Predictors of glycaemic control in patients with Type 1 diabetes commencing continuous subcutaneous insulin infusion therapy

Effects of initiating insulin pump therapy in the real world: A nationwide, register-based study of adults with type 1 diabetes

AIMS

We aimed to estimate effects of insulin pump therapy (IPT) on HbA_1c level, HbA_1c variability, and risk of hospitalised diabetic ketoacidosis (DKA) and severe hypoglycaemia (SH), compared with multiple daily insulin injections (MDI).

METHODS

We identified a cohort of all adults with type 1 diabetes in Denmark using national registry data and assigned each individual to either IPT (treatment) or MDI (control) from 2010 to 2020. We estimated average treatment effects on the treated (ATT) and treatment effects among population subgroups using treatment-staggered difference-in-differences.

RESULTS

The cohort consisted of 26,687 individuals with a collective 243,601 person-years of observation; 38,823 (16 %) were IPT person-years. We identified an ATT for HbA_1c of -0.33 % (95 % CI -0.39 to -0.27; -3.6 mmol/mol [95 % CI -4.2 to -2.9]). ATTs were larger among women and individuals who were older, had highest baseline HbA_1c, and used continuous glucose monitoring. ATT for HbA_1c variability (-0.016 % [-0.028 to -0.0041); -0.17 mmol/mol [95 % CI -0.30 to -0.045]) corresponded to a 6.5 % decrease in the standard deviation of HbA_1c. ATTs for DKA and SH corresponded to 0.52 additional and 0.11 fewer hospitalisations per 1,000 person-years, respectively.

CONCLUSIONS

IPT significantly reduced HbA_1c level and variability, compared with MDI. However, it also marginally increased the risk of hospitalised DKA.

Continuous subcutaneous insulin infusions: Closing the loop

CONTEXT

Continuous subcutaneous insulin infusions (CSIIs) and continuous glucose monitors (CGMs) have revolutionized the management of diabetes mellitus (DM). Over the last two decades the development of advanced, small, and user-friendly technology has progressed substantially, essentially closing the loop in the fasting and post-absorptive state, nearing the promise of an artificial pancreas. The momentum was mostly driven by the diabetes community itself, to improve its health and quality of life.

EVIDENCE ACQUISITION

Literature regarding CSII and CGM was reviewed.

EVIDENCE SYNTHESIS

Management of DM aims to regulate blood glucose to prevent long term micro and macrovascular complications. CSIIs combined with CGMs provide an integrated system to maintain tight glycemic control in a safe and uninterrupted fashion, while minimizing hypoglycemic events. Recent advances have allowed to 'close the loop' by better mimicking endogenous insulin secretion and glucose level regulation. Evidence supports sustained improvement in glycemic control with reduced episodes of hypoglycemia using these systems, while improving quality of life. Ongoing work in delivery algorithms with or without counterregulatory hormones will allow for further layers of regulation of the artificial pancreas.

CONCLUSION

Ongoing efforts to develop an artificial pancreas have created effective tools to improve the management of DM. CSIIs and CGMs are useful in diverse populations ranging from children to the elderly, as well as in various clinical contexts. Individually and more so together, these have had a tremendous impact in the management of DM, while avoiding treatment fatigue. However, cost and accessibility are still a hindrance to its wider application.

Values and control in type 1 diabetes beyond glycemic outcomes: A qualitative interview study of everyday life with an insulin pump

OBJECTIVES

Diabetes technology provides people with diabetes with new opportunities, but the transformations allowed by new technology do not necessarily provide improvements in clinical metrics applied in diabetes care. This study seeks to understand how everyday life impacts on the way people use diabetes technology and how this influences diabetes care.

METHODS

Individual semi-structured qualitative interviews with 21 adults with type 1 diabetes treated with insulin pumps were recruited from two Danish diabetes outpatient clinics. Data were analyzed abductively and interpreted according to predetermined and emergent perspectives.

RESULTS

Transformations in care practices derived from new technological therapies were generally well-supported by healthcare providers, but adaptation to everyday life was often challenging. More advanced technology enabled people to better control diabetes, but the control they sought was defined by individual life experiences/factors. Work involved in controlling blood glucose could cause a sense of feeling controlled by diabetes in everyday life.

DISCUSSION

Everyday life with diabetes is often characterized by uncertainty and individual coping strategies are imbued with values that extend beyond purely clinical concerns and reflect the sociality of everyday life. The social values influencing individual decision-making regarding diabetes technology could be effectively expanded and enhanced with integrated peer-supported learning.

Clinical characteristics and management of type 1 diabetes in Spain. The SED1 study

OBJECTIVES

To determine the sociodemographic and clinical profile of a representative sample of people with type 1 diabetes mellitus (DM1) in Spain and identify factors associated with glycemic control.

MATERIAL AND METHODS

A cross-sectional observational study was carried out in adults and children with DM1 treated in 75 Spanish public hospitals, geographically distributed in order to be representative of the Spanish population. Within each center, the patients were included on a consecutive basis as they visited the clinic. They were interviewed, and their clinical histories were reviewed. A descriptive statistical analysis was made, and factors associated with HbA_1c were analysed using multivariate linear regression analysis.

RESULTS

A total of 647 patients were included: 55.3% females, aged 36.6 ± 14.4 years, 97.2% Caucasians, BMI 24.7 ± 4.4 kg/m² (12.1% ≥ 30 kg/m²), and 74.0% had secondary / university education. A total of 20.2% were active smokers. The mean time from the diagnosis of DM1 was 17.9 ± 12.0 years. A total of 48.7% presented comorbidities: 19.3% retinopathy and 16.4% hypothyroidism. As regards treatment for DM1, 76.5% received basal-bolus insulin therapy and 20.7% continuous subcutaneous insulin infusion (CSII); 51.0% of the patients used an insulin/carbohydrate ratio (ICR), with 4.6 ± 1.6 self-monitored capillary blood glucose (SMCBG) measurements a day, and 24.8% used continuous glucose monitoring (CGM). The mean HbA_1c value was 7.6 ± 1.1% (30% below 7%). Metabolic control improved (lower HbA_1c) with more daily SMCBG (B = -0.053; p = 0.009), a higher educational level (B = 0.461; P < 0.001), greater number of hypoglycemia episodes (B = -0.253; P = 0.018) and carbohydrate counting (B = -0.190; P = 0.048), and worsened the longer the duration of the disease (B = 0.010; P = 0.010), higher total dose of insulin (B = 0.010; P < 0.0001), poorer adherence to diet (B = 0.650; P < 0.0001) and a family history of DM (B = -0.233; P = 0.007).

CONCLUSIONS

The management of patients with DM1 in Spain, as well as the treatment they receive, is similar to that seen in other Western countries. Blood glucose control is associated with educational level, disease duration, and the characteristics of treatment and self-care.

Impact of deprivation on glycaemic control in youth with type 1 diabetes in the southwestern region of France

OBJECTIVES

The objective of this multicenter cross-sectional study was to determine predictors of poor glycaemic control in children with type 1 diabetes mellitus (T1DM), particularly with respect to socioeconomic status (SES).

METHODS

Our study population consisted of 1154 children who attended T1DM follow-up consultation with a pediatric diabetes specialist. Clinical and demographic data were retrieved retrospectively from patients' records. Individual deprivation was defined by an EPICES (Evaluation of the Deprivation and Inequalities of Health in Healthcare Centers) score ≥ 30. Patients were assigned to quintiles of the European Deprivation Index (EDI) based on their area deprivation scores. We used multivariable linear regression models to detect potential associations between glycaemic control and indicators of low SES.

RESULTS

In total, 33% (n = 376) of patients had an EPICES score ≥ 30 and 23% (n = 268) were in the 5th EDI quintile. Multivariable linear regression analysis showed that poor glycaemic control was associated with both individual (β 0.38; 95%CI 0.26-0.5; p < 0.001) and area deprivation (β 0.26; 95%CI 0.08-0.43; p = 0.004). Demographic factors, body mass index (BMI) and insulin regimen were also independently associated with poor glycaemic control (p < 0.001). Interestingly, access to diabetes technologies was not related to SES or either glycaemic control.

