minoritized youth with type 1 diabetes: Design and development. Contemp Clin Trials 2024; 140:107493. [PMID: 38460913 PMCID: PMC11065587 DOI: 10.1016/j.cct.2024.107493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 02/13/2024] [Accepted: 03/05/2024] [Indexed: 03/11/2024]
Abstract
BACKGROUND Type 1 diabetes management is often challenging during adolescence, and many youth with type 1 diabetes struggle with sustained and optimal continuous glucose monitor (CGM) use. Due to racial oppression and racially discriminatory policies leading to inequitable access to quality healthcare and life necessities, racially minoritized youth are significantly less likely to use CGM. METHODS ROUTE-T1D: Research on Optimizing the Use of Technology with Education is a pilot behavioral intervention designed to promote optimal CGM use among racially minoritized youth with type 1 diabetes. Intervention strategies include problem solving CGM challenges and promoting positive caregiver-youth communication related to CGM data. RESULTS This randomized waitlist intervention provides participants with access to three telemedicine sessions with a Certified Diabetes Care and Education Specialist. Caregiver participants are also connected with a peer-parent coach. CONCLUSION Hypothesized findings and anticipated challenges are discussed. Future directions regarding sustaining and optimizing the use of diabetes technology among racially minoritized pediatric populations are reviewed.
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Affiliation(s)
- Emma Straton
- Children's National Hospital, Washington DC, United States of America
| | - Breana L Bryant
- Children's National Hospital, Washington DC, United States of America
| | - Leyi Kang
- Children's National Hospital, Washington DC, United States of America
| | - Christine Wang
- Children's National Hospital, Washington DC, United States of America
| | - John Barber
- Children's National Hospital, Washington DC, United States of America
| | - Amanda Perkins
- Children's National Hospital, Washington DC, United States of America
| | - Letitia Gallant
- Children's National Hospital, Washington DC, United States of America
| | - Brynn Marks
- Children's Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Shivani Agarwal
- Albert Einstein College of Medicine, Bronx, NY, United States of America
| | - Shideh Majidi
- Children's National Hospital, Washington DC, United States of America; The George Washington University School of Medicine, Washington, DC, United States of America
| | - Maureen Monaghan
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, United States of America
| | - Randi Streisand
- Children's National Hospital, Washington DC, United States of America; The George Washington University School of Medicine, Washington, DC, United States of America.
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4
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Zaharieva DP, Ding VY, Addala A, Prahalad P, Bishop F, Hood KK, Desai M, Wilson DM, Buckingham BA, Maahs DM. Diabetic Ketoacidosis at Diagnosis in Youth with Type 1 Diabetes Is Associated with a Higher Hemoglobin A1c Even with Intensive Insulin Management. Diabetes Technol Ther 2024; 26:176-183. [PMID: 37955644 PMCID: PMC10877392 DOI: 10.1089/dia.2023.0405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Introduction: Diabetic ketoacidosis (DKA) at diagnosis is associated with short- and long-term complications. We assessed the relationship between DKA status and hemoglobin A1c (A1c) levels in the first year following type 1 diabetes (T1D) diagnosis. Research Design and Methods: The Pilot Teamwork, Targets, Technology, and Tight Control (4T) study offered continuous glucose monitoring to youth with T1D within 1 month of diagnosis. A1c levels were compared between historical (n = 271) and Pilot 4T (n = 135) cohorts stratified by DKA status at diagnosis (DKA: historical = 94, 4T = 67 versus without DKA: historical = 177, 4T = 68). A1c was evaluated using locally estimated scatter plot smoothing. Change in A1c from 4 to 12 months postdiagnosis was evaluated using a linear mixed model. Results: Median age was 9.7 (interquartile range [IQR]: 6.6, 12.7) versus 9.7 (IQR: 6.8, 12.7) years, 49% versus 47% female, 44% versus 39% non-Hispanic White in historical versus Pilot 4T. In historical and 4T cohorts, DKA at diagnosis demonstrated higher A1c at 6 (0.5% [95% confidence interval (CI): 0.21-0.79; P < 0.01] and 0.38% [95% CI: 0.02-0.74; P = 0.04], respectively), and 12 months (0.62% [95% CI: -0.06 to 1.29; P = 0.07] and 0.39% [95% CI: -0.32 to 1.10; P = 0.29], respectively). The highest % time in range (TIR; 70-180 mg/dL) was seen between weeks 15-20 (69%) versus 25-30 (75%) postdiagnosis for youth with versus without DKA in Pilot 4T, respectively. Conclusions: Pilot 4T improved A1c outcomes versus the historical cohort, but those with DKA at diagnosis had persistently elevated A1c throughout the study and intensive diabetes management did not mitigate this difference. DKA prevention at diagnosis may translate into better glycemic outcomes in the first-year postdiagnosis. Clinical Trial Registration: clinicaltrials.gov: NCT04336969.
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Affiliation(s)
- Dessi P. Zaharieva
- Division of Pediatric Endocrinology, Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Victoria Y. Ding
- Division of Biomedical Informatics Research, Department of Medicine, Stanford University, Stanford, California, USA
| | - Ananta Addala
- Division of Pediatric Endocrinology, Department of Pediatrics, Stanford University, Stanford, California, USA
- Stanford Diabetes Research Center, Stanford University, Stanford, California, USA
| | - Priya Prahalad
- Division of Pediatric Endocrinology, Department of Pediatrics, Stanford University, Stanford, California, USA
- Stanford Diabetes Research Center, Stanford University, Stanford, California, USA
| | - Franziska Bishop
- Division of Pediatric Endocrinology, Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Korey K. Hood
- Division of Pediatric Endocrinology, Department of Pediatrics, Stanford University, Stanford, California, USA
- Stanford Diabetes Research Center, Stanford University, Stanford, California, USA
| | - Manisha Desai
- Division of Biomedical Informatics Research, Department of Medicine, Stanford University, Stanford, California, USA
| | - Darrell M. Wilson
- Division of Pediatric Endocrinology, Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Bruce A. Buckingham
- Division of Pediatric Endocrinology, Department of Pediatrics, Stanford University, Stanford, California, USA
| | - David M. Maahs
- Division of Pediatric Endocrinology, Department of Pediatrics, Stanford University, Stanford, California, USA
- Stanford Diabetes Research Center, Stanford University, Stanford, California, USA
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Leverenz JC, Leverenz B, Prahalad P, Bishop FK, Sagan P, Martinez-Singh A, Conrad B, Chmielewski A, Senaldi J, Scheinker D, Maahs DM. Role and Perspective of Certified Diabetes Care and Education Specialists in the Development of the 4T Program. Diabetes Spectr 2024; 37:153-159. [PMID: 38756427 PMCID: PMC11093765 DOI: 10.2337/ds23-0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Affiliation(s)
- Jeannine C. Leverenz
- Lucile Packard Children’s Hospital, Division of Pediatric Endocrinology, Palo Alto, CA
| | - Brianna Leverenz
- Stritch School of Medicine, Loyola University Chicago, Maywood, IL
| | - Priya Prahalad
- Lucile Packard Children’s Hospital, Division of Pediatric Endocrinology, Palo Alto, CA
- Division of Endocrinology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, CA
- Stanford Diabetes Research Center, Stanford, CA
| | - Franziska K. Bishop
- Division of Endocrinology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, CA
| | - Piper Sagan
- Lucile Packard Children’s Hospital, Division of Pediatric Endocrinology, Palo Alto, CA
| | - Anjoli Martinez-Singh
- Lucile Packard Children’s Hospital, Division of Pediatric Endocrinology, Palo Alto, CA
| | - Barry Conrad
- Lucile Packard Children’s Hospital, Division of Pediatric Endocrinology, Palo Alto, CA
| | - Annette Chmielewski
- Lucile Packard Children’s Hospital, Division of Pediatric Endocrinology, Palo Alto, CA
| | - Julianne Senaldi
- Lucile Packard Children’s Hospital, Division of Pediatric Endocrinology, Palo Alto, CA
| | - David Scheinker
- Division of Endocrinology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, CA
| | - David M. Maahs
- Lucile Packard Children’s Hospital, Division of Pediatric Endocrinology, Palo Alto, CA
- Division of Endocrinology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, CA
- Stanford Diabetes Research Center, Stanford, CA
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6
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Castorani V, Favalli V, Rigamonti A, Frontino G, Di Tonno R, Morotti E, Sandullo F, Scialabba F, Arrigoni F, Dionisi B, Foglino R, Morosini C, Olivieri G, Barera G, Meschi F, Bonfanti R. A comparative study using insulin pump therapy and continuous glucose monitoring in newly diagnosed very young children with type 1 diabetes: it is possible to bend the curve of HbA1c. Acta Diabetol 2023; 60:1719-1726. [PMID: 37526745 DOI: 10.1007/s00592-023-02155-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 07/03/2023] [Indexed: 08/02/2023]
Abstract
AIMS The target of metabolic control (HbA1c < 7% or 53 mmol/mol) recommended by the ADA and ISPAD is attained by 30% of children with Type 1 Diabetes (T1D). Advances in technologies for T1D aim to improve metabolic outcomes and reduce complications. This observational study assesses the long-term outcomes of advanced technologies for treatment of T1D compared to conventional approach started at onset in a group of very young children with T1D. METHODS 54 patients with less 4 years old at onset of T1D were enrolled and followed for up to 9 years after diagnosis. 24 subjects started continuous subcutaneous insulin (CSII) treatment and 30 subjects received MDI therapy from onset. Auxological data, HbA1c and total daily insulin dose (TDD/kg) have been collected at admission and every 4 months. HbA1cAUC>6%, rates of acute complications, glycemic variability indices and glucometrics were also recorded. RESULTS Patients with CSII therapy had significantly lower mean HbA1c values compared to subjects receiving MDI treatment. CSII approach also recorded lower mean HbA1cAUC>6% and TDD/kg than MDI therapy. At the last download data, the time in range (TIR) was higher in patients with CSII and hyperglycemia events were lower. Better glycemic variability indices have been described during CSII therapy, including mean glycemia, standard deviation, coefficient of variation (CV), glycemia risk index (GRI) and high blood glucose index (HBGI). There was no statistically significant difference between frequency of severe hypoglycemia and ketoacidosis episodes between groups. CONCLUSIONS Early initiation of diabetes technologies is safe and able to determine a better long term glycemic control in young children with T1D. It also allows to flatten the trajectory of HbA1c, probably reducing microvascular, macrovascular and neurological complications of diabetes in this very peculiar age group.
