Persistent differences among centers over 3 years in glycemic control and hypoglycemia in a study of 3,805 children and adolescents with type 1 diabetes from the Hvidøre Study Group

Perceptions of diabetes management among adolescents with type 1 diabetes and their caregivers: development and validation of the Japanese version of the diabetes family responsibility questionnaire

The shift in diabetes management responsibility is critical for adolescents with type 1 diabetes (T1D). Currently, in Japan, there is insufficient progress in the development of scales for evaluating diabetes management responsibility. We developed the Japanese version of the Diabetes Family Responsibility Questionnaire (DFRQ), a scale to evaluate diabetes management responsibility, and verified its reliability and validity. We recruited 12-18-year-old adolescents with T1D and their caregivers. The DFRQ questionnaires (DFRQ-A for adolescents and DFRQ-C for caregivers) were distributed. The responses of 31 pairs were analyzed (adolescents: 9 males, 22 females; mean age: 14.8 ± 1.5 years). The median total DFRQ scores of adolescents (30.0) and caregivers (32.0) were not significantly different (p = 0.269). The internal consistencies (Cronbach's α) were 0.784 and 0.687 for DFRQ-A and DFRQ-C, respectively. DFRQ-A scores and adolescent age demonstrated a weak statistically significant negative correlation (r =  - 0.397, p = 0.027), whereas DFRQ-C scores and adolescent age demonstrated a weak negative correlation not statistically significant (r =  - 0.311, p = 0.089). Both scores were significantly negatively correlated with self-efficacy for diabetes self-management scores (r =  - 0.390, p = 0.030; r =  - 0.478, p = 0.006, respectively). Furthermore, a significantly moderate positive correlation was found between these scores (r = 0.624, p < 0.001). We confirmed the reliability and validity of the Japanese version of DFRQ. DFRQ is expected to be used as a dyadic scale to evaluate the status of diabetes management responsibility and its transition during adolescence in Japan.

Adolescents with type 1 diabetes can achieve glycemic targets on intensive insulin therapy without excessive weight gain

Introduction

The aim of this study was to compare glycemic control and body mass index standard deviation score (BMI‐SDS) before and after implementation of intensive insulin therapy using multiple daily injection (MDI) or continuous subcutaneous insulin infusion (CSII) in adolescents with type 1 diabetes (T1D) attending a large multidisciplinary paediatric diabetes clinic in Australia.

Methods

Prospective data were collected for cross‐sectional comparison of youth aged 10.0–17.9 years (n = 669) from routine follow‐up visits to the diabetes clinic in 2004, 2010, and 2016. Outcome measures included HbA1c; BMI‐SDS; and insulin regimen.

Results

BMI‐SDS remained stable between 2004 to 2016 in the 10–13 and 14–17 year age group (0.7 vs. 0.5, p = .12 and 0.7 vs. 0.7, p = .93, respectively). BMI‐SDS was not different across HbA1c groups; <53 mmol/mol (7.0%), 53 to <75 mmol/mol (<7.0 to <9.0%) and >75 mmol/mol (>9.0%) in 2004 (p = .873), 2010 (p = .10) or 2016 (p = .630). Mean HbA1c decreased from 2004 to 2016 in the 10–13 year (69 mmol/mol (8.4%) vs. 57 mmol/mol (7.4%), p = <.001) and 14–17 year group (72 mmol/mol (8.7%) vs. 63 mmol/mol (7.9%), p = <.001). Prior to the implementation of MDI and CSII in 2004 only 10% of 10–13 year olds and 8% of 14–17 year olds achieved the international target for glycemic control (HbA_1c 53 mmol/mol [<7.0%]). In 2016, this increased to 31% of 10–13 year olds and 21% of 14–17 year olds.

Conclusions

BMI‐SDS did not increase with the change to intensive insulin therapy despite a doubling in the number of adolescents achieving the recommended glycemic target of <7.0% (53 mmol/mol). HbA1c was not associated with weight gain.

Center differences in diabetes treatment outcomes among children with type 1 diabetes: A nationwide study of 3866 Danish children

OBJECTIVE

Mean differences in HbA_1c across centers are well established, but less well understood. The aim was to assess whether differences in patient case-mix can explain the variation in mean HbA_1c between pediatric diabetes centers in Denmark. The association between HbA_1c , frequency of blood glucose monitoring (BGM), treatment modality, and center visits was investigated.