CONCLUSION

Low SES is associated with a higher risk of poor glycaemic control, independently of insulin regimen. BMI, age at the time of consultation, duration of diabetes, and insulin regimen. Also have an impact on HbA1c. These parameters need to be considered when developing novel treatment strategies for children with T1DM to better target at-risk patients.

Comparing continuous subcutaneous insulin infusion and multiple daily injections in children with Type 1 diabetes in Sweden from 2011 to 2016-A longitudinal study from the Swedish National Quality Register (SWEDIABKIDS)

OBJECTIVE

This study aimed to compare metabolic control measured as hemoglobin A1c (HbA1c), the risk of severe hypoglycemia, and body composition measured as body mass index standard deviation scores (BMI-SDS) in a nationwide sample of children and adolescents with Type 1 diabetes with continuous subcutaneous insulin infusion (CSII) and multiple daily injections (MDI), respectively.

RESEARCH DESIGN AND METHODS

Longitudinal data from 2011 to 2016 were extracted from the Swedish National Quality Register (SWEDIABKIDS) with both cross-sectional (6 years) and longitudinal (4 years) comparisons. Main end points were changes in HbA1c, BMI-SDS, and incidence of severe hypoglycemia.

RESULTS

Data were available from 35,624 patient-years (54% boys). In general, HbA1c decreased approximately 0.5% (2-5 mmol/mol) from 2011 to 2016 (p_trend  < 0.001) and the use of CSII increased in both sexes and all age groups. Mean HbA1c was 0.1% (0.7-1.5 mmol/mol) lower in the CSII treated group. Teenagers, especially girls, using CSII tended to have higher BMI-SDS. There was no difference in the number of hypoglycemias between CSII and MDI over the years 2011-2016.

CONCLUSIONS

There was a small decrease in HbA1c with CSII treatment but of little clinical relevance. Overall, mean HbA1c decreased in both sexes and all age groups without increasing the episodes of severe hypoglycemia, indicating that other factors than insulin method contributed to a better metabolic control.

Clinical characteristics and management of type 1 diabetes in Spain. The SED1 study

OBJECTIVES

To determine the sociodemographic and clinical profile of a representative sample of people with type 1 diabetes mellitus (DM1) in Spain and identify factors associated with glycemic control.

MATERIAL AND METHODS

A cross-sectional observational study was carried out in adults and children with DM1 treated in 75 Spanish public hospitals, geographically distributed in order to be representative of the Spanish population. Within each center, the patients were included on a consecutive basis as they visited the clinic. They were interviewed, and their clinical histories were reviewed. A descriptive statistical analysis was made, and factors associated with HbA1c were analyzed using multivariate linear regression analysis.

RESULTS

A total of 647 patients were included: 55.3% females, aged 36.6±14.4 years, 97.2% Caucasians, BMI 24.7±4.4kg/m2 (12.1% ≥30kg/m2), and 74.0% had secondary / university education. A total of 20.2% were active smokers. The mean time from the diagnosis of DM1 was 17.9±12.0 years. A total of 48.7% presented comorbidities: 19.3% retinopathy and 16.4% hypothyroidism. As regards treatment for DM1, 76.5% received basal-bolus insulin therapy and 20.7% continuous subcutaneous insulin infusion (CSII); 51.0% of the patients used an insulin/carbohydrate ratio (ICR), with 4.6±1.6 self-monitored capillary blood glucose (SMCBG) measurements a day, and 24.8% used continuous glucose monitoring (CGM). The mean HbA1c value was 7.6±1.1% (30% below 7%). Metabolic control improved (lower HbA1c) with more daily SMCBG (B=-0.053; p=0.009), a higher educational level (B=0.461; P<0.001), greater number of hypoglycemia episodes (B=-0.253; P=0.018) and carbohydrate counting (B=-0.190; P=0.048), and worsened the longer the duration of the disease (B=0.010; P=0.010), higher total dose of insulin (B=0.010; P<0.0001), poorer adherence to diet (B=0.650; P<0.0001) and a family history of DM (B=-0.233; P=0.007).

CONCLUSIONS

The management of patients with DM1 in Spain, as well as the treatment they receive, is similar to that seen in other Western countries. Blood glucose control is associated with educational level, disease duration, and the characteristics of treatment and self-care.

The Lived Experience of Continuous Subcutaneous Insulin Infusion in Adults With Type 1 Diabetes Mellitus: A Phenomenological Inquiry

Continuous subcutaneous insulin infusion (CSII) is a complex, medical device for the management of Type 1 Diabetes Mellitus (T1DM). There is limited research exploring the everyday experiences living with this device. The purpose of this study was to understand the lived experience of adults using CSII therapy to manage T1DM. Lived experiences from eight individuals were collected through semi-structured interviews and then analyzed using a hermeneutic approach to phenomenology. Four substantive themes with supporting subthemes were identified and represent the essence of participant experiences; that is, living with CSII eventually took ascendancy over managing T1DM.CSII therapy has gained popularity due to reported improvements in metabolic control and flexibility. However, the burden of the responsibility and psychological implications of CSII took ascendancy over T1DM. Living with CSII impacts the psychological well-being of individuals so psychological complications are as important to assess by healthcare professionals as physical and metabolic complications.

Clinical Outcome and Cost-Effectiveness Analysis of CSII Versus MDI in Children and Adolescent With Type 1 Diabetes Mellitus in a Public Health Care System of China

OBJECTIVES

To evaluate the clinical and economic consequences of continuous subcutaneous insulin infusion (CSII) vs. multiple daily injections (MDI) in children and adolescents with type 1 diabetes mellitus (T1DM) from a public health care system in developed areas of developing country, considering changes in glycemic Control, daily insulin requirements, lipid profile, body mass index (BMI), frequency of severe hypoglycemia and Diabetic Ketoacidosis (DKA) and diabetic complications.

METHODS

This was a retrospective cohort study of children and adolescents with T1DM. Data were collected at baseline and the end of every year including glycated hemoglobin (HbA1c), insulin dose, lipid profile, blood pressure, and adverse events (severe hypoglycemia and DKA). The Cost-effectiveness analysis was performed using the IQVIA CORE Diabetes Model (CDM) to simulate diabetes progression by utilizing the clinical data obtained from the two groups. The main outcome measures were Life Expectancy, Quality adjusted life years (QALYs), Total Costs and Incremental Costs and Effectiveness Ratio (ICER) of CSII compared with MDI in Chinese pediatric patients with T1DM in Qingdao City (60 years).

RESULTS

Mean HbA1c values and daily insulin doses were significantly lower in those receiving CSII therapy throughout follow-up. Mean direct lifetime costs were ¥ 67,137 higher with CSII treatment than with MDI for pediatric patients. Treatment with CSII was associated with an improvement in life expectancy of 0.41 years for pediatric patients compared with MDI based on CORE diabetes model simulation. The corresponding gains in QALYs were 0.42. These data produced corresponding ICER is ¥ 161,815 per QALY for pediatric T1DM patients in Qingdao. Sensitivity analyses suggested that our base-case assumptions were mostly robust.

CONCLUSIONS

CSII is associated with improved long-term clinical outcomes compared with MDI. Based on this model analysis, CSII appears to be more cost-effective for the Qingdao TIDM pediatric population and health care system.

Insulin Pump Therapy

BACKGROUND

Advances in pump technology have increased the popularity of this treatment modality among patients with type 1 diabetes and recently also among patients with type 2 diabetes.

AREAS OF UNCERTAINTY

Four decades after the incorporation of the insulin pump in clinical use, questions regarding its efficacy, occurrence rate of short-term complications as hypoglycemia and diabetes ketoacidosis, timing of pump initiation, and selected populations for use remain unanswered.

DATA SOURCES

A review of the literature was performed using the PubMed database to identify all articles published up till December 2018, with the search terms including insulin pump therapy/continuous subcutaneous insulin delivery. The Cochrane database was searched for meta-analysis evaluating controlled randomized trials. Consensuses guidelines published by the International Society for Pediatric and Adolescent Diabetes, American Diabetes Association, and Advanced Technologies and Treatments for Diabetes year books were additionally reviewed for relevant cited articles.