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Affiliation(s)
- Valeria Castorani
- Department of Pediatrics, Pediatric Diabetology Unit, Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, Vita Salute San Raffaele University, Via Olgettina, 60, 20132, Milan, Italy
| | - Valeria Favalli
- Department of Pediatrics, Pediatric Diabetology Unit, Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, Vita Salute San Raffaele University, Via Olgettina, 60, 20132, Milan, Italy
| | - Andrea Rigamonti
- Department of Pediatrics, Pediatric Diabetology Unit, Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, Vita Salute San Raffaele University, Via Olgettina, 60, 20132, Milan, Italy
| | - Giulio Frontino
- Department of Pediatrics, Pediatric Diabetology Unit, Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, Vita Salute San Raffaele University, Via Olgettina, 60, 20132, Milan, Italy
| | - Raffaella Di Tonno
- Department of Pediatrics, Pediatric Diabetology Unit, Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, Vita Salute San Raffaele University, Via Olgettina, 60, 20132, Milan, Italy
| | - Elisa Morotti
- Department of Pediatrics, Pediatric Diabetology Unit, Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, Vita Salute San Raffaele University, Via Olgettina, 60, 20132, Milan, Italy
| | - Federica Sandullo
- Department of Pediatrics, Pediatric Diabetology Unit, Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, Vita Salute San Raffaele University, Via Olgettina, 60, 20132, Milan, Italy
| | - Francesco Scialabba
- Department of Pediatrics, Pediatric Diabetology Unit, Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, Vita Salute San Raffaele University, Via Olgettina, 60, 20132, Milan, Italy
| | - Francesca Arrigoni
- Department of Pediatrics, Pediatric Diabetology Unit, Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, Vita Salute San Raffaele University, Via Olgettina, 60, 20132, Milan, Italy
| | - Benedetta Dionisi
- Department of Pediatrics, Pediatric Diabetology Unit, Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, Vita Salute San Raffaele University, Via Olgettina, 60, 20132, Milan, Italy
| | - Riccardo Foglino
- Department of Pediatrics, Pediatric Diabetology Unit, Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, Vita Salute San Raffaele University, Via Olgettina, 60, 20132, Milan, Italy
| | - Camilla Morosini
- Department of Pediatrics, Pediatric Diabetology Unit, Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, Vita Salute San Raffaele University, Via Olgettina, 60, 20132, Milan, Italy
| | - Gabriele Olivieri
- Department of Pediatrics, Pediatric Diabetology Unit, Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, Vita Salute San Raffaele University, Via Olgettina, 60, 20132, Milan, Italy
| | - Graziano Barera
- Department of Pediatrics, Pediatric Diabetology Unit, Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, Vita Salute San Raffaele University, Via Olgettina, 60, 20132, Milan, Italy
| | - Franco Meschi
- Department of Pediatrics, Pediatric Diabetology Unit, Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, Vita Salute San Raffaele University, Via Olgettina, 60, 20132, Milan, Italy
| | - Riccardo Bonfanti
- Department of Pediatrics, Pediatric Diabetology Unit, Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, Vita Salute San Raffaele University, Via Olgettina, 60, 20132, Milan, Italy.
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7
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Prahalad P, Maahs DM. Roadmap to Continuous Glucose Monitoring Adoption and Improved Outcomes in Endocrinology: The 4T (Teamwork, Targets, Technology, and Tight Control) Program. Diabetes Spectr 2023; 36:299-305. [PMID: 37982062 PMCID: PMC10654131 DOI: 10.2337/dsi23-0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
Glucose monitoring is essential for the management of type 1 diabetes and has evolved from urine glucose monitoring in the early 1900s to home blood glucose monitoring in the 1980s to continuous glucose monitoring (CGM) today. Youth with type 1 diabetes struggle to meet A1C goals; however, CGM is associated with improved A1C in these youth and is recommended as a standard of care by diabetes professional organizations. Despite their utility, expanding uptake of CGM systems has been challenging, especially in minoritized communities. The 4T (Teamwork, Targets, Technology, and Tight Control) program was developed using a team-based approach to set consistent glycemic targets and equitably initiate CGM and remote patient monitoring in all youth with new-onset type 1 diabetes. In the pilot 4T study, youth in the 4T cohort had a 0.5% improvement in A1C 12 months after diabetes diagnosis compared with those in the historical cohort. The 4T program can serve as a roadmap for other multidisciplinary pediatric type 1 diabetes clinics to increase CGM adoption and improve glycemic outcomes.
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Affiliation(s)
- Priya Prahalad
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA
- Stanford Diabetes Research Center, Stanford University, Stanford, CA
| | - David M. Maahs
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA
- Stanford Diabetes Research Center, Stanford University, Stanford, CA
- Department of Health Research and Policy (Epidemiology), Stanford University, Stanford, CA
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8
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Fang Q, Shi J, Zhang J, Peng Y, Liu C, Wei X, Hu Z, Sun L, Hong J, Gu W, Wang W, Zhang Y. Visit-to-visit HbA1c variability is associated with aortic stiffness progression in participants with type 2 diabetes. Cardiovasc Diabetol 2023; 22:167. [PMID: 37415203 PMCID: PMC10324236 DOI: 10.1186/s12933-023-01884-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 06/11/2023] [Indexed: 07/08/2023] Open
Abstract
BACKGROUND Glycemic variability plays an important role in the development of cardiovascular disease (CVD). This study aims to determine whether long-term visit-to-visit glycemic variability is associated with aortic stiffness progression in participants with type 2 diabetes (T2D). METHODS Prospective data were obtained from 2115 T2D participants in the National Metabolic Management Center (MMC) from June 2017 to December 2022. Two brachial-ankle pulse wave velocity (ba-PWV) measurements were performed to assess aortic stiffness over a mean follow-up period of 2.6 years. A multivariate latent class growth mixed model was applied to identify trajectories of blood glucose. Logistic regression models were used to determine the odds ratio (OR) for aortic stiffness associated with glycemic variability evaluated by the coefficient of variation (CV), variability independent of the mean (VIM), average real variability (ARV), and successive variation (SV) of blood glucose. RESULTS Four distinct trajectories of glycated hemoglobin (HbA1c) or fasting blood glucose (FBG) were identified. In the U-shape class of HbA1c and FBG, the adjusted ORs were 2.17 and 1.21 for having increased/persistently high ba-PWV, respectively. Additionally, HbA1c variability (CV, VIM, SV) was significantly associated with aortic stiffness progression, with ORs ranging from 1.20 to 1.24. Cross-tabulation analysis indicated that the third tertile of the HbA1c mean and VIM conferred a 78% (95% confidence interval [CI] 1.23-2.58) higher odds of aortic stiffness progression. Sensitivity analysis demonstrated that the SD of HbA1c and the highest HbA1c variability score (HVS) were significantly associated with the adverse outcomes independent of the mean of HbA1c during the follow-up. CONCLUSIONS Long-term visit-to-visit HbA1c variability was independently associated with aortic stiffness progression, suggesting that HbA1c variability was a strong predictor of subclinical atherosclerosis in T2D participants.