RESEARCH DESIGN AND METHODS

This longitudinal nationwide study included 3866 Danish children with type 1 diabetes from 2013 to 2017 (n = 12,708 child-year observations) from 16 different pediatric diabetes centers. Mean HbA_1c , proportion of children reaching HbA_1c treatment target (HbA_1c  ≤ 58 mmol/mol [7.5%]) were compared across centers using linear regression models. This was done with and without adjustment for socioeconomic characteristics (patient case-mix).

RESULTS

The mean difference in HbA_1c during follow-up was 11.6 mmol/mol (95% CI 7.9, 15.3) (1.1% [95% CI 0.7, 1.4]) when comparing the centers with the lowest versus highest mean HbA_1c . The difference was attenuated and remained significant after adjustment for the patient case-mix (difference: 10.5 mmol/mol [95% CI 6.8, 14.2] (1.0% [95% CI 0.6, 1.3])). Overall, 6.8% of the differences in mean HbA_1c across centers were explained by differences in the patient case-mix. Across centers, more frequent BGM was associated with lower HbA_1c . The proportion of insulin pump users and number of visits was not associated with HbA_1c .

CONCLUSION

In a setting of universal health care, large differences in HbA_1c across centers were found, and could not be explained by patient background, number of visits or use of technology. Only BGM was associated with center HbA_1c .

Lower HbA1c targets are associated with better metabolic control

Previous studies have suggested that clear HbA1c target setting by the diabetes team is associated with HbA1c outcomes in adolescents. The aim of this study was to evaluate whether this finding is consistent in a larger cohort of children from centers participating in the SWEET international diabetes registry. A questionnaire was sent out to 76 SWEET centers, of which responses from 53 pediatric centers were included (70%). Descriptive outcomes were presented as median with lower and upper quartile. The association between the centers' target HbA1c and mean outcome HbA1c was calculated using linear regression adjusted for age, diabetes duration, sex, and gross domestic product. Median age of the children in the studied centers (n = 35,483) was 13.3 [12.6-14.6] years (49% female). Of the 53 centers, 13.2% reported an HbA1c target between 6.0 and 6.5%, 32.1% had a target between ≥ 6.0 and 7.0%, 18.9% between ≥ 7.0 and 7.5%, and 3.8% between ≥ 7.5 and 8.5%. No specific target value was reported by 32.1% of all centers. Median HbA1c across all centers was 7.9 [7.6-8.3] %. Adjusted regression analysis showed a positive association between HbA1c outcome and target HbA1c (p = 0.005).Conclusions: This international study demonstrated that a lower target for HbA1c was associated with better metabolic control. It is unclear whether low target values result in better metabolic control, or lower HbA1c values actually result in more ambitious target values. This target setting could contribute to the differences in HbA1c values between centers and could be an approach for improving metabolic outcomes. What is Known: • Target setting of HbA1c is important in children and adolescents with type 1 diabetes. • The optimal therapeutic approach of children with type 1 diabetes requires a trained multidisciplinary team. What is New: • Lower HbA1c targets are associated with better metabolic control. • No associations between the composition of the diabetes teams and metabolic control could be demonstrated.

Systematic review and meta-analysis of randomized controlled trials of psychological interventions to improve glycaemic control in children and adults with type 1 diabetes

AIM

We conducted a systematic review aggregate and network meta-analysis of psychological interventions for people with type 1 diabetes to assess their effectiveness in improving glycaemic levels.

METHODS

We searched the following databases from 1 January 2003 to 1 July 2018: MEDLINE, CINAHL, PsycINFO, Embase, Cochrane Controlled Trials, Web of Science, clinicaltrials.gov, Dissertation Abstract International. We included randomized controlled trials (RCT) of psychological interventions for children and adults with type 1 diabetes reported in any language. We extracted data on publications, participant characteristics at baseline, intervention and control group, and data for the primary outcome, change in glycaemic control [HbA_1c (mmol/mol/%)]. Study authors were contacted for missing data. The review was registered with international prospective register of systematic reviews registration (PROSPERO) CRD42016033619.