THERAPEUTIC ADVANCES

Insulin pump therapy offers flexible management of diabetes. It enables adjustment of basal insulin to daily requirements and circadian needs, offers more precise treatment for meals and physical activity, and, when integrated with continuous glucose monitoring, allows glucose responsive insulin delivery. The ability to download and transmit data for analysis allow for treatment optimization. Newer pumps are simple to operate and increase user experience. Studies support the efficacy of pump therapy in improving glycemic control and reducing the occurrence of hypoglycemia without increasing episodes of diabetes ketoacidosis. They also improve quality of life. Recent evidence suggests a role for pump therapy in reducing microvascular and macrovascular diabetes-related complications.

CONCLUSIONS

Insulin pump therapy appears to be effective and safe in people with T1D regardless of age. Future advancements will include incorporation of closed loop and various decision support systems to aid and improve metabolic control and quality of life.

The Development and Psychometric Validation of the Diabetes Impact and Device Satisfaction Scale for Individuals with Type 1 Diabetes

BACKGROUND

With the rapid development of new insulin delivery technology, measuring patient experience has become especially pertinent. The current study reports on item development, psychometric validation, and intended use of the newly developed Diabetes Impact and Device Satisfaction (DIDS) Scale.

METHOD

The DIDS Scale was informed by a comprehensive literature review, and field tested as part of two focus groups. The finalized measure was used at baseline and 6 months post-assessment with a large US cohort. Exploratory factor analyses (EFAs) were conducted to determine and confirm factor structure and item selection. Internal reliability, test-retest reliability, and convergent/divergent validity of the emerged factors were tested with demographics, diabetes-specific information, and diabetes behavioral and satisfaction measures.

RESULTS

In all, 778 participants with type 1 diabetes (66% female, mean age 47.13 ± 17.76 years, 74% insulin pump users) completed surveys at both baseline and post-assessment. EFA highlighted two factors-Device Satisfaction (seven items, Cronbach's α = 0.85-0.90) and Diabetes Impact (four items, Cronbach's α = 0.71-0.75). DIDS Scale demonstrated good concurrent validity and test-retest reliability.

CONCLUSION

The DIDS Scale is a novel and a brief assessment tool with robust psychometric properties. It is recommended for use across all insulin delivery devices and is considered appropriate for use in longitudinal studies. Future studies are recommended to evaluate the performance of DIDS Scale in diverse populations with diabetes.

Future glycemic control of children diagnosed with type 1 diabetes mellitus at toddler and preschool/school age

Background The main objective of this study was to compare future glycemic control in children diagnosed with type 1 diabetes mellitus (T1DM) at toddler age and preschool/school age. In addition, we aimed to examine risk factors known to be associated with future glycated hemoglobin A1c (HbA1c) levels in children diagnosed with T1DM. Methods This is a retrospective cohort study of 85 patients diagnosed with T1DM at toddler age (group 1; 0-2.9 years; n = 36) or preschool/school age (group 2; 5-6.9 years; n = 49) who were followed up at the University Children's Hospital in Zurich for at least 10 consecutive years or until the age of 15 years. Results The mean HbA1c level in the first year after diagnosis had a highly predictive value about glycemic control in the following 6 years. In addition, a longer duration of T1DM was associated with higher HbA1c values. HbA1c values did not differ significantly within 11 years after diagnosis between children in the two age groups. Neither was a difference found when comparing the two groups in respect to their chronological age, although a trend was noted (p = 0.09). This trend is very likely due to a longer duration of diabetes in group 1. Conclusions HbA1c level in the first year predicts glycemic control for the next 6 years and deterioration of HbA1c values can be noted with longer duration of T1DM. Moreover, our study demonstrated similar future glycemic control in patients diagnosed with T1DM at toddler age and preschool/school age.

Investigating the Association Between Baseline Characteristics (HbA1c and Body Mass Index) and Clinical Outcomes of Fast-Acting Insulin Aspart in People with Diabetes: A Post Hoc Analysis

INTRODUCTION

The aim of this study was to investigate the association between baseline characteristics [HbA1c and body mass index (BMI)] and the effect of mealtime fast-acting insulin aspart (faster aspart) relative to insulin aspart (IAsp) or basal-only insulin therapy on several efficacy and safety outcomes in people with diabetes.

METHODS

Post hoc analysis of three randomised phase 3a trials in people with type 1 diabetes (T1D; onset 1) and type 2 diabetes (T2D; onset 2 and 3). Participants (N = 1686) were stratified according to baseline BMI (< 25 kg/m², 25-< 30 kg/m², ≥ 30 kg/m²) or HbA1c (≤ 58 mmol/mol, > 58-< 64 mmol/mol, ≥ 64 mmol/mol; ≤ 7.5%, > 7.5-< 8.0%, ≥ 8.0%).

RESULTS

In participants with T2D, the estimated treatment difference for change in HbA1c was similar for all BMI and HbA1c subgroups. No major differences between treatments were observed in risk of overall hypoglycaemia or insulin dose across subgroups. In participants with T1D, change in HbA1c was similar across BMI and HbA1c subgroups, and no major differences between treatments were observed for severe or blood glucose-confirmed hypoglycaemia across subgroups. Total daily insulin dose (U/kg) was similar across all baseline HbA1c groups and the BMI < 25 kg/m² and 25-30 kg/m² groups, but was significantly lower with mealtime faster aspart compared with IAsp in the BMI > 30 kg/m² subgroup.

CONCLUSIONS

In participants with T1D and T2D, treatment differences (for change in HbA1c and overall hypoglycaemia) between mealtime faster aspart and insulin comparators were similar to the corresponding overall analysis across baseline HbA1c and BMI subgroups. The finding of a lower total daily insulin dose in participants with obesity (BMI > 30 kg/m²) and T1D treated with faster aspart, versus those treated with IAsp, may warrant further investigation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01831765 (onset 1); NCT01819129 (onset 2); NCT01850615 (onset 3).

FUNDING

Novo Nordisk A/S, Søborg, Denmark.

Diabetes Device Use in Adults With Type 1 Diabetes: Barriers to Uptake and Potential Intervention Targets

OBJECTIVE

Diabetes devices (insulin pumps, continuous glucose monitors [CGMs]) are associated with benefits for glycemic control, yet uptake of these devices continues to be low. Some barriers to device uptake may be modifiable through psychosocial intervention, but little is known about which barriers and which patients to target.

RESEARCH DESIGN AND METHODS

We surveyed 1,503 adult T1D Exchange participants (mean age 35.3 [SD 14.8] years, mean diagnosis duration 20.4 [SD 12.5] years) to investigate barriers to device uptake, understand profiles of device users versus nonusers, and explore differences by age and sex. Scales used were the Diabetes Distress Scale, Technology Use Attitudes (General and Diabetes-Specific), and Barriers to Device Use and Reasons for Discontinuing Devices.

RESULTS

Most commonly endorsed modifiable barriers were related to the hassle of wearing devices (47%) and disliking devices on one's body (35%). CGM users (37%) were older than nonusers (mean 38.3 vs. 33.5 years), had diabetes for longer (22.9 vs. 18.8 years), had more positive technology attitudes (22.6-26.0 vs. 21.4-24.8), and reported fewer barriers to using diabetes technology than nonusers (3.3 vs. 4.3). The youngest age-group (18-25 years) had the lowest CGM (26% vs. 40-48%) and insulin pump (64% vs. 69-77%) uptake, highest diabetes distress (2.2 vs. 1.8-2.1), and highest HbA_1c levels (8.3% [67 mmol/mol] vs. 7.2-7.4% [55-57 mmol/mol]).

CONCLUSIONS

Efforts to increase device use need to target physical barriers to wearing devices. Because young adults had the lowest device uptake rates, highest distress, and highest HbA_1c compared with older age-groups, they should be the focus of future interventions to increase device use.