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Affiliation(s)
- Qianhua Fang
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai National Clinical Research Center for Metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission of the PR China, Shanghai Key Laboratory for Endocrine Tumor, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Juan Shi
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai National Clinical Research Center for Metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission of the PR China, Shanghai Key Laboratory for Endocrine Tumor, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jia Zhang
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai National Clinical Research Center for Metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission of the PR China, Shanghai Key Laboratory for Endocrine Tumor, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ying Peng
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai National Clinical Research Center for Metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission of the PR China, Shanghai Key Laboratory for Endocrine Tumor, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Cong Liu
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai National Clinical Research Center for Metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission of the PR China, Shanghai Key Laboratory for Endocrine Tumor, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xing Wei
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai National Clinical Research Center for Metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission of the PR China, Shanghai Key Laboratory for Endocrine Tumor, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhuomeng Hu
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai National Clinical Research Center for Metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission of the PR China, Shanghai Key Laboratory for Endocrine Tumor, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lin Sun
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai National Clinical Research Center for Metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission of the PR China, Shanghai Key Laboratory for Endocrine Tumor, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jie Hong
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai National Clinical Research Center for Metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission of the PR China, Shanghai Key Laboratory for Endocrine Tumor, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weiqiong Gu
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai National Clinical Research Center for Metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission of the PR China, Shanghai Key Laboratory for Endocrine Tumor, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weiqing Wang
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
- Shanghai National Clinical Research Center for Metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission of the PR China, Shanghai Key Laboratory for Endocrine Tumor, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Yifei Zhang
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
- Shanghai National Clinical Research Center for Metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission of the PR China, Shanghai Key Laboratory for Endocrine Tumor, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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9
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Tremblay ES, Bernique A, Garvey K, Astley CM. A Retrospective Cohort Study of Racial/Ethnic and Socioeconomic Disparities in Initiation and Meaningful Use of Continuous Glucose Monitoring among Youth With Type 1 Diabetes. J Diabetes Sci Technol 2023:19322968231183985. [PMID: 37394962 DOI: 10.1177/19322968231183985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
BACKGROUND Continuous glucose monitor (CGM) use improves type 1 diabetes (T1D) outcomes, yet children from diverse backgrounds and on public insurance have worse outcomes and lower CGM utilization. Using novel CGM data acquisition and analysis of two T1D cohorts, we test the hypothesis that T1D youth from different backgrounds experience disparities in meaningful CGM use following both T1D diagnosis and CGM uptake. METHODS Cohorts drawn from a pediatric T1D program were followed for one year beginning at diagnosis (n = 815, 2016-2020) or CGM uptake (n = 1392, 2015-2020). Using chart and CGM data, CGM start and meaningful use outcomes between racial/ethnic and insurance groups were compared using median days, one-year proportions, and survival analysis. RESULTS Publicly compared with privately insured were slower to start CGM (233, 151 days, P < .01), had fewer use-days in the year following uptake (232, 324, P < .001), and had faster first discontinuation rates (hazard ratio [HR] = 1.61, P < .001). Disparities were more pronounced among Hispanic and black compared with white subjects for CGM start time (312, 289, 149, P = .0013) and discontinuation rates (Hispanic HR = 2.17, P < .001; black HR = 1.45, P = .038), and remained even among privately insured (Hispanic/black HR = 1.44, P = .0286). CONCLUSIONS Given the impact of insurance and race/ethnicity on CGM initiation and use, it is imperative that we target interventions to support universal access and sustained CGM use to mitigate the potential impact of provider biases and systemic disadvantage and racism. By enabling more equitable and meaningful T1D technology use, such interventions will begin to alleviate outcome disparities between youth with T1D from different backgrounds.
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Affiliation(s)
- Elise Schlissel Tremblay
- Division of Endocrinology, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Allison Bernique
- Division of Endocrinology, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Katherine Garvey
- Division of Endocrinology, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Christina M Astley
- Division of Endocrinology, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Computational Epidemiology Lab, Boston Children's Hospital, Boston, MA, USA
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
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10
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Sandblom L, Kapadia C, Vaidya V, Chambers M, Gonsalves R, Holzmeister LA, Hoekstra F, Goldman S. Electronic Dashboard to Improve Outcomes in Pediatric Patients With Type 1 Diabetes Mellitus. J Diabetes Sci Technol 2023:19322968231159401. [PMID: 37026186 DOI: 10.1177/19322968231159401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
BACKGROUND AND OBJECTIVES Incidence of type 1 diabetes mellitus (T1DM) is increasing, and these patients often have poor glycemic control. Electronic dashboards summating patient data have been shown to improve patient outcomes in other conditions. In addition, educating patients on T1DM has shown to improve glycated hemoglobin (A1C) levels. We hypothesized that using data from the electronic dashboard to monitor defined diabetes management activities to implement population-based interventions would improve patient outcomes. METHODS Inclusion criteria included patients aged 0 to 18 years at Phoenix Children's Hospital with T1DM. Patient data were collected via the electronic dashboard, and both diabetes management activities (A1C, patient admissions, and visits to the emergency department) and patient outcomes (patient education, appointment compliance, follow-up after hospital admission) were analyzed. RESULTS This study revealed that following implementation of the electronic dashboard, the percentage of patients receiving appropriate education increased from 48% to 80% (Z-score = 23.55, P < .0001), the percentage of patients attending the appropriate number of appointments increased from 50% to 68.2%, and the percentage of patients receiving follow-up care within 40 days after a hospital admission increased from 43% to 70%. The median A1C level decreased from 9.1% to 8.2% (Z-score = -6.74, P < .0001), and patient admissions and visits to the emergency department decreased by 20%. CONCLUSIONS This study shows, with the implementation of an electronic dashboard, we were able to improve outcomes for our pediatric patients with T1DM. This tool can be used at other institutions to improve care and outcomes for pediatric patients with T1DM and other chronic conditions.
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Affiliation(s)
- Lily Sandblom
- University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
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11
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Addala A, Ding V, Zaharieva DP, Bishop FK, Adams AS, King AC, Johari R, Scheinker D, Hood KK, Desai M, Maahs DM, Prahalad P. Disparities in Hemoglobin A1c Levels in the First Year After Diagnosis Among Youths With Type 1 Diabetes Offered Continuous Glucose Monitoring. JAMA Netw Open 2023; 6:e238881. [PMID: 37074715 PMCID: PMC10116368 DOI: 10.1001/jamanetworkopen.2023.8881] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 03/05/2023] [Indexed: 04/20/2023] Open
Abstract
Importance Continuous glucose monitoring (CGM) is associated with improvements in hemoglobin A1c (HbA1c) in youths with type 1 diabetes (T1D); however, youths from minoritized racial and ethnic groups and those with public insurance face greater barriers to CGM access. Early initiation of and access to CGM may reduce disparities in CGM uptake and improve diabetes outcomes. Objective To determine whether HbA1c decreases differed by ethnicity and insurance status among a cohort of youths newly diagnosed with T1D and provided CGM. Design, Setting, and Participants This cohort study used data from the Teamwork, Targets, Technology, and Tight Control (4T) study, a clinical research program that aims to initiate CGM within 1 month of T1D diagnosis. All youths with new-onset T1D diagnosed between July 25, 2018, and June 15, 2020, at Stanford Children's Hospital, a single-site, freestanding children's hospital in California, were approached to enroll in the Pilot-4T study and were followed for 12 months. Data analysis was performed and completed on June 3, 2022. Exposures All eligible participants were offered CGM within 1 month of diabetes diagnosis. Main Outcomes and Measures To assess HbA1c change over the study period, analyses were stratified by ethnicity (Hispanic vs non-Hispanic) or insurance status (public vs private) to compare the Pilot-4T cohort with a historical cohort of 272 youths diagnosed with T1D between June 1, 2014, and December 28, 2016. Results The Pilot-4T cohort comprised 135 youths, with a median age of 9.7 years (IQR, 6.8-12.7 years) at diagnosis. There were 71 boys (52.6%) and 64 girls (47.4%). Based on self-report, participants' race was categorized as Asian or Pacific Islander (19 [14.1%]), White (62 [45.9%]), or other race (39 [28.9%]); race was missing or not reported for 15 participants (11.1%). Participants also self-reported their ethnicity as Hispanic (29 [21.5%]) or non-Hispanic (92 [68.1%]). A total of 104 participants (77.0%) had private insurance and 31 (23.0%) had public insurance. Compared with the historical cohort, similar reductions in HbA1c at 6, 9, and 12 months postdiagnosis were observed for Hispanic individuals (estimated difference, -0.26% [95% CI, -1.05% to 0.43%], -0.60% [-1.46% to 0.21%], and -0.15% [-1.48% to 0.80%]) and non-Hispanic individuals (estimated difference, -0.27% [95% CI, -0.62% to 0.10%], -0.50% [-0.81% to -0.11%], and -0.47% [-0.91% to 0.06%]) in the Pilot-4T cohort. Similar reductions in HbA1c at 6, 9, and 12 months postdiagnosis were also observed for publicly insured individuals (estimated difference, -0.52% [95% CI, -1.22% to 0.15%], -0.38% [-1.26% to 0.33%], and -0.57% [-2.08% to 0.74%]) and privately insured individuals (estimated difference, -0.34% [95% CI, -0.67% to 0.03%], -0.57% [-0.85% to -0.26%], and -0.43% [-0.85% to 0.01%]) in the Pilot-4T cohort. Hispanic youths in the Pilot-4T cohort had higher HbA1c at 6, 9, and 12 months postdiagnosis than non-Hispanic youths (estimated difference, 0.28% [95% CI, -0.46% to 0.86%], 0.63% [0.02% to 1.20%], and 1.39% [0.37% to 1.96%]), as did publicly insured youths compared with privately insured youths (estimated difference, 0.39% [95% CI, -0.23% to 0.99%], 0.95% [0.28% to 1.45%], and 1.16% [-0.09% to 2.13%]). Conclusions and Relevance The findings of this cohort study suggest that CGM initiation soon after diagnosis is associated with similar improvements in HbA1c for Hispanic and non-Hispanic youths as well as for publicly and privately insured youths. These results further suggest that equitable access to CGM soon after T1D diagnosis may be a first step to improve HbA1c for all youths but is unlikely to eliminate disparities entirely. Trial Registration ClinicalTrials.gov Identifier: NCT04336969.