RESULTS

Twenty-four adult RCTs and 23 of children with type 1 diabetes were included in the systematic review. In aggregate meta-analysis there was no overall effect of psychological intervention compared with control on HbA_1c [adults, nine RCTs, n = 1102, pooled mean difference -0.12, 95% confidence intervals (CI) -0.27 to 0.03, I² = 29.0%, P = 0.19; children, 20 RCTs, n = 2567, -0.09, 95% CI -0.22 to 0.04, I² =54.0% P=0.002]. Network meta-analysis suggested that probability and rank-ordering of effectiveness is highest for attention control groups (b = -0.47, 95% CI -0.80 to -0.12) followed by cognitive behavioural therapy (CBT) (-0.26, 95% CI -0.45 to -0.06) compared with usual care for adults.

CONCLUSIONS

Overall psychological interventions for children and adults with type 1 diabetes do not improve glycaemic control. For adults, CBT-based interventions have the potential to be effective.

Supplementary Nitric Oxide Donors and Exercise as Potential Means to Improve Vascular Health in People with Type 1 Diabetes: Yes to NO?

Type 1 diabetes (T1D) is associated with a greater occurrence of cardiovascular pathologies. Vascular dysfunction has been shown at the level of the endothelial layers and failure to maintain a continuous pool of circulating nitric oxide (NO) has been implicated in the progression of poor vascular health. Biochemically, NO can be produced via two distinct yet inter-related pathways that involve an upregulation in the enzymatic activity of nitric oxide synthase (NOS). These pathways can be split into an endogenous oxygen-dependent pathway i.e., the catabolism of the amino acid L-arginine to L-citrulline concurrently yielding NO in the process, and an exogenous oxygen-independent one i.e., the conversion of exogenous inorganic nitrate to nitrite and subsequently NO in a stepwise fashion. Although a body of research has explored the vascular responses to exercise and/or compounds known to stimulate NOS and subsequently NO production, there is little research applying these findings to individuals with T1D, for whom preventative strategies that alleviate or at least temper vascular pathologies are critical foci for long-term risk mitigation. This review addresses the proposed mechanisms responsible for vascular dysfunction, before exploring the potential mechanisms by which exercise, and two supplementary NO donors may provide vascular benefits in T1D.

Effectiveness of Continuous Subcutaneous Insulin Infusion Pump Therapy During Five Years of Treatment on Metabolic Control in Children and Adolescents with Type 1 Diabetes Mellitus

OBJECTIVE

To compare continuous subcutaneous insulin infusion (CSII) therapy with multiple daily insulin (MDI) therapy on metabolic control in children and adolescents with type 1 diabetes mellitus (T1DM) over the long term.

METHODS

Fifty-two T1DM patients treated with CSII and monitored for at least one year prior to and at least five years following CSII were included. Thirty-eight age and sex-matched MDI controls with a 5-year follow up were recruited.

RESULTS

Mean age of the subjects, duration of diabetes and CSII therapy were 17.0±4.8 years, 10.7±2.8 years and 7.7±1.5 years respectively. Mean hemoglobin A1c (HbA1c) in the year prior to CSII, during the first year of treatment and after 5 years of CSII were 7.3±1% (56 mmol/mol), 7.0±0.7% (53 mmol/mol) and 7.8±1.3% (62 mmol/mol) respectively. Initial and 5-year mean HbA1C levels of controls were 7.9±1.08% and 8.6±1.8%. Mean HbA1c values were significantly lower in those receiving CSII therapy throughout follow-up. Basal and total insulin doses were significantly lower in the CSII group at all times. HbA1c was compared between subjects by age (0-5, 6-11 and 12-18 years) with no significant difference between them.

CONCLUSION

Although CSII mean HbA1c values exceeded accepted good metabolic control limits after 5 years, CSII produces better HbA1c control at all times and in all age groups compared to MDI.

Exploring Variation in Glycemic Control Across and Within Eight High-Income Countries: A Cross-sectional Analysis of 64,666 Children and Adolescents With Type 1 Diabetes

OBJECTIVE

International studies on childhood type 1 diabetes (T1D) have focused on whole-country mean HbA_1c levels, thereby concealing potential variations within countries. We aimed to explore the variations in HbA_1c across and within eight high-income countries to best inform international benchmarking and policy recommendations.

RESEARCH DESIGN AND METHODS

Data were collected between 2013 and 2014 from 64,666 children with T1D who were <18 years of age across 528 centers in Germany, Austria, England, Wales, U.S., Sweden, Denmark, and Norway. We used fixed- and random-effects models adjusted for age, sex, diabetes duration, and minority status to describe differences between center means and to calculate the proportion of total variation in HbA_1c levels that is attributable to between-center differences (intraclass correlation [ICC]). We also explored the association between within-center variation and children's glycemic control.