Diabetes Technology: Uptake, Outcomes, Barriers, and the Intersection With Distress

Patients managing type 1 diabetes have access to new technologies to assist in management. This manuscript has two aims: 1) to briefly review the literature on diabetes technology use and how this relates to psychological factors and 2) to present an example of human factors research using our data to examine psychological factors associated with technology use. Device/technology uptake and use has increased over the years and at present day is a common clinical practice. There are mixed results in terms of health and psychosocial outcomes, with specific subgroups doing better than others with technology. Our data demonstrated that patients have moderately elevated diabetes distress across differing types of technology used, from low-tech to high-tech options, possibly meaning that technology does not add or take away distress. In addition, users on multiple daily injections compared to all other technology groups have less positive attitudes about technology. Finally, we discuss implications for clinical practice and future research.

Prevalence of Insulin Pump Therapy and Its Association with Measures of Glycemic Control: Results from the Canadian Study of Longevity in Type 1 Diabetes

OBJECTIVE

We aimed to determine cross-sectional insulin pump prevalence and factors associated with measures of glycemic control as a secondary analysis in a long-standing type 1 diabetes mellitus (T1DM) national cohort.

RESEARCH DESIGN AND METHODS

Canadian participants with ≥50 years of T1DM (n = 305) were administered a comprehensive mail-based questionnaire including acquisition of contemporaneous laboratory results. Factors associated with pump use, glycosylated hemoglobin (HbA1c), and hypoglycemia were analyzed by regression.

RESULTS

The 305 participants had a median age of 65 [interquartile range, 59, 71] years, median diabetes duration of 54 [51, 59] years, and mean HbA1c level of 7.5 ± 1.1%. Prevalence of pump use was 44% (133/305), with median duration of use 8 [4, 13] years. Compared with the non-pump subgroup, the pump subgroup had numerically lower but similar HbA1c levels (7.4 ± 0.9% vs. 7.6 ± 1.2%; P = 0.22) and reported greater numbers of minor hypoglycemia events (6.5 vs. 5.1 events/patient·month; P = 0.004) and fewer severe hypoglycemia events (0.5 vs. 1.3 events/patient·year; P = 0.02) in the past year. More frequent daily glucose tests and more frequent minor hypoglycemia events-but not pump therapy or its prescription parameters-were independently associated with lower HbA1c level in multivariable regression. However, use of insulin pump and habitual use of continuous glucose monitoring (≥1 week/month) were each independently associated with lower risk of severe hypoglycemia (risk ratio = 0.50 [P < 0.0001] and 0.30 [P = 0.001], respectively).

CONCLUSIONS

Insulin pump and continuous glucose monitoring technologies were associated with lower risk of severe hypoglycemia, while frequent daily glucose testing was associated with lower HbA1c level. These findings imply that basic self-management skill and technology play complementary roles in glycemic control among older adults with long-standing T1DM.

Influences on Technology Use and Efficacy in Type 1 Diabetes

The majority of people with type 1 diabetes have suboptimal glycemic control, increasing their complication risk. Technology to support diabetes self-care has advanced significantly and includes self-monitoring of blood glucose (SMBG), insulin pump therapy (IPT), continuous glucose monitoring (CGM), and sensor-augmented pump therapy (SAPT), which are stepping stones toward the "artificial pancreas" using closed-loop technology. Use of these technologies improves clinical outcomes for patients with the appropriate skills and motivation. This review addresses the psychosocial factors that influence both technology provision and clinical outcome and also how technology impacts on psychological outcomes. Optimal use of the various diabetes self-management technologies is influenced by previous self-care behaviors, demographic and psychological factors. Provision of IPT is also influenced by the same factors. Despite technology increasing the complexity of treatment, the lack of evidence for adverse psychological outcomes is reassuring. Treatment satisfaction is high, and discontinuation rates are low. However, technology will widen the health inequality gap if its use is limited to motivated patients who demonstrate good self-care behaviors. Pivotal to the success of the various technologies is provision of appropriate education at initiation of the technology, regular ongoing contact for treatment adjustments and trouble-shooting device issues plus access to psychological support when required. Additional support strategies may be required to help patients struggling with their diabetes to benefit from the available technology, recognizing that they may have most to gain.

A novel tool to predict youth who will show recommended usage of diabetes technologies

BACKGROUND AND OBJECTIVE

Controversy exists regarding which individuals will benefit most from commencement of diabetes technologies such as continuous subcutaneous insulin infusion (CSII) or continuous glucose monitoring systems (CGMS), such as 'real-time' sensor-augmented pumping (SAP). Because higher usage correlates with haemoglobin A1c (HbA1c) achieved, we aimed to predict future usage of technologies using a questionnaire-based tool.

SUBJECTS

The tool was distributed to two groups of youth with type 1 diabetes; group A (n = 50; mean age 12 ± 2.5 yr) which subsequently commenced 'real-time' CGMS and group B (n = 47; mean age 13 ± 3 yr) which commenced CSII utilisation.

METHODS

For the CGMS group, recommended usage was ≥5 days (70%) per week [≥70% = high usage (HU); <70% = low usage (LU)], assessed at 3 months. In the CSII group, HU was quantified as entering ≥5 blood sugars per day to the pump and LU as <5 blood sugars per day, at 6 months from initiation. Binary logistic regression with forward stepwise conditional was used to utilise tool scales and calculate an applied formula.

RESULTS

Of the CGMS group, using gender, baseline HbA1c, and two subscales of the tool generated a formula which predicted both high and low usage with 92% accuracy. Twelve (24%) showed HU vs. 38 who exhibited LU at 3 months. Of the CSII group, 32 (68%) exhibited HU vs. 15 who exhibited LU at 6 months. Four tool items plus gender predicted HU/LU with 95% accuracy.

CONCLUSIONS

This pilot study resulted in successful prediction of individuals who will and those who will not go on to show recommended usage of CSII and CGMS.

Impact of insulin pump therapy on long-term glycemic control in a pediatric Spanish cohort

AIMS

To evaluate the efficacy and safety of Continuous Subcutaneous Insulin Infusion (CSII) in a pediatric cohort and to determine if the ISPAD/IDF/ADA criteria for good metabolic control are achieved during long periods of time.

METHODS

Retrospective longitudinal study including ninety patients [10.5 (6.5-13.9) years of age, 58% males]. Age at debut, type 1 diabetes mellitus duration, pubertal stage, HbA1c, insulin dose, mean number of glycemic controls, number of basal rates, % basal/total insulin, severe hypoglycemia and diabetic ketoacidosis events were analyzed. Subgroup analysis based on age and pubertal stage was performed.

RESULTS

HbA1c decreased from 6.9% [52 mmol/mol] to 6.7% [50 mmol/mol] after one year of CSII. Afterwards, it remained less than 7% during the follow-up period (median 3.5 ± 1.8 years (range 1-8). Prior to CSII, 76% of the subjects met ISPAD/ADA criteria. One year after initiating CSII, 96% of children had HbA1c<7.5%. Improvement in glycohemoglobin levels was most prominent in those patients with the highest HbA1c initial levels. Total insulin dose decreased from 0.89 to 0.73 UI/kg/day (p<0.001). Proportion of basal/total insulin changed significantly (47 to 42% (p<0.05)). Number of fractions of the basal rate increased from 5.6 ± 1.8 at one year of CSII to 6.7 ± 2.1 five years later. Incidence of severe hypoglycemic events decreased from 19 to 6.9 episodes/100 patient-year. Only 2 episodes of diabetic ketoacidosis occurred.

CONCLUSIONS

CSII allows reaching ISPAD/IDF/ADA goals safely during an extended follow-up period in a diabetic pediatric cohort.

Who gains clinical benefit from using insulin pump therapy? A qualitative study of the perceptions and views of health professionals involved in the Relative Effectiveness of Pumps over MDI and Structured Education (REPOSE) trial

AIMS

To explore health professionals' views about insulin pump therapy [continuous subcutaneous insulin infusion (CSII)] and the types of individuals they thought would gain greatest clinical benefit from using this treatment.

METHODS

In-depth interviews with staff (n = 18) who delivered the Relative Effectiveness of Pumps Over MDI and Structured Education (REPOSE) trial. Data were analysed thematically.