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Affiliation(s)
- Ananta Addala
- Division of Pediatric Endocrinology, Department of Pediatrics, Stanford University, Stanford, California
| | - Victoria Ding
- Division of Biomedical Informatics Research, Department of Medicine, Stanford University, Stanford, California
| | - Dessi P. Zaharieva
- Division of Pediatric Endocrinology, Department of Pediatrics, Stanford University, Stanford, California
| | - Franziska K. Bishop
- Division of Pediatric Endocrinology, Department of Pediatrics, Stanford University, Stanford, California
| | - Alyce S. Adams
- Division of Pediatric Endocrinology, Department of Pediatrics, Stanford University, Stanford, California
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California
- Department of Health Policy, Stanford University School of Medicine, Stanford, California
- Stanford Diabetes Research Center, Stanford University, Stanford, California
| | - Abby C. King
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California
- Stanford Prevention Research Center Division, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Ramesh Johari
- Clinical Excellence Research Center, Stanford University, Stanford, California
| | - David Scheinker
- Division of Pediatric Endocrinology, Department of Pediatrics, Stanford University, Stanford, California
- Stanford Diabetes Research Center, Stanford University, Stanford, California
- Clinical Excellence Research Center, Stanford University, Stanford, California
- Department of Management Science and Engineering, Stanford University, Stanford, California
| | - Korey K. Hood
- Division of Pediatric Endocrinology, Department of Pediatrics, Stanford University, Stanford, California
- Stanford Diabetes Research Center, Stanford University, Stanford, California
| | - Manisha Desai
- Division of Biomedical Informatics Research, Department of Medicine, Stanford University, Stanford, California
| | - David M. Maahs
- Division of Pediatric Endocrinology, Department of Pediatrics, Stanford University, Stanford, California
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California
- Stanford Diabetes Research Center, Stanford University, Stanford, California
| | - Priya Prahalad
- Division of Pediatric Endocrinology, Department of Pediatrics, Stanford University, Stanford, California
- Stanford Diabetes Research Center, Stanford University, Stanford, California
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12
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Maahs DM, Prahalad P, Schweiger DŠ, Shalitin S. Diabetes Technology and Therapy in the Pediatric Age Group. Diabetes Technol Ther 2023; 25:S118-S145. [PMID: 36802194 DOI: 10.1089/dia.2023.2508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
- David M Maahs
- Department of Pediatrics, Division of Endocrinology and Diabetes, Stanford University, Stanford, CA, USA
- Stanford Diabetes Research Center, Stanford University, Stanford, CA, USA
- Department of Health Research and Policy (Epidemiology), Stanford University, Stanford, CA, USA
| | - Priya Prahalad
- Department of Pediatrics, Division of Endocrinology and Diabetes, Stanford University, Stanford, CA, USA
- Stanford Diabetes Research Center, Stanford University, Stanford, CA, USA
| | - Darja Šmigoc Schweiger
- University Medical Center-University Children's Hospital Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Shlomit Shalitin
- Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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13
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Patton SR, Maahs D, Prahalad P, Clements MA. Psychosocial Needs for Newly Diagnosed Youth with Type 1 Diabetes and Their Families. Curr Diab Rep 2022; 22:385-392. [PMID: 35727439 PMCID: PMC9211050 DOI: 10.1007/s11892-022-01479-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/07/2022] [Indexed: 11/23/2022]
Abstract
PURPOSE OF REVIEW To synthesize findings from studies published within the last 5 to 10 years and recruiting families of children with new-onset type 1 diabetes (T1D). RECENT FINDINGS Children can establish glycated hemoglobin (HbA1c) trajectories in the new-onset period that may persist for up to a decade. Demographic factors, family conflict, and diabetic ketoacidosis at the time of diagnosis may be risk factors for sub-optimal child HbA1c, while new immune modulating therapies and a treatment approach that combines advanced technologies and remote patient monitoring may improve child HbA1c. Nonetheless, recent trials in the new-onset period have largely overlooked how treatments may impact families' psychosocial functioning and longitudinal observational studies have been limited. The new-onset period of T1D is an important time for research and clinical intervention, though gaps exist specific to families' psychosocial needs. Filling these gaps is essential to inform clinical management and standard of care guidelines and improve outcomes.
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Affiliation(s)
- Susana R. Patton
- grid.472715.20000 0000 9331 5327Center for Healthcare Delivery Science, Nemours Children’s Health, 807 Children’s Way, Jacksonville, FL 32207 USA
| | - David Maahs
- grid.168010.e0000000419368956Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA 94304 USA
- grid.168010.e0000000419368956Stanford Diabetes Research Center, Stanford University, Stanford, CA 94304 USA
- grid.168010.e0000000419368956Department of Health Research and Policy (Epidemiology), Stanford University, Stanford, CA 94304 USA
| | - Priya Prahalad
- grid.168010.e0000000419368956Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA 94304 USA
- grid.168010.e0000000419368956Stanford Diabetes Research Center, Stanford University, Stanford, CA 94304 USA
| | - Mark A. Clements
- grid.239559.10000 0004 0415 5050Department of Pediatrics, Division of Endocrinology and Diabetes, Children’s Mercy Kansas City, 2401 Gilham Road, Kansas City, MO 64108 USA
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14
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Prahalad P, Ding VY, Zaharieva DP, Addala A, Johari R, Scheinker D, Desai M, Hood K, Maahs DM. Teamwork, Targets, Technology, and Tight Control in Newly Diagnosed Type 1 Diabetes: the Pilot 4T Study. J Clin Endocrinol Metab 2022; 107:998-1008. [PMID: 34850024 PMCID: PMC8947228 DOI: 10.1210/clinem/dgab859] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Youth with type 1 diabetes (T1D) do not meet glycated hemoglobin A1c (HbA1c) targets. OBJECTIVE This work aimed to assess HbA1c outcomes in children with new-onset T1D enrolled in the Teamwork, Targets, Technology and Tight Control (4T) Study. METHODS HbA1c levels were compared between the 4T and historical cohorts. HbA1c differences between cohorts were estimated using locally estimated scatter plot smoothing (LOESS). The change from nadir HbA1c (month 4) to 12 months post diagnosis was estimated by cohort using a piecewise mixed-effects regression model accounting for age at diagnosis, sex, ethnicity, and insurance type. We recruited 135 youth with newly diagnosed T1D at Stanford Children's Health. Starting July 2018, all youth within the first month of T1D diagnosis were offered continuous glucose monitoring (CGM) initiation and remote CGM data review was added in March 2019. The main outcomes measure was HbA1c. RESULTS HbA1c at 6, 9, and 12 months post diagnosis was lower in the 4T cohort than in the historic cohort (-0.54% to -0.52%, and -0.58%, respectively). Within the 4T cohort, HbA1c at 6, 9, and 12 months post diagnosis was lower in those patients with remote monitoring than those without (-0.14%, -0.18% to -0.14%, respectively). Multivariable regression analysis showed that the 4T cohort experienced a significantly lower increase in HbA1c between months 4 and 12 (P < .001). CONCLUSION A technology-enabled, team-based approach to intensified new-onset education involving target setting, CGM initiation, and remote data review statistically significantly decreased HbA1c in youth with T1D 12 months post diagnosis.
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Affiliation(s)
- Priya Prahalad
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, California 94304, USA
- Stanford Diabetes Research Center, Stanford University, Stanford, California 94304, USA
- Correspondence: Priya Prahalad, MD, PhD, Department of Pediatrics, Division of Pediatric Endocrinology, Center for Academic Medicine, 453 Quarry Rd, Palo Alto, CA 94304, USA.
