Increased mortality in a Danish cohort of young people with Type 1 diabetes mellitus followed for 24 years

Serum angiopoietin-2: a promising biomarker for early diabetic kidney disease in children and adolescents with type 1 diabetes

Albuminuria has been considered the golden standard biomarker for diabetic kidney disease (DKD), but appears once significant kidney damage has already occurred. Angiopoietin-2 (Angpt-2) has been implicated in the development and progression of DKD in adults. We aimed to explore the association of serum Angpt-2 levels with DKD in children and adolescents with type 1 diabetes mellitus (T1DM) of short duration (3-5 years) and to evaluate the predictive power of serum Angpt-2 in the early detection of DKD prior to the microalbuminuric phase. The current cross-sectional study included 90 children divided into three age and sex-matched groups based on urinary albumin-to-creatinine ratio (UACR): microalbuminuric diabetic group (n = 30), non-albuminuric diabetic group (n = 30), and control group (n = 30). All participants were subjected to anthropometric measurements, serum Angpt-2 and fasting lipid profile (total cholesterol, triglycerides, LDL-C, HDL-C, and Non-HDL-C) assessment. Glomerular filtration rate was estimated based on serum creatinine (eGFR-Cr). Higher serum Angpt-2 levels were detected in both diabetic groups compared to controls and in microalbuminuric compared to non-albuminuric diabetic group. There was no detected significant difference in eGFR-Cr values across the study groups. Serum Angpt-2 was positively correlated with triglycerides, LDL, Non-HDL-C, HbA1c, and UACR, while UACR, HbA1c, and Non-HDL-C were independent predictors for serum Angpt-2. Serum Angpt-2 at level of 137.4 ng/L could discriminate between microalbuminuric and non-albuminuric diabetic groups with AUC = 0.960 and at level of 115.95 ng/L could discriminate between the non-albuminuric diabetic group and controls with AUC = 0.976.Conclusion: Serum Angpt-2 is a promising potent biomarker for the detection of early stage of DKD in childhood T1DM before albuminuria emerges. What is Known? • Urine albumin-to-creatinine ratio (UACR) and glomerular filtration rate (GFR) are the golden standard but late biomarkers for DKD. • Angiopoietin-2 has been implicated in the development and progression of DKD in adults with diabetes, but has not been explored in T1DM children with DKD. What is New? • Higher serum angiopoietin-2 was detected in diabetic groups compared to controls and in microalbuminuric compared to non-albuminuric group. • Angiopoietin-2 correlated positively with triglycerides, LDL, Non-HDL-C, HbA1c, and UACR. • Serum angiopoietin-2 is a promising early diagnostic biomarker for DKD in children with T1DM.

Health Literacy Among Young People With Type 1 Diabetes: A Qualitative Study of Patient Involvement

OBJECTIVE

This qualitative study explored the challenges and knowledge gaps among Danish youth with type 1 diabetes and subsequently introduced an information program to empower these youth in their diabetes self-management.

RESEARCH DESIGN AND METHODS

Nine young patients 18-25 years of age who were diagnosed with type 1 diabetes, living independently, or cohabiting with a partner were included. Relevant participants were invited by mail or telephone. Group interviews were conducted to uncover the specific knowledge requirements essential for improving their diabetes health literacy. Based on these interviews, four education sessions were held.

RESULTS

The participants identified pertinent topics, including alcohol consumption, blood glucose control, educational and employment aspects, nutrition, sexuality, pregnancy, relationships, and interactions with health care professionals (HCPs). Notably, the participants expressed a preference for personalized interactions over information dissemination through digital platforms such as mobile applications. Building on this insight, we organized four sessions to provide education on the identified subjects. These sessions were designed to facilitate networking among participants and offer them the opportunity for discussion. Although invitations were extended to all individuals aged 18-25 years with type 1 diabetes (n = 52), only 13 patients and seven relatives participated. The feedback from attendees was overwhelmingly positive. Reasons for nonparticipation included forgetfulness or a reluctance to engage in group settings.

CONCLUSION

Young people with type 1 diabetes appreciate personal contact with HCPs. They do not want to receive knowledge via digital apps and virtual media but instead to meet with equals. However, it remains difficult to involve them in social events. The problem of how to create contact with young people with type 1 diabetes to strengthen their health literacy remains unsolved, and there is a need for further innovative initiatives.

Pressure pain sensitivity: A new stress measure in children and adolescents with type 1 diabetes?

Type 1 diabetes (T1D) is associated with general- and diabetes-specific stress which has multiple adverse effects. Hence measuring stress is of great importance. An algometer measuring pressure pain sensitivity (PPS) has been shown to correlate to certain stress measures in adults. However, it has never been investigated in children and adolescents. The aim of our study was to examine associations between PPS and glycated hemoglobin (HbA1c), salivary cortisol and two questionnaires as well as to identify whether the algometer can be used as a clinical tool among children and adolescents with T1D. Eighty-three participants aged 6-18 years and diagnosed with T1D were included in this study with data from two study visits. Salivary cortisol, PPS and questionnaires were collected, measured, and answered on site. HbA1c was collected from medical files. We found correlations between PPS and HbA1c (rho = 0.35, P = 0.046), cortisol (rho = -0.25, P = 0.02) and Perceived Stress Scale (rho = -0.44, P = 0.02) in different subgroups based on age. Males scored higher in PPS than females (P < 0.001). We found PPS to be correlated to HbA1c but otherwise inconsistent in results. High PPS values indicated either measurement difficulties or hypersensibility towards pain.

Incidence and predictors of mortality in children with diabetic ketoacidosis in the comprehensive specialized referral hospitals of West Amhara Region, Northwest Ethiopia: a retrospective follow-up study

Background

Diabetic ketoacidosis is one of the major life-threatening conditions associated with acute metabolic complications. It remains a major public health problem in developing countries such as Ethiopia.