RESULTS

Staff perceived insulin pumps as offering a better self-management tool to some individuals due to the drip feed of insulin, the ability to alter basal rates and other advanced features. However, staff also noted that, because of the diversity of features on offer, CSII is a more technically complex therapy to execute than multiple daily injections. For this reason, staff described how, alongside clinical criteria, they had tended to select individuals for CSII in routine clinical practice based on their perceptions about whether they possessed the personal and psychological attributes needed to make optimal use of pump technology. Staff also described how their assumptions about personal and psychological suitability had been challenged by working on the REPOSE trial and observing individuals make effective use of CSII who they would not have recommended for this type of therapy in routine clinical practice.

CONCLUSIONS

Our findings add to those studies that highlight the difficulties of using patient characteristics and variables to predict clinical success using CSII. To promote equitable access to CSII, attitudinal barriers and prejudicial assumptions amongst staff about who is able to make effective use of CSII may need to be addressed.

Insulin pump use and glycemic control in adolescents with type 1 diabetes: Predictors of change in method of insulin delivery across two years

Few studies have explored durability of insulin pump use, and none have explored the link between depression and pump discontinuation. To examine the relationship between depressive symptoms [measured by the Children's Depression Inventory (CDI)], method of insulin delivery, and hemoglobin A1c (A1c), mixed models were used with data from 150 adolescents with type 1 diabetes (T1D) and visits every 6 months for 2 years. Of the 63% who used a pump, compared with multiple daily injections (MDI) at baseline, there were higher proportions who were non-minorities, had caregivers with a college degree, private insurance, and two caregivers in the home (p ≤ 0.01). After adjusting for time, sex, age, T1D duration, frequency of blood glucose monitoring, ethnicity, insurance, and caregiver number and education, baseline pump use was associated with -0.79% lower mean A1c [95% confidence interval (CI): -1.48, -0.096; p = 0.03]. For those using a pump at baseline, but switching to MDI during the study (n = 9), mean A1c was 1.38% higher (95% CI: 0.68, 2.08; p < 0.001) than that for those who did not switch method of delivery. A 10-point increase in CDI was associated with a 0.39% increase in A1c (95% CI: 0.16, 0.61; p = 0.001), independent of pump use. Regarding the temporal relationship between CDI score and changing method of insulin delivery, prior higher CDI score was associated with switching from pump to MDI (odds ratio = 1.21; 95% CI: 1.05, 1.39; p = 0.007). Clinicians should be aware of the associations between depressive symptoms, change in insulin delivery method, and the effect on glycemic control.

Testing for rewards: a pilot study to improve type 1 diabetes management in adolescents

OBJECTIVE

To evaluate the effectiveness of monetary reinforcement to increase the frequency of self-monitoring blood glucose (SMBG).

RESEARCH DESIGN AND METHODS

Ten adolescents with poorly controlled diabetes enrolled in a 12-week program in which they earned monetary reinforcers based on SMBG frequency ($0.10 per test, with bonuses for ≥4 tests per day, and $251.40 maximum).

RESULTS

SMBG increased from 1.8 ± 1.0 to 4.9 ± 1.0 tests per day (P < 0.001) with 90% completing four or more tests per day. Mean A1C fell from 9.3 ± 0.9% to 8.4 ± 1.5% (P = 0.05). Adolescents and parents reported high satisfaction with procedures.

CONCLUSIONS

Reinforcing adolescents for SMBG may increase testing and improve A1C.

A Comparison of Continuous Subcutaneous Insulin Infusion vs. Multiple Daily Insulin Injection in Children with Type I Diabetes in Kuwait: Glycemic Control, Insulin Requirement, and BMI

OBJECTIVE

Continuous subcutaneous insulin infusion (CSII) and multiple daily insulin injections (MDI) are two methods currently used to manage type I diabetes mellitus (T1DM). Here we compare our experiences with CSII and MDI in a large cohort of pediatric patients in Kuwait.

METHODS

Data on 326 patients with T1DM who were started on CSII between 2007 and 2012 were retrospectively compared with those of 326 patients on MDI. They were matched for sex, age at diagnosis, T1DM duration, glycemic control, insulin requirement, and body mass index (BMI). Data were collected at baseline and every three months and included glycated hemoglobin (HbA1c), insulin dose, and adverse events (severe hypoglycemia, diabetic ketoacidosis, and skin problems).

RESULTS

The main reason for switching to CSII was to achieve better glycemic control (37%), followed by reducing hypoglycemia, and improving the quality of life (13.3% each). Although HbA1c decrease was most significant in the first year, it continued to be significantly lower in the CSII group compared to the MDI throughout the study period. Total daily insulin requirements were significantly lower in the CSII group. BMI increased in both groups, but the difference was significant only at the end of the fifth year. There was no significant change in the rate of diabetic ketoacidosis in either group. The CSII patients had more severe hypoglycemic episodes at baseline; however, it significantly decreased throughout the study period. Only five patients discontinued CSII therapy and two of these restarted within three months.

CONCLUSION

CSII is a safe intensive insulin therapy in youngsters with T1DM and achieved markedly fewer severe hypoglycemic episodes and lower daily insulin requirements.

Characterization of metabolic responders on CSII treatment amongst children and adolescents in Denmark from 2007 to 2013

AIM

This prospective study aimed to identify and estimate the frequency of responders offered Continuous subcutaneous insulin infusion (CSII) from baseline data and during follow-up, and secondly to characterize CSII users with good adherence to pump therapy among 463 children and adolescents with Type 1 diabetes mellitus.

METHODS

A response was defined as lowering HbA1c with 1% or achieving an HbA1c<7.5% (58 mmol/mol). Good adherence was defined as measuring ≥7 self monitored blood glucoses (SMBGs) and taking ≥7 boluses daily. Logistic regression was used to estimate the effect of demographic and clinical variables prior to and during pump treatment.

RESULTS

At 24 months follow-up 32% qualified as responders. Stratifying for age at onset, 45% of the children aged <6 yrs qualified as responders vs. 32% and 28% of the youngsters and adolescents aged 6-12 yrs. and 12-19 yrs., respectively (p=0.02). Responders were characterized by their HbA1c-level at pump onset (p=0.001), taking more daily boluses (7.64 ± 3.33 vs. 6.40 ± 3.18 p=0.003) and measuring more SMBGs per day at follow-up (6.88 ± 2.35 vs. 6.31 ± 2.54 p=0.03). The incidence of severe hypoglycemia decreased from 14.3 to 3.3 events per 100 person years (p<0.0001). Twenty percent did not respond despite a good adherence toward CSII therapy.

CONCLUSION

Age <6 years, high or low HbA1c at pump initiation and number of daily boluses were associated with improved or sustained near-normal metabolic outcome. The incidence of severe hypoglycemia was significantly reduced. Twenty percent of the population had good adherence without any metabolic improvement.

Insulin pump treatment; increasing prevalence, and predictors for better metabolic outcome in Danish children and adolescents with type 1 diabetes

AIMS

Few studies have looked at nationwide data for insulin pump treatment. Since 1996 the Danish Childhood Diabetes Registry (DanDiabKids) has collected data on all Danish diabetic patients aged 0-15 yr. The purpose of this study is to evaluate the prevalence of continuous subcutaneous insulin infusion (CSII) use among Danish children with diabetes and to compare metabolic control in CSII-treated children and adolescents to those treated with MDI.

MATERIALS AND METHODS

The Registry collects on a yearly basis data on insulin regimen, central measured hemoglobin A1c (HbA1c), and demographic data on all patients. In the period 2005-2011, 2983 young patients (1721 males) with diabetes were followed in the Registry. Mean observation period was 5.11 yr [standard error (SE) 0.09]. In the total period 1846 patients were treated with MDI and 1493 changed from MDI to CSII. In 2005, less than 5% of children were treated with CSII whereas the percentage of children on CSII increased to approximately 50% in 2011. The patients were divided into age groups, <5 yr, 5-10 yr, and > 15 yr.

RESULTS

HbA1c was significantly higher in MDI-treated children, +5.29 (CI 95% 4.29; 6.29 mmol/mol). HbA1c in all age groups was significantly lower in CSII-treated patients, and longitudinally HbA1c continued to be lower in all age groups. In multivariate analysis, a low HbA1c at CSII start, centers with more than 100 pump patients, a more recent year of diabetes onset, a higher number of self-monitoring of blood glucose (SMBG) measurements, a higher number of daily boluses, and a higher percentage of bolus insulin were all related to a lower HbA1c.