| | - Victoria Y Ding
- Department of Medicine, Division of Biomedical Informatics Research, Stanford University, Stanford, California 94304, USA
| | - Dessi P Zaharieva
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, California 94304, USA
| | - Ananta Addala
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, California 94304, USA
| | - Ramesh Johari
- Stanford Diabetes Research Center, Stanford University, Stanford, California 94304, USA
- Department of Management Science and Engineering, Stanford University, Stanford, California 94304, USA
| | - David Scheinker
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, California 94304, USA
- Stanford Diabetes Research Center, Stanford University, Stanford, California 94304, USA
- Department of Management Science and Engineering, Stanford University, Stanford, California 94304, USA
- Clinical Excellence Research Center, Stanford University, Stanford, California 94304, USA
| | - Manisha Desai
- Department of Medicine, Division of Biomedical Informatics Research, Stanford University, Stanford, California 94304, USA
| | - Korey Hood
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, California 94304, USA
- Stanford Diabetes Research Center, Stanford University, Stanford, California 94304, USA
| | - David M Maahs
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, California 94304, USA
- Stanford Diabetes Research Center, Stanford University, Stanford, California 94304, USA
- Department of Health Research and Policy (Epidemiology) Stanford University, Stanford, California 94304, USA
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15
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Prahalad P, Schwandt A, Besançon S, Mohan M, Obermannova B, Kershaw M, Bonfanti R, Lyckå AP, Hanas R, Casteels K. Hemoglobin A1c trajectories in the first 18 months after diabetes diagnosis in the SWEET diabetes registry. Pediatr Diabetes 2022; 23:228-236. [PMID: 34779090 DOI: 10.1111/pedi.13278] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 10/26/2021] [Accepted: 11/03/2021] [Indexed: 11/30/2022] Open
Abstract
AIM A majority of youth with type 1 diabetes do not meet recommended hemoglobin A1c (HbA1c) targets. The SWEET diabetes registry is a multi-national registry of youth with diabetes. We used data from this registry to identify characteristics associated with glycemic control. METHODS Patients in the SWEET diabetes registry with at least one HbA1c value within 10 days of diagnosis and three follow up measurements in the first 18 months of diagnosis were included (~10% of the SWEET diabetes registry). Locally weighted scatterplot smoothing was used to generate curves of HbA1c. Wilcoxon, Kruskal-Wallis, or χ2-tests were used to calculate differences between groups. RESULTS The mean HbA1c of youth in the SWEET diabetes registry is highest at diagnosis and lowest between months 4 and 5 post-diabetes diagnosis. HbA1c continues to increase steadily through the first 18 months of diagnosis. There are no differences in HbA1c trajectories based on sex or use of diabetes technology. Youth in North America/Australia/New Zealand had the highest HbA1c throughout the first 18 months of diagnosis. The trajectory of youth from countries with nationalized health insurance was lower than those countries without nationalized health insurance. Youth from countries with the highest gross domestic product (GDP) had the highest HbA1c throughout the first 18 months of diagnosis. CONCLUSIONS In this subset of patients, the trajectory of youth from countries with nationalized health insurance was lower than those countries without nationalized health insurance. High GDP and high use of technology did not seem to protect from a higher trajectory.
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Affiliation(s)
- Priya Prahalad
- Division of Pediatric Endocrinology, Stanford University, Stanford, California, USA.,Stanford Diabetes Research Center, Stanford, California, USA
| | - Anke Schwandt
- Institute of Epidemiology and Medical Biometry, ZIBMT, Ulm University, Ulm, Germany.,German Centre for Diabetes Research (DZD), Neuherberg, Germany
| | - Stéphane Besançon
- NGO Santé Diabète Headquarter France and Delegation in Mali, Grenoble, France
| | - Meena Mohan
- Department of Endocrinology, PSG Super Speciality Hospitals, Coimbatore, India
| | - Barbora Obermannova
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Melanie Kershaw
- Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Riccardo Bonfanti
- Pediatric Diabetes, Diabetes Research Institute, Ospedale San Raffaele Milano, Milan, Italy
| | - Auste Pundziute Lyckå
- Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ragnar Hanas
- Department of Pediatrics, NU Hospital Group, Uddevalla, Sweden.,Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Kristina Casteels
- Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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16
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Hobbs A, Thus M, Couper J, Tham E, Fairchild J. Does introduction of continuous glucose monitoring at diagnosis of type 1 diabetes increase uptake in children and adolescents? Pediatr Diabetes 2022; 23:98-103. [PMID: 34820964 DOI: 10.1111/pedi.13293] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 10/05/2021] [Accepted: 11/14/2021] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To assess whether introduction of continuous glucose monitoring (CGM) at diagnosis of type 1 diabetes (T1D), leads to greater uptake and continuation at 12 and 24 months, in a population-based pediatric diabetes clinic. RESEARCH DESIGN AND METHODS All T1D children and adolescents diagnosed in the 12 months following full government subsidization of CGM were offered CGM from diagnosis at Women's and Children's Hospital, SA (Cohort 1). Uptake and continuation of CGM was compared to those diagnosed in the preceding year, who were started on CGM after diagnosis, but otherwise had identical diabetes management (Cohort 2). Demographic and clinical data were collected prospectively. The primary outcome variable was CGM wear >75% of the time at 12 and 24 months. RESULTS In Cohort 1, 84% were started on CGM at diagnosis. 88% had commenced CGM by 12 months and 90% by 24 months. In Cohort 2, CGM was started on average 10 months after diagnosis (range 1-25 months), with 81% started on CGM within 24 months of subsidization. At 24 months, 78% of Cohort 1 and 66% of Cohort 2 were wearing CGM >75% of the time (p = 0.26), higher than the WCH Clinic as a whole (58%). There was no difference in HbA1c between cohorts. CONCLUSION Starting CGM at diagnosis of T1D is feasible and well received by families, with high uptake across all ages. Although CGM continuation (wearing CGM >75% of the time) was slightly higher in Cohort 1 than Cohort 2, this did not reach statistical significance.
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Affiliation(s)
- Annabelle Hobbs
- Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Maree Thus
- Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Jennifer Couper
- Women's and Children's Hospital, Adelaide, South Australia, Australia.,Robinson Research Institute, University of Adelaide, Adelaide, South Australia, Australia
| | - Elaine Tham
- Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Jan Fairchild
- Women's and Children's Hospital, Adelaide, South Australia, Australia
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17
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Franceschi R, Cauvin V, Stefani L, Berchielli F, Soffiati M, Maines E. Early Initiation of Intermittently Scanned Continuous Glucose Monitoring in a Pediatric Population With Type 1 Diabetes: A Real World Study. Front Endocrinol (Lausanne) 2022; 13:907517. [PMID: 35784525 PMCID: PMC9247237 DOI: 10.3389/fendo.2022.907517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 05/18/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Use of Continuous Glucose Monitoring (CGM) systems early in the course of diabetes has the potential to help glycemic management and to improve quality of life (QoL). No previous research has examined these outcomes in children-adolescents with type 1 diabetes (T1D) who use intermittently scanned CGM (isCGM) starting within the first month after diagnosis. AIM To evaluate the impact of isCGM early after T1D diagnosis, on metabolic control and QoL, comparing a group who started the use of the device within one month from the onset with another one who started at least one year later. SUBJECTS AND METHODS Patients who used isCGM within 1 month from T1D diagnosis were enrolled in group A; those who didn't have the device during the first year were considered as control group (group B). HbA1c and total daily insulin were evaluated at 3 (T1), 6 (T2) and 12 (T3) months post-baseline (T0, diabetes onset), QoL after 1 year. In group A, isCGM glucose metrics were also recorded. RESULTS 85 patients were enrolled in group A and 67 patients in group B. In group A isCGM was well accepted during follow up: no patient dropped out; percentage of time with active sensor was in mean > 87%; number of scans/day remained stable. QoL was higher in group A than in group B both in children-adolescents (p<0.0001) and in parents (p 0.003). Group A presented lower HbA1c during the first year after diagnosis (p<0.001), and this data correlated with glucose management indicator (GMI), time in range (TIR) and mean glucose. The honeymoon period lasted more in group A than in B (p 0.028). Furthermore, the mean hypoglycemia duration decreased during follow-up (p 0.001) in group A. CONCLUSIONS Early use of isCGM, starting within the first month after diagnosis, improves metabolic control and QoL in pediatric patients with T1D.
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Affiliation(s)
- Roberto Franceschi
- Pediatric Diabetology Unit, Pediatric Department, S. Chiara General Hospital, Trento, Italy
- *Correspondence: Roberto Franceschi,
| | - Vittoria Cauvin
- Pediatric Diabetology Unit, Pediatric Department, S. Chiara General Hospital, Trento, Italy
| | - Lorenza Stefani
- Pediatric Diabetology Unit, Pediatric Department, S. Chiara General Hospital, Trento, Italy
| | | | - Massimo Soffiati
- Pediatric Diabetology Unit, Pediatric Department, S. Chiara General Hospital, Trento, Italy
| | - Evelina Maines
- Pediatric Diabetology Unit, Pediatric Department, S. Chiara General Hospital, Trento, Italy
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Zaharieva DP, Senanayake R, Brown C, Watkins B, Loving G, Prahalad P, Ferstad JO, Guestrin C, Fox EB, Maahs DM, Scheinker D. Adding glycemic and physical activity metrics to a multimodal algorithm-enabled decision-support tool for type 1 diabetes care: Keys to implementation and opportunities. Front Endocrinol (Lausanne) 2022; 13:1096325. [PMID: 36714600 PMCID: PMC9877334 DOI: 10.3389/fendo.2022.1096325] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 12/15/2022] [Indexed: 01/15/2023] Open
Abstract
Algorithm-enabled patient prioritization and remote patient monitoring (RPM) have been used to improve clinical workflows at Stanford and have been associated with improved glucose time-in-range in newly diagnosed youth with type 1 diabetes (T1D). This novel algorithm-enabled care model currently integrates continuous glucose monitoring (CGM) data to prioritize patients for weekly reviews by the clinical diabetes team. The use of additional data may help clinical teams make more informed decisions around T1D management. Regular exercise and physical activity are essential to increasing cardiovascular fitness, increasing insulin sensitivity, and improving overall well-being of youth and adults with T1D. However, exercise can lead to fluctuations in glycemia during and after the activity. Future iterations of the care model will integrate physical activity metrics (e.g., heart rate and step count) and physical activity flags to help identify patients whose needs are not fully captured by CGM data. Our aim is to help healthcare professionals improve patient care with a better integration of CGM and physical activity data. We hypothesize that incorporating exercise data into the current CGM-based care model will produce specific, clinically relevant information such as identifying whether patients are meeting exercise guidelines. This work provides an overview of the essential steps of integrating exercise data into an RPM program and the most promising opportunities for the use of these data.