Objective

To assess the incidence and prediction of mortality in children with diabetic ketoacidosis in West Amhara Region Comprehensive Specialized Referral Hospitals, Northwest Ethiopia, in 2022.

Methods

An institution-based retrospective follow-up study was conducted among 423 study participants with a confirmed diagnosis of diabetic ketoacidosis from 01/01/2017 to 31/12/2021. Data were entered, coded, cleaned, and checked using Epi-Data version 4.6 and exported to Stata version 14 for data analysis.

Results

A total of 401 child records were included in the final analysis and were followed for 3781 days during the study period. The overall mortality of children with diabetic ketoacidosis was 10.6 per 1000 person-days observed (95% CI: 7.8-14.4) during the entire follow-up period. Hypoglycemia (AHR=4.6; 95% CI: 2.13-10.1), rural residence (AHR=2.9; 95% CI=1.01-8.11), age younger than five (AHR=4.4; 95% CI=1.4-13.7) or between five and 10 (AHR=3.1; 95% CI=1.1-8.8), and female gender (AHR=2.6; 95% CI=1.1-5.8) were significant predictors of mortality.

Conclusions

The incidence rate of mortality in children with diabetic ketoacidosis was relatively high. Age, rural residence, female gender, and hypoglycemia were significantly predictive of mortality. Community education or mass campaigns about the signs and symptoms of diabetic ketoacidosis may reduce the mortality rate in children.

Personal continuity of GP care and outpatient specialist visits in people with type 2 diabetes: A cross-sectional survey

BACKGROUND

Continuity of care is particularly important for patients with chronic conditions, such as type 2 diabetes (T2D). Continuity is shown to reduce overall health service utilization among people with diabetes, however, evidence about how it relates to the utilization of outpatient specialist services in Norway is lacking. The aim of this study was to investigate continuity of GP care for people with T2D, and its association with the use of outpatient specialist health care services.

METHODS

We used e-mail questionnaire data obtained from members of The Norwegian Diabetes Association in 2018. Eligible for analyses were 494 respondents with T2D and at least one GP visit during the previous year. By descriptive statistics and logistic regressions, we studied usual provider continuity (UPC) and duration of the patient-GP relationship and associations of these measures with somatic outpatient specialist visits. Analyses were adjusted for gender, age, education, self-rated health, and diabetes duration.

RESULTS

Mean age was 62.6 years and mean UPC was 0.85 (CI 0.83-0.87). Two thirds of the sample (66.0%) had made all visits to the regular GP during the previous year (full continuity). Among these, 48.1% had made one or more specialist visits during the previous year, compared to 65.2% among those without full continuity. The probability of outpatient specialist visits was significantly lower among participants with full continuity, compared to those without full continuity (Odds Ratio 0.53, Confidence Interval 0.35-0.80). The probability of visiting outpatient specialist services was not associated with duration of the patient-GP relationship.

CONCLUSIONS

We conclude that continuity of care, as measured by Usual Provider Continuity, is high and associated with reduced use of somatic outpatient specialist services in people with T2D in Norway. Continuity and its benefits will become increasingly important as the number of older people with diabetes and other chronic diseases increases.

Cardiac Autonomic Nerve Dysfunction Predicts Incident Retinopathy and Early Kidney Dysfunction in Adolescents With Type 1 Diabetes

OBJECTIVE

Cardiac autonomic neuropathy (CAN) may contribute to vascular complications in diabetes. We hypothesized that adolescents with CAN are at greater risk of diabetic retinopathy and early kidney dysfunction.

RESEARCH DESIGN AND METHODS

In this prospective longitudinal study of 725 adolescents with type 1 diabetes without retinopathy and albuminuria at baseline, early CAN was defined as one or more abnormalities in seven heart rate tests derived from a 10-min electrocardiogram. Retinopathy was defined as the presence of one or more microaneurysms, early kidney dysfunction as an albumin excretion rate (AER) >7.5 μg/min, and albuminuria as an AER >20 μg/min. Multivariable generalized estimating equations were used to examine the association between CAN and retinopathy or early kidney dysfunction. Cox proportional hazards regression analysis was used to assess cumulative risks of incident retinopathy and albuminuria.

RESULTS

At baseline, the mean age of the sample was 13.6 ± 2.6 years, 52% were male, and mean diabetes duration was 6.1 ± 3.3 years. Over a median follow-up of 3.8 (interquartile range 2.2-7.5) years, the complication rate 27% for retinopathy, 16% for early kidney dysfunction, and 3% for albuminuria. The mean study HbA1c was 72.3 ± 16 mmol/mmol (8.6 ± 1.4%). CAN predicted incident retinopathy (odds ratio 2.0 [95% CI 1.4, 2.9]) and early kidney dysfunction (1.4 [1.0, 2.0]) after adjusting for HbA1c and diabetes duration. CAN also predicted retinopathy (hazard ratio 1.57 [95% CI 1.09, 2.26]) and albuminuria (2.30 [1.05, 5.04]) independently of HbA1c.

CONCLUSIONS

CAN predicted incident retinopathy and kidney dysfunction in adolescents with type 1 diabetes, likely reflecting autonomic microvascular dysregulation contributing to complications. Therefore, screening and interventions to reduce CAN may influence the risk of complications.

Adherence to Mediterranean Diet Is Associated With Better Glycemic Control in Children With Type 1 Diabetes: A Cross-Sectional Study

Type 1 diabetes (T1D) is a chronic condition, with increased morbidity and mortality, due to a higher rate of cardiovascular disease among other factors. Cardiovascular risk increases with the worse glycemic profile. Nutrition has a deep impact on diabetes control. Adherence to the Mediterranean diet (MD) has been shown to decrease cardiovascular risk in children and adults with obesity and adults with type 2 diabetes, but its impact on T1D children has been scarcely analyzed. We hypothesized that the degree of adherence to MD could relate to the increased time in range in children with T1D.