CONCLUSION

The percentage of children on pumps (CSII) is CSII treatment is associated with a significantly lower Hba1c, achieved just after treatment initiation. In the following years there is a parallel rise in HbA1c in both MDI as well as in MDI treated patients. Patients coming from larger clinics, and patients measuring more blood glucose values and taking more boluses have a better metabolic control.

Type 1 Diabetes in the Young: Organization of Two National Centers in Israel and Slovenia

Type 1 diabetes is a chronic autoimmune disease that affects mainly young people. In the last 50 years, a steady increase of the T1D incidence in the young is reported worldwide, with an average 4 % increase annually. In addition, the mean age at the diagnosis is decreasing. Studies show that good metabolic control is important not only for delaying the chronic complications of diabetes but also for improving the quality of life of patients and their families. Continuous education, together with modern technology, is crucial in achieving these goals. Longitudinal data on glycated hemoglobin (HbA1c), along with the data on severe hypoglycemia and severe diabetic ketoacidosis, can describe the quality of care in a defined population. Two national reference diabetes centres taking care of children, adolescents and young adults with diabetes in Israel and Slovenia are described.

The effectiveness and durability of an early insulin pump therapy in children and adolescents with type 1 diabetes mellitus

BACKGROUND

This study evaluated the predictors of effectiveness and durability of insulin pump therapy in children and adolescents who have initiated continuous subcutaneous insulin infusion (CSII) within 2 years after the diagnosis of type 1 diabetes mellitus (T1DM).

SUBJECTS AND METHODS

The charts of individuals with T1DM using insulin pumps who were treated at our center were reviewed, including subjects with age at onset of <22 years, interval between onset and insulin pump commencement (interval onset-commencement) of <2 years, use of pumps of >1 year, and use of glucose sensors for <4 weeks/year. The primary end point was the mean glycosylated hemoglobin (HbA1c) value (MHbA1c) throughout the follow-up.

RESULTS

From 684 patients treated with insulin pumps, 119 met the inclusion criteria, and 113 were selected for statistical analysis (60 females; age at diabetes onset, 8.9±5.6 years [mean±SD]; follow-up, 4.0±1.8 years; range, 1-8 years; baseline HbA1c, 9.3±1.8%). Only the interval onset-commencement was a linear predictor of the MHbA1c (P=0.01; R(2)=0.089). A significant reduction of the mean yearly HbA1c from baseline throughout all the follow-up was observed (P<0.001). Categorizing the sample into four quartiles on the basis of an increasing interval onset-commencement resulted in levels of MHbA1c significantly lower in the first and second quartiles in comparison with the fourth quartile (7.6±0.8% and 7.8±1.0%, respectively, versus 8.5±0.8%; P<0.001 and P=0.004, respectively).

CONCLUSIONS

The present study suggests that early pump commencement in children and adolescents with T1DM provides lower and more durable HbA1c values than a late commencement. It is possible that an early pump commencement could prolong the honeymoon phase, but we cannot confirm or exclude this hypothesis because the lack of data about C-peptide levels during the follow-up.

Can integrated technology improve self-care behavior in youth with type 1 diabetes? A randomized crossover trial of automated pump function

Automated blood glucose (BG) and insulin pump systems allow wireless transmission of all BG readings to a user's pump. This study aimed to assess whether use of such a system, as compared with a manual BG entry insulin pump, resulted in higher mean daily frequency of BGs recorded after 6 months. A 12-month randomized crossover trial, comprising 2 phases, was conducted. All participants used insulin pump devices with automated vs manual BG entry for 6 months each; order of system use was randomly assigned. Device interactions were assessed from pump and glucometer downloads. Thirty-five participants were enrolled; 9 withdrew during the study. Use of the automated insulin pump system resulted in higher mean daily BG recorded over 6 months of use when compared to a manual BG entry system (5.8 ± 1.7 vs 5.0 ± 1.9; P = .02 [95% confidence interval, 0.14 to 1.58]). Bolus frequency was similar between groups. No HbA1c difference was observed between groups at 6 months (8.0% [64 mmol/l] ± 1.3 automated vs 7.7% [61 mmol/l] ± 0.9 manual; P = .38). Post hoc analysis demonstrated improved ΔHbA1c with automated system use in an adolescent subgroup with suboptimal baseline BG frequency (-0.9% vs + 0.5%; P = .003). Use of an automated glucometer/insulin pump resulted in higher number of BGs recorded over 6 months when compared to an insulin pump with manual BG entry. This may be especially beneficial for adolescent manual system users who enter <5 BGs per day into their pump.

Insulin pump therapy: impact on the lives of children/young people with diabetes mellitus and their parents

BACKGROUND

Advances in medical technology and research documenting clinical effectiveness have led to the increased use of insulin pumps worldwide. However, their use by children in the UK is relatively limited and there is little evidence regarding their impact on patients' lives.

OBJECTIVE

This study aimed to examine the impact of switching from multiple daily injections to insulin pumps on the glycaemic control and daily lives of children/young people and their families.

SETTING

University College London Hospital, London.

METHOD

Face-to-face semi-structured interviews were conducted with children/young people with type 1 diabetes mellitus (5-17 years; N = 34) and their parents (N = 38), receiving insulin pump therapy and attending paediatric diabetes outpatients clinics at a major university teaching hospital in London. Glycated haemoglobin A1c values from 6 months prior to, and after pump therapy were obtained. Qualitative and quantitative approaches were undertaken for data analysis.

MAIN OUTCOME MEASURE

Glycated haemoglobin A1c and the impact of the use of insulin pumps on the children and their families.

RESULTS

The majority of parents (N = 32) and the children/young people (N = 30) reported that glycaemic control was easier to maintain within the target range with pumps compared to injections. This was supported by glycated haemoglobin A1c measures. Participants generally found the devices easy to use and more acceptable than injections. However, parents and children/young people reported many challenges in the early stages of pump therapy (e.g. 7 children/young had worse control at 6 months after starting CSII). Parents and children/young people reported an overall increase in lifestyle flexibility and an improved ability to participate in home, school and social activities whilst maintaining glycaemic control.

CONCLUSION

Administration of insulin via pumps rather than injections was generally preferred. Participants reported most difficulty at the commencement of use. Pump therapy conferred benefits in terms of glycaemic control, general well-being, enabling young people to be more in control of their condition and live more normal lives, as reported by most participants. These are important goals of health policy for children/young people with long-term conditions in the UK.

A 7-year follow-up retrospective, international, multicenter study of insulin pump therapy in children and adolescents with type 1 diabetes

We evaluated the long-term glycemic control in children with type 1 diabetes, using continuous subcutaneous insulin infusion (CSII) for at least 5 years in three diabetes centers from three different countries: Canada, Italy and Spain. This was an observational retrospective multicenter cohort study. Subjects were included if they were followed at one of the participating centers, had type 1 diabetes, age 5-20 years at time of data collection and used CSII for more than 5 years. Data collected included gender, age, disease duration, age at CSII initiation, body mass index (BMI), hemoglobin A1c (HbA1c), insulin requirement and serious adverse events (SAE) at baseline and every 12 months during follow-up. One hundred fifteen patients were included in the study (55% males), aged 5-20 years (mean: 13.5 ± 3.8 years), with mean diabetes duration of 6.3 ± 3.4 years, using CSII for mean of 6.9 ± 1.2 years (range 5-12 years.). HbA1c significantly improved after 1 year of CSII treatment and during follow-up (p = 0.02). When HbA1c was compared between countries, a difference was observed, with slightly lower values in Italy than in Canada and Spain (p = 0.04). When evaluated by gender, HbA1c was similar at baseline, but significantly improved only in males during all follow-up (p = 0.004). No significant differences were observed for BMI, insulin requirement or SAE. Insulin pump therapy is safe and effective in the pediatric population, although in this study, the major benefit in HbA1c was seen in males. The use of advanced pump features was associated with greater improvement in HbA1c.