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Affiliation(s)
- Dessi P. Zaharieva
- Division of Endocrinology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, CA, United States
- *Correspondence: Dessi P. Zaharieva,
| | - Ransalu Senanayake
- Department of Computer Science, Stanford University, Stanford, CA, United States
| | - Conner Brown
- Stanford Children’s Health, Lucile Packard Children’s Hospital, Stanford, CA, United States
| | - Brendan Watkins
- Stanford Children’s Health, Lucile Packard Children’s Hospital, Stanford, CA, United States
| | - Glenn Loving
- Stanford Children’s Health, Lucile Packard Children’s Hospital, Stanford, CA, United States
| | - Priya Prahalad
- Division of Endocrinology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, CA, United States
- Stanford Diabetes Research Center, Stanford University, Stanford, CA, United States
| | - Johannes O. Ferstad
- Department of Management Science and Engineering, Stanford University School of Engineering, Stanford, CA, United States
| | - Carlos Guestrin
- Department of Computer Science, Stanford University, Stanford, CA, United States
| | - Emily B. Fox
- Department of Computer Science, Stanford University, Stanford, CA, United States
- Chan Zuckerberg Biohub, San Francisco, CA, United States
- Department of Statistics, Stanford University, Stanford, CA, United States
| | - David M. Maahs
- Division of Endocrinology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, CA, United States
- Stanford Diabetes Research Center, Stanford University, Stanford, CA, United States
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford, CA, United States
| | - David Scheinker
- Division of Endocrinology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, CA, United States
- Stanford Children’s Health, Lucile Packard Children’s Hospital, Stanford, CA, United States
- Stanford Diabetes Research Center, Stanford University, Stanford, CA, United States
- Department of Management Science and Engineering, Stanford University School of Engineering, Stanford, CA, United States
- Clinical Excellence Research Center, Stanford University School of Medicine, Stanford, CA, United States
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19
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Addala A, Zaharieva DP, Gu AJ, Prahalad P, Scheinker D, Buckingham B, Hood KK, Maahs DM. Clinically Serious Hypoglycemia Is Rare and Not Associated With Time-in-range in Youth With New-onset Type 1 Diabetes. J Clin Endocrinol Metab 2021; 106:3239-3247. [PMID: 34265059 PMCID: PMC8530719 DOI: 10.1210/clinem/dgab522] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Indexed: 02/06/2023]
Abstract
CONTEXT Early initiation of continuous glucose monitoring (CGM) is advocated for youth with type 1 diabetes (T1D). Data to guide CGM use on time-in-range (TIR), hypoglycemia, and the role of partial clinical remission (PCR) are limited. OBJECTIVE Our aims were to assess whether 1) an association between increased TIR and hypoglycemia exists, and 2) how time in hypoglycemia varies by PCR status. METHODS We analyzed 80 youth who were started on CGM shortly after T1D diagnosis and were followed for up to 1-year post diagnosis. TIR and hypoglycemia rates were determined by CGM data and retrospectively analyzed. PCR was defined as (visit glycated hemoglobin A1c) + (4*units/kg/day) less than 9. RESULTS Youth were started on CGM 8.0 (interquartile range, 6.0-13.0) days post diagnosis. Time spent at less than 70 mg/dL remained low despite changes in TIR (highest TIR 74.6 ± 16.7%, 2.4 ± 2.4% hypoglycemia at 1 month post diagnosis; lowest TIR 61.3 ± 20.3%, 2.1 ± 2.7% hypoglycemia at 12 months post diagnosis). No events of severe hypoglycemia occurred. Hypoglycemia was rare and there was minimal difference for PCR vs non-PCR youth (54-70 mg/dL: 1.8% vs 1.2%, P = .04; < 54mg/dL: 0.3% vs 0.3%, P = .55). Approximately 50% of the time spent in hypoglycemia was in the 65 to 70 mg/dL range. CONCLUSION As TIR gradually decreased over 12 months post diagnosis, hypoglycemia was limited with no episodes of severe hypoglycemia. Hypoglycemia rates did not vary in a clinically meaningful manner by PCR status. With CGM being started earlier, consideration needs to be given to modifying CGM hypoglycemia education, including alarm settings. These data support a trial in the year post diagnosis to determine alarm thresholds for youth who wear CGM.
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Affiliation(s)
- Ananta Addala
- Division of Endocrinology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, California, USA
- Correspondence: Ananta Addala, DO, MPH, Division of Endocrinology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, CA 94305, USA.
| | - Dessi P Zaharieva
- Division of Endocrinology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, California, USA
| | - Angela J Gu
- Division of Endocrinology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, California, USA
- Department of Management Science and Engineering, Stanford University, Stanford, California, USA
| | - Priya Prahalad
- Division of Endocrinology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, California, USA
- Stanford Diabetes Research Center, Stanford, California, USA
| | - David Scheinker
- Division of Endocrinology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, California, USA
- Department of Management Science and Engineering, Stanford University, Stanford, California, USA
- Stanford Diabetes Research Center, Stanford, California, USA
| | - Bruce Buckingham
- Division of Endocrinology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, California, USA
- Stanford Diabetes Research Center, Stanford, California, USA
| | - Korey K Hood
- Division of Endocrinology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, California, USA
- Stanford Diabetes Research Center, Stanford, California, USA
| | - David M Maahs
- Division of Endocrinology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, California, USA
- Stanford Diabetes Research Center, Stanford, California, USA
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20
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Case H, Williams DD, Majidi S, Ferro D, Clements MA, Patton SR. Longitudinal associations between family conflict, parent engagement, and metabolic control in children with recent-onset type 1 diabetes. BMJ Open Diabetes Res Care 2021; 9:9/1/e002461. [PMID: 34645616 PMCID: PMC8515442 DOI: 10.1136/bmjdrc-2021-002461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 09/26/2021] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION We prospectively investigated the associations between diabetes-related family conflict, parent engagement in child type 1 diabetes (T1D) care, and child glycated hemoglobin (HbA1c) in 127 families of school-age children who we recruited within the first year of their T1D diagnosis. RESEARCH DESIGN AND METHODS Parents completed the Diabetes Family Conflict Scale-Revised (DFCS-R) to assess for diabetes-related family conflict and the Diabetes Self-Management Questionnaire-Brief (DSMQ-Brief) to assess parent engagement in child T1D care at the initial study visit (T1) and at 12 (T2) and 27 (T3) months later. We also collected child HbA1c at these time points. Our analyses included Pearson correlations and repeated measures linear mixed models controlling for child age, sex, and T1D duration at T1. RESULTS Parents' DFCS-R scores negatively correlated with DSMQ-Brief scores (r=-0.13, p<0.05) and positively correlated with children's HbA1c (r=0.26, p<0.001). In our linear mixed models, parents' DSMQ-Brief scores were unchanged at T2 (β=-0.71, 95% CI -1.59 to 0.16) and higher at T3 (β=8.01, 95% CI 6.89 to 9.13) compared with T1, and there was an association between increasing DFCS-R and decreasing DSMQ-Brief scores (β=-0.14, 95% CI -0.21 to -0.06). Child HbA1c values were significantly higher at T2 (β=0.66, 95% CI 0.38 to 0.94) and T3 (β=0.95, 95% CI 0.63 to 1.27) compared with T1, and there was an association between increasing DFCS-R scores and increasing child HbA1c (β=0.04, 95% CI 0.02 to 0.06). CONCLUSIONS Increasing diabetes-specific family conflict early in T1D may associate with decreasing parent engagement in child T1D care and increasing child HbA1c, suggesting a need to assess and intervene on diabetes-specific family conflict. Trial registration number NCT03698708.
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Affiliation(s)
- Hannah Case
- Mayo Clinic Alix School of Medicine, Mayo Clinic Hospital Jacksonville, Jacksonville, Florida, USA
| | - David D Williams
- Division of Health Services and Health Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
| | - Shideh Majidi
- Barbara Davis Center for Diabetes and the University of Colorado Anschutz School of Medicine, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA
| | - Diana Ferro
- Division of Health Services and Health Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
| | - Mark Allen Clements
- Pediatrics, Endocrinology, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
| | - Susana R Patton
- Center for Healthcare Delivery Science, Nemours Children's Health System, Jacksonville, Florida, USA
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21
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Patton SR, Feldman K, Majidi S, Noser A, Clements MA. Identifying HbA1c trajectories and modifiable risk factors of trajectories in 5- to 9-year-olds with recent-onset type 1 diabetes from the United States. Diabet Med 2021; 38:e14637. [PMID: 34240466 PMCID: PMC8373785 DOI: 10.1111/dme.14637] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 06/17/2021] [Accepted: 07/07/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To explore glycated haemoglobin (HbA1c) patterns in 5- to 9-year-olds in the recent-onset period of type 1 diabetes and identify parent psychosocial factors that may predict children's HbA1c trajectory using a prospective, longitudinal design. RESEARCH DESIGN AND METHODS We measured family demographics and parent psychosocial factors at baseline. We collected HbA1c levels from children every 3 months for up to 30 months. Deriving several features around HbA1c trends, we used k-means clustering to group trajectories and linear and logistic regressions to identify parent psychosocial predictors of children's HbA1c trajectories. RESULTS The final cohort included 106 families (48 boys, mean child age 7.50 ± 1.35 years and mean diabetes duration 4.71 ± 3.19 months). We identified four unique HbA1c trajectories in children: high increasing, high stable, intermediate increasing and low stable. Compared to a low stable trajectory, increasing parent-reported hypoglycaemia fear total score was associated with decreased odds of having a high stable or intermediate increasing trajectory. Increasing parent-reported diabetes-specific family conflict total score was associated with increased odds of having a high stable or intermediate increasing trajectory. CONCLUSIONS We are the first to identify distinct HbA1c trajectories in 5- to 9-year-olds with recent-onset type 1 diabetes as well as parent psychosocial factors that may predict high stable or increasing trajectories and could represent future treatment targets.