RESULTS

Sweden had the lowest mean HbA_1c (59 mmol/mol [7.6%]) and together with Norway and Denmark showed the lowest between-center variations (ICC ≤4%). Germany and Austria had the next lowest mean HbA_1c (61-62 mmol/mol [7.7-7.8%]) but showed the largest center variations (ICC ∼15%). Centers in England, Wales, and the U.S. showed low-to-moderate variation around high mean values. In pooled analysis, differences between counties remained significant after adjustment for children characteristics and center effects (P value <0.001). Across all countries, children attending centers with more variable glycemic results had higher HbA_1c levels (5.6 mmol/mol [0.5%] per 5 mmol/mol [0.5%] increase in center SD of HbA_1c values of all children attending a specific center).

CONCLUSIONS

At similar average levels of HbA_1c, countries display different levels of center variation. The distribution of glycemic achievement within countries should be considered in developing informed policies that drive quality improvement.

Type 1 diabetes during adolescence: International comparison between Germany, Austria, and Sweden

OBJECTIVES

By using pediatric diabetes quality registries in Austria, Germany, and Sweden treatment of type 1 diabetes and the outcome of care during the vulnerable adolescence period were compared.

METHODS

Data in DPV, broadly used in Austria and Germany, and Swediabkids used in Sweden, from clinical visits in the year 2013 on 14 383 patients aged 11 to 16 years regarding hemoglobin A1c (HbA1c), insulin regimen, body mass index (BMI)-SD score (SDS), blood pressure, hypoglycemia, ketoacidosis, and smoking habits were analyzed.

RESULTS

Patients in Sweden had fewer clinical visits per year (P < .05), lower insulin dose per kg (P < .001), and lower proportion of fast acting insulin compared with Germany and Austria (P < .001). The proportion of pump users was higher in Sweden (P < .001). Patients in Sweden had lower mean HbA1c levels (Austria: 64 mmol/mol, Germany: 63 mmol/mol, and Sweden: 61 mmol/mol [8.0%, 7.9%, and 7.7%, respectively]; P < .001). The frequency of severe hypoglycemia was higher in Sweden while it was lower for ketoacidosis (3.3% and 1.1%, respectively) than in Austria (1.1% and 5.3%) and Germany (2.0% and 4.4%) (P < .001). Girls in all 3 countries had higher HbA1c and BMI-SDS than boys.

CONCLUSIONS

Sharing data between diabetes registries and nations enables us to better understand differences in diabetes outcome between countries. In this particular comparison, pediatric patients with diabetes in Sweden were more often treated with insulin pump, had lower HbA1c levels and a higher rate of severe hypoglycemia. Patients in Austria and Germany used rapid acting insulin analogs more often and had a lower rate of ketoacidosis.

Targets and teamwork: Understanding differences in pediatric diabetes centers treatment outcomes

OBJECTIVE

The reason for center differences in metabolic control of childhood diabetes is still unknown. We sought to determine to what extent the targets, expectations, and goals that diabetes care professionals have for their patients is a determinant of center differences in metabolic outcomes.

RESEARCH DESIGN AND METHODS

Children, under the age of 11 with type 1 diabetes and their parents treated at the study centers participated. Clinical, medical, and demographic data were obtained, along with blood sample for centralized assay. Parents and all members of the diabetes care team completed questionnaires on treatment targets for hemoglobin A1c (HbA1c) and recommended frequency of blood glucose monitoring.

RESULTS

Totally 1113 (53% male) children (mean age 8.0 ± 2.1 years) from 18 centers in 17 countries, along with parents and 113 health-care professionals, participated. There were substantial differences in mean HbA1c between centers ranging from 7.3 ± 0.8% (53 mmol/mol ± 8.7) to 8.9 ± 1.1% (74 mmol/mol ± 12.0). Centers with lower mean HbA1c had (1) parents who reported lower targets for their children, (2) health-care professionals that reported lower targets and more frequent testing, and (3) teams with less disagreement about recommended targets. Multiple regression analysis indicated that teams reporting higher HbA1c targets and more target disagreement had parents reporting higher treatment targets. This seemed to partially account for center differences in Hb1Ac.