Race, socioeconomic status, and treatment center are associated with insulin pump therapy in youth in the first year following diagnosis of type 1 diabetes

BACKGROUND

Increasing numbers of children and adolescents with type 1 diabetes (T1D) have been placed on insulin pump therapy. Nevertheless, data are limited regarding patterns of pump use during the first year of treatment and the clinical and socioeconomic factors associated with early use of pump therapy. Therefore, we sought to determine factors associated with pump therapy within the first year of diagnosis in youth enrolled in the Pediatric Diabetes Consortium (PDC) T1D New-Onset (NeOn) Study.

SUBJECTS AND METHODS

The NeOn Study includes youth <19 years old at T1D diagnosis who have been followed from the time of diagnosis at seven U.S. pediatric diabetes centers. Cox regression was used to determine factors associated with transition from injection to pump therapy during the first year of T1D in 1,012 participants.

RESULTS

Twenty-seven percent (n=254) of participants began pump therapy within the first year of diagnosis, ranging from 18% to 59% among the seven centers. After adjusting for center effect, factors associated with pump use in multivariate analysis included private health insurance (37% vs. 7%; P<0.001), having annual household income over $100,000 (50% vs. 15%; P<0.001), and non-Hispanic white race (36% vs. 11%; P<0.001). The hemoglobin A1c level did not appear to influence the decision to initiate pump use.

CONCLUSIONS

Participants of non-Hispanic white race and higher socioeconomic status were more likely to be placed on pumps during the first year. Further investigations are needed to gain a better understanding of barriers to use of pumps in youth with T1D, especially in disadvantaged and minority families.

Demographic and personal factors associated with metabolic control and self-care in youth with type 1 diabetes: a systematic review

Optimal use of recent technological advances in insulin delivery and glucose monitoring remain limited by the impact of behaviour on self-care. In recent years, there has been a resurgence of interest in psychosocial methods of optimizing care in youth with type 1 diabetes. We therefore sought to examine the literature for demographic, interpersonal and intrapersonal correlates of self-care and/or metabolic control. Studies for this systematic review were obtained via an electronic search of Medline, Embase, Cumulative Index to Nursing and Allied Health Literature and PsycINFO databases. Seventy studies fulfilled the inclusion criteria. These studies have indicated that identifiable individual characteristics in each domain are robustly associated with metabolic control and/or self-care in children and adolescents. We present these characteristics and propose a theoretical model of their interactions and effect on diabetes outcomes. There is currently no consensus regarding patient selection for insulin pump therapy. In this era of scarce healthcare resources, it may be prudent to identify youth requiring increased psychosocial support prior to regimen intensification. The importance of this review lies in its potential to create a framework for rationally utilizing resources by stratifying costly therapeutic options to those who, in the first instance, will be most likely to benefit from them.

Quality of life and technology: impact on children and families with diabetes

Ensuring quality of life (QOL) while maintaining glycemic control within targets is an important challenge in type 1 and type 2 diabetes treatment. For children with diabetes, QOL includes enjoying meals, feeling safe in school, and perceiving positive, supportive relationships with parents, siblings, and friends. Yet many treatment-related and psychosocial barriers can interfere with a child's QOL and their ability to manage diabetes effectively. Diabetes management also imposes considerable lifestyle demands that are difficult and often frustrating for children to negotiate at a young age. Recent advances in diabetes medications and technologies have improved glycemic control in children with diabetes. Two widely used technologies are the insulin pump and continuous glucose monitoring (CGM) system. These technologies provide patients with more flexibility in their daily life and information about glucose fluctuations. Several studies report improvements in glycemic control in children with type 1 diabetes using the insulin pump or sensor-augmented pump therapy. Importantly, these technologies may impact QOL for children and families with diabetes, although they are rarely used or studied in the treatment of children with type 2 diabetes. Further, emerging closed loop and web- and phone-based technologies have great potential for supporting diabetes self-management and perhaps QOL. A deeper understanding and appreciation of the impact of diabetes technology on children's and parents' QOL is critical for both the medical and psychological care of diabetes. Thus, the purpose of this review is to discuss the impact of new diabetes technologies on QOL in children, adolescents and families with type 1 diabetes.

Which factors predict glycemic control in children diagnosed with type 1 diabetes before 6.5 years of age?

Predictors of long-term glycemic control and growth patterns in children diagnosed with type 1 diabetes (T1D) before 6.5 years of age were evaluated. One hundred seventy-three children (84 boys) with a mean diabetes duration of 4.9 ± 2.8 years participated in this observational study. Medical charts were reviewed for background, disease- and treatment-related parameters, and growth parameters. Study endpoints were HbA1c value, rates of severe hypoglycemia and diabetic ketoacidosis events, and growth patterns. Mean HbA1c for the total duration of diabetes (HbA1c-TDD) was 7.9 ± 0.8%. Comparison of the study variables between patients with HbA1c-TDD <7.5% (n = 53) or ≥7.5% yielded a significantly shorter duration of diabetes (P = 0.01) and lower rate of diabetic ketoacidosis (P = 0.02) in those with HbA1C-TDD <7.5%, without differences between these groups in age at diabetes onset, insulin regimens, daily glucose measurements, and rate of severe hypoglycemia. Factors significantly predicting achievement of the mean target HbA1c-TDD <7.5% were lower HbA1c at 0.5 years and 1 year after diabetes diagnosis (P = 0.002 and P < 0.001, respectively). Patients followed for at least 5 years (n = 48) showed a significant decrease in height-SDS (P < 0.001) and a significant increase in weight-SDS (P = 0.004) from diabetes diagnosis to the last follow-up visit, without a significant change in weight-SDS from 0.5 years after diagnosis to the last follow-up visit. Our results suggest that in patients with T1D diagnosed during the preschool-age, mean HbA1c level in the first year is a strong predictor of achieving target HbA1c level in the subsequent years, regardless the type of insulin regimen. This "metabolic tracking" emphasizes the importance of achieving early optimal control even in younger children.

Does the timing of insulin pump therapy initiation after type 1 diabetes onset have an impact on glycemic control?

BACKGROUND

Continuous subcutaneous insulin infusion (CSII) mimics physiologic insulin release better than multiple daily injection (MDI) therapy and allows for greater flexibility in food intake and physical activity. Given these benefits, it raises the question "Is it required to wait to offer CSII to patients with type 1 diabetes (T1D) only after MDI therapy has failed"? This study sought to determine if starting CSII in patients with T1D within 1 year of diagnosis results in better long-term glycemic control than starting it later.

METHODS

This retrospective observational study was conducted in a tertiary-care medical center. The charts of 488 patients with T1D (273 females) 2.6-39 years old (mean, 19.9 ± 7.7 years) who started CSII in 1998-2008 and used it for at least 1 year were reviewed for background, disease-related, and treatment-related variables. Study end points were glycosylated hemoglobin (HbA1c) level, rate of severe hypoglycemia, and diabetic ketoacidosis events during CSII use. Findings were compared between patients who started CSII within 1 year of diagnosis (Group 1, n=93) or later (Group 2, n=395).

RESULTS

Compared with Group 2, Group 1 patients were characterized by a significantly younger age at CSII initiation (10.7±5.7 vs. 16.4±7.0 years, P<0.001), more frequent blood glucose monitoring (5.4 ± 1.8 vs. 3.9 ± 1.5 times per day, P<0.001), and shorter total duration of diabetes (4.3 ± 2.1 vs. 11.9 ± 6.4 years, P<0.001) and of CSII therapy (3.6 ± 2.1 vs. 4.7 ± 2.5 years, P<0.001). There were no significant between-group differences in patient gender or ethnicity, indications for initiating CSII, mean HbA1c level, attainment of target HbA1c, or rates of severe hypoglycemia or ketoacidosis events after CSII initiation.

CONCLUSIONS

Starting pump therapy at an early disease stage has no added benefit for glycemic control over time than starting later. The timing of CSII initiation should be tailored to the individual patient by the diabetes care team.