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Affiliation(s)
- Susana R Patton
- Department of Pediatrics, University of Kansas Medical Center, Kansas City, KS, USA
| | - Keith Feldman
- Division of Health Outcomes and Health Services Research, Children's Mercy Hospital and Clinics, Kansas City, MO, USA
| | - Shideh Majidi
- Barbara Davis Center for Childhood Diabetes, University of Colorado Anschatz Medical Campus, Aurora, CO, USA
| | - Amy Noser
- Clinical Child Psychology Program, University of Kansas, Lawrence, KS, USA
| | - Mark A Clements
- Division of Endocrinology, Children's Mercy Hospital and Clinics, Kansas City, MO, USA
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22
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Sherr JL, Schwandt A, Phelan H, Clements MA, Holl RW, Benitez-Aguirre PZ, Miller KM, Woelfle J, Dover T, Maahs DM, Fröhlich-Reiterer E, Craig ME. Hemoglobin A1c Patterns of Youth With Type 1 Diabetes 10 Years Post Diagnosis From 3 Continents. Pediatrics 2021; 148:peds.2020-048942. [PMID: 34315809 PMCID: PMC8785705 DOI: 10.1542/peds.2020-048942] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Distinct hemoglobin A1c (HbA1c) trajectories during puberty are identified in youth with established type 1 diabetes (T1D). We used data from 3 international registries to evaluate whether distinct HbA1c trajectories occur from T1D onset. METHODS Participants were <18 years old at diagnosis with at least 1 HbA1c measured within 12 months post diagnosis, along with ≥3 duration-year-aggregated HbA1c values over 10 years of follow-up. Participants from the Australasian Diabetes Data Network (n = 7292), the German-Austrian-Luxembourgian-Swiss diabetes prospective follow-up initiative (Diabetes Patienten Verlaufsdokumentation) (n = 39 226) and the US-based Type 1 Diabetes Exchange Clinic Registry (n = 3704) were included. With group-based trajectory modeling, we identified unique HbA1c patterns from the onset of T1D. RESULTS Five distinct trajectories occurred in all 3 registries, with similar patterns of proportions by group. More than 50% had stable HbA1c categorized as being either low stable or intermediate stable. Conversely, ∼15% in each registry were characterized by stable HbA1c >8.0% (high stable), and ∼11% had values that began at or near the target but then increased (target increase). Only ∼5% of youth were above the target from diagnosis, with an increasing HbA1c trajectory over time (high increase). This group differed from others, with higher rates of minority status and an older age at diagnosis across all 3 registries (P ≤ .001). CONCLUSIONS Similar postdiagnostic HbA1c patterns were observed across 3 international registries. Identifying the youth at the greatest risk for deterioration in HbA1c over time may allow clinicians to intervene early, and more aggressively, to avert increasing HbA1c.
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Affiliation(s)
- Jennifer L. Sherr
- Division of Pediatric Endocrinology, Department of Pediatrics,
Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Anke Schwandt
- Institute of Epidemiology and Medical Biometry, Zentralinstitut
für Biomedizinische Technik, Ulm University, Ulm, Germany,German Centre for Diabetes Research, Munich-Neuherberg,
Germany
| | - Helen Phelan
- John Hunter Children’s Hospital, Newcastle,
Australia,Division of Child and Adolescent Health, The University of
Sydney, Sydney, Australia
| | - Mark A. Clements
- Children’s Mercy Hospital, Kansas City, Missouri,Department of Pediatrics, University of Missouri-Kansas City,
Kansas City, Missouri
| | - Reinhard W. Holl
- Institute of Epidemiology and Medical Biometry, Zentralinstitut
für Biomedizinische Technik, Ulm University, Ulm, Germany,German Centre for Diabetes Research, Munich-Neuherberg,
Germany
| | - Paul Z. Benitez-Aguirre
- Division of Child and Adolescent Health, The University of
Sydney, Sydney, Australia,Children’s Hospital at Westmead, Sydney, Australia
| | | | - Joachim Woelfle
- Children’s Hospital, University of Erlangen, Erlangen,
Germany
| | - Thomas Dover
- Ipswich Hospital, Brisbane, Australia,Mater Hospitals, Brisbane, Australia
| | - David M. Maahs
- Stanford Diabetes Research Center,Division of Endocrinology and Diabetes, Department of
Pediatrics, School of Medicine, Stanford University, Stanford, California
| | - Elke Fröhlich-Reiterer
- Department of Pediatrics and Adolescent Medicine, Medical
University of Graz, Graz, Austria
| | - Maria E. Craig
- Division of Child and Adolescent Health, The University of
Sydney, Sydney, Australia,Children’s Hospital at Westmead, Sydney, Australia
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23
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Sun R, Banerjee I, Sang S, Joseph J, Schneider J, Hernandez-Boussard T. Type 1 Diabetes Management With Technology: Patterns of Utilization and Effects on Glucose Control Using Real-World Evidence. Clin Diabetes 2021; 39:284-292. [PMID: 34421204 PMCID: PMC8329015 DOI: 10.2337/cd20-0098] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This retrospective cohort study evaluated diabetes device utilization and the effectiveness of these devices for newly diagnosed type 1 diabetes. Investigators examined the use of continuous glucose monitoring (CGM) systems, self-monitoring of blood glucose (SMBG), continuous subcutaneous insulin infusion (CSII), and multiple daily injection (MDI) insulin regimens and their effects on A1C. The researchers identified 6,250 patients with type 1 diabetes, of whom 32% used CGM and 37.1% used CSII. A higher adoption rate of either CGM or CSII in newly diagnosed type 1 diabetes was noted among White patients and those with private health insurance. CGM users had lower A1C levels than nonusers (P = 0.039), whereas no difference was noted between CSII users and nonusers (P = 0.057). Furthermore, CGM use combined with CSII yielded lower A1C than MDI regimens plus SMBG (P <0.001).
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Affiliation(s)
- Ran Sun
- Department of Medicine, Stanford University, Stanford, CA
| | - Imon Banerjee
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, GA
- Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, GA
| | - Shengtian Sang
- Department of Medicine, Stanford University, Stanford, CA
| | | | | | - Tina Hernandez-Boussard
- Department of Medicine, Stanford University, Stanford, CA
- Department of Biomedical Data Sciences, Stanford University, Stanford, CA
- Department of Surgery, Stanford University, Stanford, CA
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24
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Marker AM, Monzon AD, Goggin K, Clements MA, Patton SR. Parent Perspectives on Educational and Psychosocial Intervention for Recent-Onset Type 1 Diabetes in Their School-Age Child: A Qualitative Study. Diabetes Spectr 2021; 34:166-174. [PMID: 34149257 PMCID: PMC8178719 DOI: 10.2337/ds20-0058] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The recent-onset period of type 1 diabetes (T1D) in early school-age children should include comprehensive, parent-focused T1D education as well as family-centered resources and support to help with adjustment. Here, we present parent/caregiver perspectives on specific areas of concern during the recent-onset period of T1D and their preferred timing for different topics related to T1D education. METHODS Parents/caregivers of 5- to 9-year-old children with T1D completed a card-sorting task and qualitative interview to describe ongoing areas of concern and preferred educational topics during the first year after T1D diagnosis. RESULTS Thirteen parents/caregivers (aged 35.1 ± 6.9 years) of a child with T1D (aged 8.9 ± 0.8 years, 11.3 ± 7.0 months post-diagnosis) completed the card-sorting task, and 11 completed the qualitative interview. Parents/caregivers endorsed four preferred stages of education: basic education and T1D survival skills during month 1 post-diagnosis, application and practice of T1D skills from months 1-3, access to community supports to cope with anxiety and distress from months 3-6, and support to build autonomy and manage burnout beyond month 6 post-diagnosis. Parents/caregivers endorsed four main themes for ongoing concerns: anxiety, autonomy, distress, and support. CONCLUSION Parents endorsed four time points for education and psychosocial services within the first year of a T1D diagnosis. Parents/caregivers may benefit the most from psychosocial interventions 3-6 months post-diagnosis, once they have had sufficient time to develop basic T1D management skills. These findings support the need for regular parent psychosocial screening and access to scalable psychosocial interventions in the first year post-diagnosis of T1D.