Patients and Methods

Cross-sectional analysis involving two university hospitals. We measured the adherence to MD with the Mediterranean Diet Quality Index for children and teenagers (KIDMED) questionnaire, which is a validated tool for this purpose. A score of &lt;5 indicates poor adherence to MD, while a good adherence is indicated by a score of &gt;7. Demographic and clinical data were registered on the same day that the questionnaire was taken, with informed consent. Additionally, the patients' ambulatory glucose profiles (AGPs), were registered from the participants' glucose monitors (continuous or flash devices), and daily insulin needs were recorded from patients' insulin pumps (n=28). Other cardiovascular risk factors such as lipid profile, vitamin D levels, and other biochemical parameters were registered from a blood test, performed 2 weeks before recruitment, as part of the patients' annual screening.

Results

Ninety-seven patients (44 girls), with an average age of 11.4 years (± 3.01), were included. Seventy-one of them were on multiple daily injection regimens, and all had either continuous or flash glucose monitoring. Fifty-three had HbA1c levels of &lt;7.5%, while only 21 had a time in range (TIR) of &gt;70%. Contingency analysis showed that the odds of having HbA1c &lt;7.5% increase in children with KIDMED score of &gt;7 (O.R. 2.38; ICR 1.05–5.41; p = 0.036). Moreover, the KIDMED score and the HbA1c levels were negatively correlated (R: −0.245; p-value: 0.001), while the KIDMED score and TIR showed a positive correlation (R: 0.200; p-value: 0.009).

Conclusions

Our data suggest that adherence to MD may contribute to better glycemic control in children. This should be taken into account at the time of nutritional education on T1D patients and their families.

Are lifestyle changes from online information associated with discussing the information with a doctor? A cross -sectional study

BACKGROUND

The prevalence of diabetes and the use of electronic health (eHealth) are increasing. Lifestyle changes in a positive direction may reduce morbidity and mortality in patients with diabetes. The main objective of this study was to test the association between lifestyle changes based on online information seeking and discussing the information with a doctor.

METHODS

In this cross-sectional study we used e-mail survey data from 1250 members of The Norwegian Diabetes Association, collected in 2018. Included in the analyses were 847 men and women aged 18 to 89 years diagnosed with diabetes and who reported use of eHealth within the previous year. We used descriptive statistics to estimate lifestyle changes based on information from the internet. Logistic regressions were used to estimate the associations between lifestyle changes after online information seeking and discussing the information with a doctor. Analyses were adjusted for gender, age, education, and self-rated health.

RESULTS

Lifestyle changes accomplished after online information seeking was reported by 46.9% (397/847) of the participants. The odds of changing lifestyle were more than doubled for those who had discussed information from the internet with a doctor (odds ratio 2.54, confidence interval 1.90-3.40). The odds of lifestyle changes were lower in the age groups 30-39 years and 60 years and over, compared to those aged 18-29 years (the reference group). Lifestyle changes were not associated with gender, education, or self-rated health.

CONCLUSIONS

Our findings indicate that health-care professionals can play an important role in lifestyle changes additional to health-advice found on the internet. This study underlines the importance of easily accessible high-quality online information, as well as the importance of making room for discussing lifestyle in the clinical encounter.

Overall and Cause-Specific Mortality in Patients With Type 1 Diabetes Mellitus: A Population-Based Cohort Study in Taiwan From 1998 Through 2014

Background

To investigate all-cause and cause-specific mortality in Taiwanese patients with type 1 diabetes.

Methods

A cohort of 17,203 patients with type 1 diabetes were identified from Taiwan’s National Health Insurance claims in the period of 1998–2014. Person-years were accumulated for each individual from date of type 1 diabetes registration to date of death or the last day of 2014. Age, sex, and calendar year standardized mortality ratios (SMRs) were calculated with reference to the general population.

Results

In up to 17 years of follow-up, 4,916 patients died from 182,523 person-years. Diabetes (30.15%), cancer (20.48%), circulatory diseases (13.14%), and renal diseases (11.45%) were the leading underlying causes of death. Mortality rate (26.93 per 1,000 person-years) from type 1 diabetes in Taiwan was high, the cause of death with the highest mortality rate was diabetes (8.12 per 1,000 person-years), followed by cancer (5.52 per 1,000 person-years), and circulatory diseases (3.54 per 1,000 person-years). The all-cause SMR was significantly elevated at 4.16 (95% confidence interval, 4.04–4.28), with a greater all-cause SMR noted in females than in males (4.62 vs 3.79). The cause-specific SMR was highly elevated for diabetes (SMR, 16.45), followed by renal disease (SMR, 14.48), chronic hepatitis and liver cirrhosis (SMR, 4.91) and infection (SMR, 4.59). All-cause SMRs were also significantly increased for all ages, with the greatest figure noted for 15–24 years (SMR, 8.46).

Conclusions

Type 1 diabetes in both genders and all ages was associated with significantly elevated SMRs for all-cause and mostly for diabetes per se and renal disease.

Genetic association between interleukin-10 gene rs1518111 and rs3021094 polymorphisms and risk of type 1 diabetes and diabetic nephropathy in Egyptian children and adolescents

OBJECTIVE

Genetic and environmental factors have been implicated in etiopathogenesis and progression of type 1 diabetes mellitus (T1DM) and diabetic nephropathy (DN). Genetic association between interleukin-10 (IL-10) single nucleotide polymorphisms (SNPs) with T2DM and DN was recently established. We aimed to explore the potential genetic risk of IL-10 gene rs1518111 and rs3021094 SNPs in susceptibility to T1DM and DN.