Recent advances in the prevention of hypoglycemia in type 1 diabetes

Iatrogenic hypoglycemia is one of the chief barriers to optimal glycemic control in people with type 1 diabetes (T1D). As a common contributor to morbidity and mortality in T1D, severe hypoglycemia (SH) is also a major fear for people with T1D and their families. Consequently, fear of hypoglycemia and hypoglycemia-avoidant behaviors are predominant limiting factors in achieving euglycemia in people with T1D. Nocturnal SH and hypoglycemia unawareness are prevalent obstacles in the detection of hypoglycemia which further impair the prevention and treatment of SH. Various strategies and technologies have already been developed to help detect and prevent hypoglycemia, including improved patient education, frequent self-monitoring of blood glucose levels, the use of rapid-acting and basal insulin analogs, continuous subcutaneous insulin infusion therapy, exercise-related insulin modifications, and continuous glucose monitors. The efficacy of these methods is well established, but further advances are still needed. The purpose of this review is to describe these currently available methods and to emphasize recent progress related to the prevention of hypoglycemia in T1D.

Diabetes technology and treatments in the paediatric age group

Type 1 diabetes (T1D) is one of the most common chronic childhood diseases and its incidence has doubled during the last decade. The goals of intensive management of diabetes were established in 1993 by the Diabetes Control and Complications Trial (DCCT) (1). Children with T1D and their caregivers continue to face the challenge to maintain blood glucose levels in the near-normal range. It is important to prevent sustained hyperglycaemia which is associated with long-term microvascular and macrovascular complications and to avoid recurrent episodes of hypoglycaemia or hyperglycaemia, especially in young children, which may have adverse effects on cognitive function and impede efforts to achieve the recommended glycaemic targets. Advances in the use of technology that may help maintain the metabolic control goals for young people with T1D were centred on continuous subcutaneous insulin infusion (CSII) (2-4), continuous glucose monitoring (CGM) (5-7), and combining both technologies into a closed-loop system (8-10). The dilemma in paediatrics of patient selection for insulin pump therapy was found to be most successful in those with more frequent self-monitoring of blood glucose (SMBG) and younger age prior to pump initiation (2). Similarly, those who used a dual-wave bolus probably paid closer attention to their management and had lower HbA1c levels (3). The advantage of using a pre-meal bolus to improve postprandial glucose levels was shown to offer another potential method to improve glycaemic control (4). SMBG is an important component of therapy in patients with diabetes, especially in the paediatric age group. Standard use of glucose meters for SMBG provides only intermittent single blood glucose levels, without giving the 'whole picture' of glucose variability during the 24 h, and especially during the night, when blood glucose levels are seldom measured. Therefore, the use of a device such as real-time continuous glucose monitoring (RT-CGM) that provides continuous glucose measurements can help patients optimise glycaemic control. These devices may have the potential to increase the proportion of patients who are able to maintain target HbA1c values, to decrease glucose excursions and to decrease the risk of severe hypoglycaemia. Previous studies in paediatric T1D patients (11,12) have demonstrated that the frequency of CGM use was significantly associated with the effect of lowering HbA1c levels. The important STAR 3 study of 485 patients (156 children) with T1D showed the benefit of sensor-augmented pump therapy over remaining on multiple daily injections (MDI) (10). The Juvenile Diabetes Research Foundation Continuous Glucose Monitoring (JDRF-CGM) studies were initially described in the 2009 Yearbook (13). Further reports of youths and adults in this study found that those with initial low HbA1c levels (< 7%) show a significant benefit from the use of CGM (5). Prolonged nocturnal hypoglycaemia was shown to continue to be a common occurrence in the entire cohort using CGM (7). Thus, there is an obvious need for closing the loop. Many patients with diabetes and especially parents of diabetic children dream about the invention of an 'artificial pancreas'. CSII and RT-CGM can be combined to form closed-loop systems. Insulin is then delivered according to RT-CGM data, as directed by a control algorithm, rather than at pre-programmed rates. Few closed-loop prototypes have been developed with advanced control algorithms, such as those that are based on model predictive control (14). The group at Cambridge studied 19 young people in closed-loop systems and was able to demonstrate that exercise and diet variations could be aptly managed (9). It is expected that closed-loop studies in young people will continue to multiply in future years. T1D is characterised by immune-mediated pancreatic β-cell destruction. Thus, a major goal in the treatment of T1D in youth will be in the area of prevention. The identification of increased levels of inflammatory markers in the SEARCH study of young people with T1D may provide an important clue (15). Most of the studies countered the diabetes process by immunomodulation and/or enhancement of β-cell proliferation and regeneration (16). An initial pilot trial of a tumour necrosis factor α (TNF-α) binding agent, Entanercept, showed benefit in preserving C-peptide production in 18 young people with newly diagnosed T1D. HbA1c levels were also lower in the treatment group (5.9% ± 0.5% vs. 6.98% ± 1.2%; p < 0.05) (17). Similarly, β-cell function was shown to be preserved in children receiving the lower of two doses of ingested human recombinant interferon-α (hrINF-α) in comparison with subjects who received placebo (18). A future larger trial of both of these agents will be of interest. In this review of the literature we have tried to select recent publications that offer some insight into these issues in paediatric patients with T1D.

Factors associated with increased risk of insulin pump discontinuation in pediatric patients with type 1 diabetes

BACKGROUND

There are few reports on rates and predictors for pump discontinuation in the pediatric population.

OBJECTIVE

To study the rate of and predictors for insulin pump discontinuation among pediatric patients with type 1 diabetes.

METHODS

Medical chart review of 530 patients with type 1 diabetes who had started pump therapy between 2000 and 2008 in our center revealed that 11.3% had discontinued pump use after 3 d to 5 yr; of these, 9.1% discontinued pump use at least 3 months after initiation. Relevant data were retrieved from the files of these patients and from those of 100 randomly assigned pump-treated patients.

RESULTS

The pump discontinuation group had a significantly higher proportion of female patients (75 vs. 46%, p = 0.001) and patients above 10 yr of age (93.8 vs. 80%, p = 0.03) than the reference group. Comparable findings were noted for age at diagnosis, pubertal stage, anthropometric data and duration of diabetes at pump initiation, rate of severe hypoglycemic and diabetic ketoacidosis episodes. There were no between-group differences in number of daily insulin injections and blood glucose measurements before pump treatment. At pump initiation, HbA(1c) was significantly higher in patients discontinuing pump therapy than in the controls (8.6 ± 1.4 vs. 8.1 ± 1.0, p = 0.02). This difference was maintained at the last follow-up visit recorded.

CONCLUSIONS

Almost 90% of our cohort maintained pump therapy. Female gender, age older than 10 years in girls and poor metabolic control at pump initiation were associated with higher risk for pump discontinuation - for such patients intensified individual and family support may serve to maximize persistent pump therapy.

Fear of hypoglycemia in type 1 diabetes managed by continuous subcutaneous insulin infusion: is it associated with poor glycemic control?

BACKGROUND

We surveyed the extent of fear of hypoglycemia in people with type 1 diabetes treated by continuous subcutaneous insulin infusion (CSII) and tested the hypothesis that suboptimal glycemic control during CSII is related to fear of hypoglycemia.

METHODS

We audited nonpregnant type 1 diabetes patients attending an Insulin Pump Clinic with at least 6 months' duration of CSII. In 104 eligible subjects, fear of hypoglycemia was assessed by questionnaire; 75 responded.

RESULTS

The median duration of CSII was 5 years (range, 1-29 years). Poor glycemic control (hemoglobin A1c [HbA1c] ≥ 8.5%; mean ± SD, 9.1 ± 1.0%) was present in 27%, and this group had more men than a good-control group with HbA1c < 7.0% (43% vs. 11%). Substantial fear of hypoglycemia (score > 50%) occurred in 27% of subjects, but fear of hypoglycemia was not correlated with HbA1c. The only significant correlates of fear of hypoglycemia were accumulated episodes of severe hypoglycemia (r = 0.48, P < 0.001) and rate of hypoglycemia on CSII (r = 0.48, P < 0.001). The HbA1c on CSII was correlated with multiple daily injection (MDI) HbA1c (r = 0.66, P < 0.001) and the change in HbA1c (r = 0.63, P < 0.001).

CONCLUSIONS

Fear of hypoglycemia is not correlated with, and is unlikely to be a major determinant of, HbA1c on CSII. Other factors (such as HbA1c on MDI and adherence to insulin pump procedures) are likely to be more important. Nevertheless, substantial fear of hypoglycemia is present in many CSII-treated people and may adversely affect quality of life and psychological well-being.