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Affiliation(s)
| | | | - Kathy Goggin
- Children’s Mercy–Kansas City, Kansas City, MO
- University of Missouri Kansas City, Kansas City, MO
| | - Mark A. Clements
- Children’s Mercy–Kansas City, Kansas City, MO
- University of Missouri Kansas City, Kansas City, MO
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25
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Scheinker D, Gu A, Grossman J, Ward A, Ayerdi O, Miller D, Leverenz J, Hood K, Lee MY, Maahs DM, Prahalad P. Algorithm-Enabled, Personalized Glucose Management for Type 1 Diabetes at the Population Scale: A Prospective Evaluation in Clinical Practice (Preprint). JMIR Diabetes 2021; 7:e27284. [PMID: 35666570 PMCID: PMC9210201 DOI: 10.2196/27284] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 05/19/2021] [Accepted: 02/22/2022] [Indexed: 01/04/2023] Open
Abstract
Background The use of continuous glucose monitors (CGMs) is recommended as the standard of care by the American Diabetes Association for individuals with type 1 diabetes (T1D). Few hardware-agnostic, open-source, whole-population tools are available to facilitate the use of CGM data by clinicians such as physicians and certified diabetes educators. Objective This study aimed to develop a tool that identifies patients appropriate for contact using an asynchronous message through electronic medical records while minimizing the number of patients reviewed by a certified diabetes educator or physician using the tool. Methods We used consensus guidelines to develop timely interventions for diabetes excellence (TIDE), an open-source hardware-agnostic tool to analyze CGM data to identify patients with deteriorating glucose control by generating generic flags (eg, mean glucose [MG] >170 mg/dL) and personalized flags (eg, MG increased by >10 mg/dL). In a prospective 7-week study in a pediatric T1D clinic, we measured the sensitivity of TIDE in identifying patients appropriate for contact and the number of patients reviewed. We simulated measures of the workload generated by TIDE, including the average number of time in range (TIR) flags per patient per review period, on a convenience sample of eight external data sets, 6 from clinical trials and 2 donated by research foundations. Results Over the 7 weeks of evaluation, the clinical population increased from 56 to 64 patients. The mean sensitivity was 99% (242/245; SD 2.5%), and the mean reduction in the number of patients reviewed was 42.6% (182/427; SD 10.9%). The 8 external data sets contained 1365 patients with 30,017 weeks of data collected by 7 types of CGMs. The rates of generic and personalized TIR flags per patient per review period were, respectively, 0.15 and 0.12 in the data set with the lowest average MG (141 mg/dL) and 0.95 and 0.22 in the data set with the highest average MG (207 mg/dL). Conclusions TIDE is an open-source hardware-agnostic tool for personalized analysis of CGM data at the clinical population scale. In a pediatric T1D clinic, TIDE identified 99% of patients appropriate for contact using an asynchronous message through electronic medical records while reducing the number of patients reviewed by certified diabetes care and education specialists by 43%. For each of the 8 external data sets, simulation of the use of TIDE produced fewer than 0.25 personalized TIR flags per patient per review period. The use of TIDE to support telemedicine-based T1D care may facilitate sensitive and efficient guideline-based population health management.
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Affiliation(s)
- David Scheinker
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA, United States
- Lucile Packard Children's Hospital, Stanford University, Stanford, CA, United States
- Department of Management Science and Engineering, Stanford University School of Engineering, Stanford, CA, United States
- Stanford Diabetes Research Center, Stanford University, Stanford, CA, United States
| | - Angela Gu
- Department of Management Science and Engineering, Stanford University School of Engineering, Stanford, CA, United States
| | - Joshua Grossman
- Department of Management Science and Engineering, Stanford University School of Engineering, Stanford, CA, United States
| | - Andrew Ward
- Department of Management Science and Engineering, Stanford University School of Engineering, Stanford, CA, United States
| | - Oseas Ayerdi
- Department of Management Science and Engineering, Stanford University School of Engineering, Stanford, CA, United States
| | - Daniel Miller
- Department of Management Science and Engineering, Stanford University School of Engineering, Stanford, CA, United States
| | - Jeannine Leverenz
- Lucile Packard Children's Hospital, Stanford University, Stanford, CA, United States
| | - Korey Hood
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA, United States
- Stanford Diabetes Research Center, Stanford University, Stanford, CA, United States
| | - Ming Yeh Lee
- Lucile Packard Children's Hospital, Stanford University, Stanford, CA, United States
| | - David M Maahs
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA, United States
- Stanford Diabetes Research Center, Stanford University, Stanford, CA, United States
- Department of Health Research and Policy, Stanford University, Stanford, CA, United States
| | - Priya Prahalad
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA, United States
- Stanford Diabetes Research Center, Stanford University, Stanford, CA, United States
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26
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Sawalha N, Geddie H. Insulin Edema Associated With Newly Diagnosed Type 1 Diabetes and High Glycated Hemoglobin: A Case and Review of the Pediatric Literature. Can J Diabetes 2020; 45:571-574. [PMID: 33549500 DOI: 10.1016/j.jcjd.2020.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/19/2020] [Accepted: 11/19/2020] [Indexed: 01/17/2023]
Abstract
Insulin edema is a rare and poorly understood complication of insulin therapy. It has been associated with the initiation of insulin in patients with newly diagnosed diabetes or the intensification of insulin therapy in those with poor glycemic control. This condition is rarely reported in pediatric patients. We describe a case of insulin edema in a 14-year-old boy with potential risk factors of highly elevated glycated hemoglobin at diagnosis and history of unilateral renal atrophy. We also present a discussion of the pathophysiology of this condition and a review of the pediatric literature.
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Affiliation(s)
- Noor Sawalha
- Division of Pediatric Endocrinology, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Hannah Geddie
- Division of Pediatric Endocrinology, McMaster Children's Hospital, Hamilton, Ontario, Canada.
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27
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Prahalad P, Zaharieva DP, Addala A, New C, Scheinker D, Desai M, Hood KK, Maahs DM. Improving Clinical Outcomes in Newly Diagnosed Pediatric Type 1 Diabetes: Teamwork, Targets, Technology, and Tight Control-The 4T Study. Front Endocrinol (Lausanne) 2020; 11:360. [PMID: 32733375 PMCID: PMC7363838 DOI: 10.3389/fendo.2020.00360] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 05/07/2020] [Indexed: 12/12/2022] Open
Abstract
Many youth with type 1 diabetes (T1D) do not achieve hemoglobin A1c (HbA1c) targets. The mean HbA1c of youth in the USA is higher than much of the developed world. Mean HbA1c in other nations has been successfully modified following benchmarking and quality improvement methods. In this review, we describe the novel 4T approach-teamwork, targets, technology, and tight control-to diabetes management in youth with new-onset T1D. In this program, the diabetes care team (physicians, nurse practitioners, certified diabetes educators, dieticians, social workers, psychologists, and exercise physiologists) work closely to deliver diabetes education from diagnosis. Part of the education curriculum involves early integration of technology, specifically continuous glucose monitoring (CGM), and developing a curriculum around using the CGM to maintain tight control and optimize quality of life.
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Affiliation(s)
- Priya Prahalad
- Division of Endocrinology, Department of Pediatrics, Stanford University, Stanford, CA, United States
- *Correspondence: Priya Prahalad
| | - Dessi P. Zaharieva
- Division of Endocrinology, Department of Pediatrics, Stanford University, Stanford, CA, United States
| | - Ananta Addala
- Division of Endocrinology, Department of Pediatrics, Stanford University, Stanford, CA, United States
| | - Christin New
- Division of Endocrinology, Department of Pediatrics, Stanford University, Stanford, CA, United States
| | - David Scheinker
- Division of Endocrinology, Department of Pediatrics, Stanford University, Stanford, CA, United States
- Department of Management Science and Engineering, Stanford University, Stanford, CA, United States
| | - Manisha Desai
- Quantitative Sciences Unit, Division of Biomedical Informatics Research, Stanford University, Stanford, CA, United States
- Stanford Diabetes Research Center, Stanford, CA, United States
| | - Korey K. Hood
- Division of Endocrinology, Department of Pediatrics, Stanford University, Stanford, CA, United States
- Stanford Diabetes Research Center, Stanford, CA, United States
| | - David M. Maahs
- Division of Endocrinology, Department of Pediatrics, Stanford University, Stanford, CA, United States
- Stanford Diabetes Research Center, Stanford, CA, United States
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28
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Prahalad P, Addala A, Scheinker D, Hood KK, Maahs DM. CGM Initiation Soon After Type 1 Diabetes Diagnosis Results in Sustained CGM Use and Wear Time. Diabetes Care 2020; 43:e3-e4. [PMID: 31558548 PMCID: PMC7011198 DOI: 10.2337/dc19-1205] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 07/03/2019] [Indexed: 02/03/2023]
Affiliation(s)
- Priya Prahalad
- Division of Endocrinology, Department of Pediatrics, Stanford University, Stanford, CA
| | - Ananta Addala
- Division of Endocrinology, Department of Pediatrics, Stanford University, Stanford, CA
| | - David Scheinker
- Division of Endocrinology, Department of Pediatrics, Stanford University, Stanford, CA.,Department of Management Science and Engineering, Stanford University, Stanford, CA
| | - Korey K Hood
- Division of Endocrinology, Department of Pediatrics, Stanford University, Stanford, CA
| | - David M Maahs
- Division of Endocrinology, Department of Pediatrics, Stanford University, Stanford, CA.,Stanford Diabetes Research Center, Stanford, CA
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