RESEARCH DESIGN AND METHODS

Cross-sectional study included 140 T1DM children, of whom 74 had DN and 90 controls. IL-10 gene rs1518111 and rs3021094 SNP were genotyped by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) technique of the extracted genomic DNA from participants. Odds ratios (ORs) and 95% confidence intervals (CIs) were applied to explore the association between IL-10 gene polymorphisms and the risk of T1DM and DN.

RESULTS

For rs1518111 SNP, AA genotype was associated with high risk of T1DM (OR = 4.53; CI = 2.11-9.74; p < 0.001), while A allele was associated with high risk of both T1DM (OR = 3.35; CI = 2.20-5.09; p < 0.001) and DN (OR = 2.36; CI = 1.27-4.38; p = 0.006). For rs3021094 SNP, AC genotype displayed lower risk to develop T1DM (OR = 0.35; CI = 0.13-0.94; p = 0.037), while A allele displayed higher risk to develop T1DM (OR = 1.69; CI = 1.11-2.56; p = 0.013). GA and AC haplotypes of rs1518111 and rs3021094 had lower ORs for having T1DM and DN, while GC had lower OR for having T1DM.

CONCLUSIONS

AA genotype and A allele of IL-10 rs1518111 SNP could be linked to increased risk for T1DM and DN among Egyptian children. None of rs3021094 genotypes or alleles displayed significant association with DN. GA and AC haplotypes could be protective against T1DM and DN susceptibility.

Association between glycaemic outcome and BMI in Danish children with type 1 diabetes in 2000-2018: a nationwide population-based study

AIM

To describe the development of HbA_1c and BMI over time in Danish children with type 1 diabetes; and to investigate the association between HbA_1c and BMI including influence of age, gender, diabetes duration, severe hypoglycaemia and treatment method.

METHODS

We used the nationwide Danish Registry of Childhood and Adolescent Diabetes, DanDiabKids, including annual registrations of all children with diabetes treated at Danish hospitals. With linear mixed-effects models and splines we analyzed the HbA_1c and BMI development over time as well as the association between HbA_1c and BMI including effects of gender, age, disease duration, hypoglycaemia and treatment method. BMI z-scores were calculated for these analyses.

RESULTS

For the period from 2000 to 2018, 6097 children with type 1 diabetes were identified from the DanDiabKids database. The median (interquartile range) HbA_1c level was 65 (57-74) mmol/mol (8.1%) and the median BMI z-score was 0.85 in girls and 0.67 in boys. A non-linear association was found between HbA_1c and BMI z-score, with the highest BMI z-score observed for HbA_1c values in the range of approximately 60-70 mmol/mol (7.6-6.8%). The association was modified by gender, age and diabetes duration. Severe hypoglycaemia and insulin pump treatment had a small positive impact on BMI z-score.

CONCLUSION

The association between HbA_1c and BMI z-score was non-linear, with the highest BMI z-score being observed for intermediate HbA_1c levels; however, specific patterns depended on gender, age and diabetes duration.

Priorities in the Interdisciplinary Approach of Specific Learning Disorders (SLD) in Children with Type I Diabetes Mellitus (T1DM). From Theory to Practice

BACKGROUND

A considerable endeavor had taken place in order to understand the associated challenges for children and adolescents with Specific Learning Disorder (SLD) and Type 1 Diabetes Mellitus (T1DM) but also in order to describe the necessary skills and approaches that the care givers have to develop to assist both children and parents. (1) Aim: The aim of this review is twofold. Firstly, to highlight the T1DM's potential impact on psychological well-being, on cognitive functioning and on school performance in children and adolescents who confront SLD. Secondly, to discuss the necessity of a multidiscipline approach of poor school performance in students with SLD and T1DM, presenting the serious contribution of care providers: (a) parents/carers in the family setting, (b) teachers and psychologists in the school setting and (c) health specialists (pediatricians, nutricians, nurses, child psychiatrists and psychologists) in the medical setting. (2) Methods: In this narrative literature review of 12 selected articles, each one studies a special aspect of approach, during the diagnosis and the treatment of individuals with T1DM and SLD. The review concerns the arising problems and difficulties in the adherence to diagnosis, the management of insulin, the mental and physical wellbeing, the school performance, the cognitive functioning and learning difficulties of patients. We tried to synthesize an interdisciplinary approach that involves collaboration between family, school and medical frame; facilitating children's and adolescents' difficulties management, as well as parent and teacher involvement during the intervention implementation. (3) Results: The main issues of concern were examined through the available literature, as different factors had to be re-examined in the previous studies, regarding the potential impact of T1DM in cognitive and psychological functioning, as well as the effects of the intervention/approach/treatment of children and adolescents with SLD and T1DM. (4) Conclusions: Although T1DM diagnosis and demanding treatment are a heavy burden for children and their families, T1DM may or may not be associated with a variety of academic and psychological outcomes. Despite the variability of the reviewed research design quality, it was clearly defined that the impact of T1DM is not uniform across educational and mental variables. Strengthening the children's physical, psychological and social wellbeing is an especially important factor, as it facilitates the insulin's management as well as the learning difficulties. This is possible by supporting the parental and teacher involvement in the intervention process. This review highlights the need to reduce the distance between theory/research and practice, in some of the proposed areas in this field of knowledge.

Carotid-Femoral Pulse Wave Velocity as a Risk Marker for Development of Complications in Type 1 Diabetes Mellitus

Background

The value of carotid‐femoral pulse wave velocity (cfPWV) as risk factor for development of complications in type 1 diabetes mellitus remains to be determined. We investigated associations between cfPWV and renal outcomes, cardiovascular events, and all‐cause mortality in people with type 1 diabetes mellitus.

Methods and Results

cfPWV was measured with SphygmoCor in 633 people with type 1 diabetes mellitus. Median (interquartile range) follow‐up was 6.2 (5.8−6.7) years. End points included progression in albuminuria group, decline in estimated glomerular filtration rate (eGFR) ≥30%, end‐stage kidney disease, cardiovascular event, mortality, and a composite renal end point. Hazard ratios (HRs) were calculated per 1‐SD increase in cfPWV. Adjustments included age, sex, hemoglobin A1c, mean arterial pressure, body mass index, low‐density lipoprotein cholesterol, smoking, urine albumin excretion rate, and eGFR. The cohort included 45% women, mean (SD) age was 54 (13) years, mean (SD) eGFR was 83.2 (27.9) mL/min per 1.73 m², and mean (SD) cfPWV was 10.4 (3.3) m/s. Median (interquartile range) albumin excretion rate was 17 (17‐63) mg/24 h. After adjustment, higher cfPWV was associated with increased hazard of progression in albuminuria (HR, 1.59; 95% CI, 1.10−2.32); decline in eGFR ≥30% (HR, 1.38; 95% CI, 1.06−1.79); cardiovascular event (HR, 1.31; 95% CI, 1.01−1.70); mortality (HR, 1.36; 95% CI, 1.00−1.85); and the composite renal end point (HR, 1.30; 95% CI, 1.04−1.63), but not with end‐stage kidney disease (HR, 1.18; 95% CI, 0.62−2.26). Higher cfPWV was associated with steeper yearly increase in albumin excretion and steeper yearly decline in eGFR after adjustment (P=0.002 and P=0.01, respectively).

Conclusions

cfPWV was associated with increased hazard of renal outcomes, cardiovascular event, and mortality. cfPWV may be suited for risk stratification in type 1 diabetes mellitus.

Time trends in deaths before age 50 years in people with type 1 diabetes: a nationwide analysis from Scotland 2004-2017

AIMS/HYPOTHESIS

We aimed to examine whether crude mortality and mortality relative to the general population below 50 years of age have improved in recent years in those with type 1 diabetes.

METHODS

Individuals with type 1 diabetes aged below 50 and at least 1 year old at any time between 2004 and 2017 in Scotland were identified using the national register. Death data were obtained by linkage to Scottish national death registrations. Indirect age standardisation was used to calculate sex-specific standardised mortality ratios (SMRs). Poisson regression was used to test for calendar-time effects as incidence rate ratios (IRRs).

RESULTS

There were 1138 deaths in 251,143 person-years among 27,935 people with type 1 diabetes. There was a significant decline in mortality rate over time (IRR for calendar year 0.983 [95% CI 0.967, 0.998], p = 0.03), but the SMR remained approximately stable at 3.1 and 3.6 in men and 4.09 and 4.16 in women for 2004 and 2017, respectively. Diabetic ketoacidosis or coma (DKAoC) accounted for 22% of deaths and the rate did not decline significantly (IRR 0.975 [95% CI 0.94, 1.011], p = 0.168); 79.3% of DKAoC deaths occurred out of hospital. Circulatory diseases accounted for 27% of deaths and did decline significantly (IRR 0.946 [95% CI 0.914, 0.979], p = 0.002).

CONCLUSIONS/INTERPRETATION

Absolute mortality has fallen, but the relative impact of type 1 diabetes on mortality below 50 years has not improved. There is scope to improve prevention of premature circulatory diseases and DKAoC and to develop more effective strategies for enabling people with type 1 diabetes to avoid clinically significant hyper- or hypoglycaemia. Graphical abstract.

The DISABKIDS generic and diabetes-specific modules are valid but not directly comparable between Denmark, Sweden, and Norway

BACKGROUND/OBJECTIVES

Government guidance promote benchmarking comparing quality of care including both clinical values and patient reported outcome measures in young persons with type 1 diabetes. The aim was to test if the Nordic DISABKIDS health-related quality of life (HrQoL) modules were construct valid and measurement comparable within the three Nordic countries.

METHODS

Data from three DISABKIDS validation studies in Sweden, Denmark, and Norway were compared using Rasch and the graphical log-linear Rasch modeling. Monte Carlo methods were used to estimate reliability coefficient and target was defined as the point with the lowest SE of the mean. Self-report data were available from 99 Danish (8-18 years), 103 Norwegian (7-19 years), and 131 Swedish (8-18 years) young people.

RESULTS

For the DISABKIDS higher scores on most subscales were noted in the Norwegian population. The Swedish sample had a significantly higher score on the "Diabetes treatment" subscale and scores closer to optimal target than the other countries. For each country, construct validity and sensitivity were acceptable when accounting for differential item function (DIF) and local dependency (LD). Less LD and DIF were found if only Denmark and Norway were included. The combined model was reliable; however, some differences were noted in the scale translations relating to the stem and response alternatives, which could explain the discrepancies.

CONCLUSION

The Nordic versions of the DISABKIDS questionnaires measures valid and reliable HrQoL both within and between countries when adjusted for DIF and LD. Adjusting the Likert scales to the same respond categories may improve comparability.

Poor metabolic control in childhood strongly correlates to diabetes-related premature death in persons <30 years of age-A population-based cohort study

BACKGROUND/OBJECTIVE

The importance of metabolic control in childhood regarding excess risk of death in young persons has not been well studied. This registry-based study aimed to investigate mortality rates and cause of death related to metabolic control in young persons (≤29 years) in Sweden with type 1 diabetes.

METHODS

All 12 652 subjects registered in the Swedish pediatric diabetes quality register, from 2006 to 2014, were included. Data were merged with the Swedish Cause of Death Register. Standardized mortality rates were calculated using the official Swedish population register.

RESULTS

Of 68 deaths identified, 38.2% of the deaths were registered as being due to diabetes whereof the major cause of death was acute complications. Overall standardized mortality ratio was 2.7 (2.1-3.4, 95% CI). Subjects who died from diabetes had a mean HbA1c of 74 ± 19 mmol/mol (8.9 ± 1.7%) during childhood vs 62 ± 12 mmol/mol (7.8 ± 1.1%) in those still alive (P < .001).

CONCLUSIONS

In this nationwide cohort of young subjects with type 1 diabetes, there was a high mortality rate compared to the general population. Mean HbA1c in childhood was significantly higher in those who died from diabetes, compared to subjects who were still alive. To decrease mortality in young persons with type 1 diabetes it is essential not only to achieve but also to maintain a good metabolic control during childhood and adolescence.

Model-based characterization of the relationship between dapagliflozin systemic exposure and HbA1c response in patients with type 1 diabetes mellitus

AIMS

To quantitatively describe the relationship between dapagliflozin systemic exposure and HbA1c response among patients with type 1 diabetes mellitus (T1DM) and assess the potential impact of covariate effects.

MATERIALS AND METHODS

Individual longitudinal HbA1c data from two phase 3 studies in patients with T1DM (24-week treatment with once-daily dapagliflozin 5 or 10 mg or placebo, with adjustable insulin) were analyzed using a non-linear mixed effect modeling approach. Area under the concentration curve was used to measure dapagliflozin systemic exposure. Baseline HbA1c, estimated glomerular filtration rate, reduction in total insulin dose, baseline glucose concentrations, age, sex, race (Asian vs. non-Asian), and insulin administration method (multiple daily injections vs. insulin pump) were assessed as covariates.

RESULTS

A maximum effect (Emax ) model identified a positive exposure-response relationship. Model-predicted placebo-corrected HbA1c reductions after 24 weeks for dapagliflozin 5- and 10-mg doses were - 0.42% [95% confidence interval (CI) -0.47 to -0.36) and - 0.45% (95% CI -0.50 to -0.40), respectively; baseline HbA1c was ~8.4%. This was in good agreement with actual observations from both studies. Baseline HbA1c was a significant covariate: patients with higher baseline HbA1c were predicted to have greater HbA1c reductions.

CONCLUSIONS

The relationship between dapagliflozin systemic exposure and HbA1c response was successfully described in patients with T1DM. None of the tested covariates affected the efficacy of dapagliflozin to a clinically relevant extent. Therefore, no dose adjustment of dapagliflozin is required in patients with T1DM based on the tested covariates. ClinicalTrials.gov, NCT02268214; NCT02460978.

Associations Between the Use of eHealth and Out-of-Hours Services in People With Type 1 Diabetes: Cross-Sectional Study

BACKGROUND

Despite the increasing prevalence of diabetes and the increasing use of eHealth, little is known about the association between provider-based health services and eHealth among people with diabetes. This is the second study in a project exploring the associations between the use of eHealth and the use of provider-based health services.

OBJECTIVE

The objective of this study was to investigate which eHealth services are used among out-of-hours (OOH) visitors with type 1 diabetes (T1D), and whether the use of eHealth (eg, apps, search engines, video services, and social media) was associated with the use of OOH services. We also wanted to investigate associations between anxiety, reassurance, and change in doctor-seeking behavior because of health information acquired from the Internet, and the use of OOH services.

METHODS

We used data from a 2018 email survey of members of the Norwegian Diabetes Association (18-89 years old). Respondents with T1D were eligible for analyses. Using descriptive statistics, we estimated the use of OOH services and eHealth. Using logistic regressions, we studied the associations between the use of OOH services and the use of eHealth, as well as associations between the use of OOH services and reported consequences of using Internet-based health information.

RESULTS

In the sample of 523 people with T1D (mean age 47 years), 26.7% (129/484) visited OOH services once or more during the previous year. Among the OOH visitors, search engines were used for health purposes by 86.7% (111/128), apps (health apps in general) by 63.6% (82/129), social media by 45.3% (58/128), and video services by 28.4% (36/127). The use of OOH services was positively associated with self-reported anxiety/depression (odds ratio [OR] 4.53, 95% CI 1.43-14.32) and with the use of apps (OR 1.73, 95% CI 1.05-2.85), but not with other types of eHealth. Those who had felt anxious based on information from the Internet were more likely to visit OOH services compared with those who had not felt anxious (OR 2.38, 95% CI 1.50-3.78). People who had decided to consult a doctor based on information from the Internet were more likely to visit OOH services (OR 2.76, 95% CI 1.64-4.66), compared to those who had not made such an Internet-based decision.

CONCLUSIONS

People with T1D were frequent users of OOH services, and the OOH visitors were frequent users of eHealth. The use of OOH services was positively associated with the use of health apps, with self-reported anxiety/depression, and with feeling anxious based on information from the Internet. Likewise, deciding to consult a doctor based on information from the Internet was positively associated with OOH visits. The use of eHealth seems to have a significant impact on people with T1D.

Differential growth of craniofacial and tibial bones to sympathetic hyperactivity-related hypertension in rats

OBJECTIVE

To evaluate the effect of sympathetic nervous system hyperactivity on craniofacial skeletal growth in growing spontaneously hypertensive rats (SHRs).

DESIGN

Craniofacial skeletal growth was compared between male SHR and Wistar-Kyoto rats (WKR) using linear measurements on lateral and transverse cephalometric radiographs at the age of 12 weeks. Tibia length was measured as an index of whole body growth. Body weight　and blood pressure were measured from 3 to 12 weeks of age. Bone microstructure in the mandibular condyle and tibia between the two groups was compared at the age of 12 weeks using microcomputed tomography.

RESULTS

The SHRs had a significantly lower body weight than WKRs from 7 weeks of age, and tibial length was significantly smaller in the SHRs than in the WKR at 12 weeks of age. In all SHRs, blood pressure was significantly higher than in WKRs from 3 to 12 weeks of age. Cephalometric analyses revealed decreased measurements of the neurocranium, viscerocranium, and mandible in SHRs, and mandibular growth was most negatively affected in this group. Lastly, in SHRs, microcomputed tomography analyses revealed decreased bone mineral density and bone volume/tissue volume in the mandibular condyle but not in the tibia.

CONCLUSION

In growing SHRs, hypertension related to the hyperactivity of the sympathetic nervous system reduced craniofacial skeletal growth more than the growth of the tibia.

Relations Between the Use of Electronic Health and the Use of General Practitioner and Somatic Specialist Visits in Patients With Type 1 Diabetes: Cross-Sectional Study

BACKGROUND

The prevalence of diabetes and the use of electronic health (eHealth) are increasing. People with diabetes need frequent monitoring and follow-up of health parameters, and eHealth services can be of great value. However, little is known about the association between the use of eHealth and provider-based health care services among people with diabetes.

OBJECTIVE

The objective of this study was to investigate the use of 4 different eHealth platforms (apps, search engines, video services, and social media sites) and associations with the use of provider-based health care visits among people diagnosed with type 1 diabetes mellitus (T1DM).

METHODS

We used email survey data collected from 1250 members of the Norwegian Diabetes Association (aged 18 to 89 years) in 2018. Eligible for analyses were the 523 respondents with T1DM. Using descriptive statistics, we estimated the use of eHealth and the use of general practitioners (GPs) and somatic specialist outpatient services. By logistic regressions, we studied the associations between the use of these provider-based health services and the use of eHealth, adjusted for gender, age, education, and self-rated health.

RESULTS

Of the sample of 523 people with T1DM, 90.7% (441/486) had visited a GP once or more, and 61.0% (289/474) had visited specialist services during the previous year. Internet search engines (such as Google) were used for health purposes sometimes or often by 84.0% (431/513), apps by 55.4% (285/514), social media (such as Facebook) by 45.2% (232/513), and video services (such as YouTube) by 23.3% (118/506). Participants aged from 18 to 39 years used all forms of eHealth more than people aged 40 years and older, with the exception of social media. The use of search engines was positively associated with the use of somatic specialist services (odds ratio 2.43, 95% CI 1.33-4.45). GP visits were not associated with any kind of eHealth use.

CONCLUSIONS

eHealth services are now widely used for health support and health information by people with T1DM, primarily in the form of search engines but often in the form of apps and social media as well. We found a positive association between the use of search engines and specialist visits and that people with T1DM are frequent users of eHealth, GPs, and specialist services. We found no evidence that eHealth reduces the use of provider-based health care; these services seem to be additional rather than alternative. Future research should focus on how health care services can meet and adapt to the high prevalence of eHealth use. Our results also indicate that many patients with T1DM do not visit specialist clinics once a year as recommended. This raises questions about collaboration in health care services and needs to be followed up in future research.

Poor Metabolic Control in Children and Adolescents With Type 1 Diabetes and Psychiatric Comorbidity

OBJECTIVE

Type 1 diabetes is associated with an increased risk of psychiatric morbidities. We investigated predictors and diabetes outcomes in a pediatric population with and without psychiatric comorbidities.

RESEARCH DESIGN AND METHODS

Data from the Danish Registry of Childhood and Adolescent Diabetes (DanDiabKids) and National Patient Register were collected (1996-2015) for this population-based study. We used Kaplan-Meier plots to investigate whether age at type 1 diabetes onset and average glycated hemoglobin (HbA_1c) levels during the first 2 years after onset of type 1 diabetes (excluding HbA_1c at debut) were associated with the risk of being diagnosed with a psychiatric disorder. Mixed-effects linear and logistic regression models were used to analyze HbA_1c, BMI, severe hypoglycemia (SH), or ketoacidosis as outcomes, with psychiatric comorbidities as explanatory factor.

RESULTS

Among 4,725 children and adolescents with type 1 diabetes identified in both registers, 1,035 were diagnosed with at least one psychiatric disorder. High average HbA_1c levels during the first 2 years predicted higher risk of psychiatric diagnoses. Patients with psychiatric comorbidity had higher HbA_1c levels (0.22% [95% CI 0.15; 0.29]; 2.40 mmol/mol [1.62; 3.18]; P < 0.001) and an increased risk of hospitalization with diabetic ketoacidosis (1.80 [1.18; 2.76]; P = 0.006). We found no associations with BMI or SH.

CONCLUSIONS

High average HbA_1c levels during the first 2 years after onset of type 1 diabetes might indicate later psychiatric comorbidities. Psychiatric comorbidity in children and adolescents with type 1 diabetes increases the risk of poor metabolic outcomes. Early focus on the disease burden might improve outcomes.

Mortality in type 1 diabetes diagnosed in childhood in Northern Ireland during 1989-2012: A population-based cohort study

OBJECTIVE

To investigate long-term mortality rates and causes of death in individuals diagnosed with type 1 diabetes before the age of 15 years during the period 1989-2012 or known to paediatric diabetes teams in 1989, in Northern Ireland.

METHODS

A cohort of 3129 patients from the Northern Ireland Childhood Diabetes Register was linked to death registrations and underlying causes, coded according to ICD-9 or ICD-10. Standardized mortality ratios (SMRs) were calculated as the ratio of observed to expected deaths by sex, attained age, time since diagnosis, calendar period, and cause of death.

RESULTS

Subjects were followed to December 31, 2012 giving 39 764 person-years of follow-up (median 12.1 years). In total, 59 subjects had died (1.5 per 1000 person-years) compared with 19.9 deaths expected, an SMR of 296 (95% confidence interval (CI) 229-382). Women had a significantly higher excess risk of mortality than men with SMRs of 535 (95% CI 361-764) and 203 (95% CI 136-291), respectively. Over half of the deaths (56%) were judged to be related or possibly related to diabetes with most of these due to acute (n = 24) or late (n = 6) complications.

CONCLUSIONS

Subjects with type 1 diabetes diagnosed less than 15 years of age had 3 times the mortality risk of the general population. Over half of the deaths were related to acute or chronic complications of diabetes.

Efficacy and safety of dapagliflozin in patients with inadequately controlled type 1 diabetes (DEPICT-1): 24 week results from a multicentre, double-blind, phase 3, randomised controlled trial

BACKGROUND

Dapagliflozin is a sodium-glucose cotransporter-2 inhibitor approved for the treatment of type 2 diabetes. We aimed to assess the efficacy and safety of dapagliflozin as an add-on to adjustable insulin in patients with inadequately controlled type 1 diabetes.

METHODS

DEPICT-1 was a double-blind, randomised, parallel-controlled, three-arm, phase 3, multicentre study done at 143 sites in 17 countries. Eligible patients were aged 18-75 years and had inadequately controlled type 1 diabetes (HbA_1c between ≥7·7% and ≤11·0% [≥61·0 mmol/mol and ≤97·0 mmol/mol]) and had been prescribed insulin for at least 12 months before enrolment. After an 8 week lead-in period to optimise diabetes management, patients were randomly assigned (1:1:1) using an interactive voice response system to dapagliflozin 5 mg or 10 mg once daily, given orally, or matched placebo. Randomisation was stratified by current use of continuous glucose monitoring, method of insulin administration, and baseline HbA_1c. The primary efficacy outcome was the change from baseline in HbA_1c after 24 weeks of treatment in the full analysis set, which consisted of all randomly assigned patients who received at least one dose of study drug. An additional 55 patients who were incorrectly and non-randomly allocated to only dapagliflozin treatment groups were included in the safety analysis set. This study was registered with ClinicalTrials.gov, number NCT02268214; data collection for the present analysis was completed on Jan 4, 2017, and a 28 week extension phase is ongoing.

FINDINGS

Between Nov 11, 2014, and April 16, 2016, 833 patients were assigned to treatment groups and included in safety analyses (dapagliflozin 5 mg [n=277] vs dapagliflozin 10 mg [n=296] vs placebo [n=260]; 778 of these patients were randomly assigned and included in the full analysis set for efficacy analyses (259 vs 259 vs 260; difference due to randomisation error affecting 55 patients). Mean baseline HbA_1c was 8·53% (70 mmol/mol; SD 0·67% [7·3 mmol/mol]). At week 24, both doses of dapagliflozin significantly reduced HbA_1c compared with placebo (mean difference from baseline to week 24 for dapagliflozin 5 mg vs placebo was -0·42% [95% CI -0·56 to -0·28; p<0·0001] and for dapagliflozin 10 mg vs placebo was -0·45% [-0·58 to -0·31; p<0·0001]). Among patients in the dapagliflozin 5 mg (n=277), dapagliflozin 10 mg (n=296), and placebo (n=260) groups, the most common adverse events were nasopharyngitis (38 [14%] vs 36 [12%] vs 39 [15%]), urinary tract infection (19 [7%] vs 11 [4%] vs 13 [5%]), upper respiratory tract infection (15 [5%] vs 15 [5%] vs 11 [4%]), and headache (12 [4%] vs 17 [6%] vs 11 [4%]). Hypoglycaemia occurred in 220 (79%), 235 (79%), and 207 (80%) patients in the dapagliflozin 5 mg, dapagliflozin 10 mg, and placebo groups, respectively; severe hypoglycaemia occurred in 21 (8%), 19 (6%), and 19 (7%) patients, respectively. Adjudicated definite diabetic ketoacidosis occurred in four (1%) patients in the dapagliflozin 5 mg group, five (2%) in the dapagliflozin 10 mg group, and three (1%) in the placebo group.

INTERPRETATION

Our results suggest that dapagliflozin is a promising adjunct treatment to insulin to improve glycaemic control in patients with inadequately controlled type 1 diabetes.

FUNDING

AstraZeneca and Bristol-Myers Squibb.

Noninvasive Retinal Markers in Diabetic Retinopathy: Advancing from Bench towards Bedside

The retinal vascular system is the only part of the human body available for direct, in vivo inspection. Noninvasive retinal markers are important to identity patients in risk of sight-threatening diabetic retinopathy. Studies have correlated structural features like retinal vascular caliber and fractals with micro- and macrovascular dysfunction in diabetes. Likewise, the retinal metabolism can be evaluated by retinal oximetry, and higher retinal venular oxygen saturation has been demonstrated in patients with diabetic retinopathy. So far, most studies have been cross-sectional, but these can only disclose associations and are not able to separate cause from effect or to establish the predictive value of retinal vascular dysfunction with respect to long-term complications. Likewise, retinal markers have not been investigated as markers of treatment outcome in patients with proliferative diabetic retinopathy and diabetic macular edema. The Department of Ophthalmology at Odense University Hospital, Denmark, has a strong tradition of studying the retinal microvasculature in diabetic retinopathy. In the present paper, we demonstrate the importance of the retinal vasculature not only as predictors of long-term microvasculopathy but also as markers of treatment outcome in sight-threatening diabetic retinopathy in well-established population-based cohorts of patients with diabetes.