CONCLUSIONS

The diabetes care teams' cohesiveness and perspectives on treatment targets, expectations, and recommendations have an influence on parental targets, contributing to the differences in pediatric diabetes center outcomes.

Child and parental executive functioning in type 1 diabetes: Their unique and interactive role toward treatment adherence and glycemic control

OBJECTIVE

Managing type 1 diabetes (T1D) requires the ability to make complex and critical decisions regarding treatment, to execute complex tasks accurately, and to make adjustments when problems arise. This requires effective neuropsychological competences of patients and their families, especially in the domain of executive functioning (EF): the ability to self-monitor, plan, solve problems, and set priorities. Previous research focused mainly on child EF, neglecting the impact of parental EF. This study included both mothers and fathers and examined associations between child and parental EF and treatment adherence to T1D in a broad age range of patients.

METHODS

Parents of 270 patients (6-18 years) with T1D (mean age 12.7 years; 52.6% female) were included. Mothers (N = 232) and fathers (N = 168) completed questionnaires on child and parental EF and on treatment adherence. Analyses examined the associations linking child and parental EF to treatment adherence and glycemic control (and potential moderation effects in these associations) using hierarchical linear regression.

RESULTS

Child EF problems were negatively associated with treatment adherence. As an indication of moderation, this effect was stronger in older children. Better treatment adherence and glycemic control were reported when both child and parent showed less EF problems. Effects were more pronounced in mothers than in fathers.

CONCLUSIONS

This study demonstrated a significant interplay between child and parental EF in the association with treatment adherence and glycemic control. Researchers and clinicians should remain attentive toward the role of neuropsychological concepts such as EF. Implementation in clinical practice seems meaningful.

Continued improvement of metabolic control in Swedish pediatric diabetes care

BACKGROUND

To prospectively investigate if the grand mean HbA1c and the differences in mean HbA1c between centers in Sweden could be reduced, thereby improving care delivered by pediatric diabetes teams.

METHODS

We used an 18-month quality improvement collaborative (QIC) together with the Swedish pediatric diabetes quality registry (SWEDIABKIDS). The first program (IQ-1), started in April 2011 and the second (IQ-2) in April 2012; together they encompassed 70% of Swedish children and adolescents with diabetes.

RESULTS

The proportion of patients in IQ-1 with a mean HbA1c <7.4% (57 mmol/mol) increased from 26.4% before start to 35.9% at 36 months (P < .001), and from 30.2% to 37.2% (P < .001) for IQ-2. Mean HbA1c decreased in both participating and non-participating (NP) centers in Sweden, thereby indicating an improvement by a spatial spill over effect in NP centers. The grand mean HbA1c decreased by 0.45% (4.9 mmol/mol) during 36 months; at the end of 2014 it was 7.43% (57.7 mmol/mol) (P < .001). A linear regression model with the difference in HbA1c before start and second follow-up as dependent variable showed that QIC participation significantly decreased mean HbA1c both for IQ-1 and IQ-2. The proportion of patients with high HbA1c values (>8.7%, 72 mmol/mol) decreased significantly in both QICs, while it increased in the NP group.

CONCLUSIONS

The grand mean HbA1c has decreased significantly in Sweden from 2010 to 2014, and QICs have contributed significantly to this decrease. There seems to be a spatial spill-over effect in NP centers.

Clinic variation in glycaemic control for children with Type 1 diabetes in England and Wales: a population-based, multilevel analysis

AIM

To understand the scope for improving children's glycaemic outcomes by reducing variation between clinics and examine the role of insulin regimen and clinic characteristics.

METHODS

Cross-sectional analysis of 2012-2013 National Paediatric Diabetes Audit data from 21 773 children aged < 19 years with Type 1 diabetes cared for at 176 clinics organized into 11 regional diabetes networks in England and Wales. Variation in HbA_1c was explored by multilevel models with a random effect for clinic. The impact of clinic context was quantified by computing the per cent of total variation in HbA_1c which occurs between clinics (intraclass correlation coefficient; ICC).

RESULTS

Overall, 69 of the 176 diabetes clinics (39%) had a glycaemic performance that differed significantly from the national average after adjusting for patient case-mix with respect to age, gender, diabetes duration, deprivation and ethnicity. However, differences between clinics accounted for 4.7% of the total variation in HbA_1c . Inclusion of within-clinic HbA_1c standard deviation led to a substantial reduction in ICC to 2.4%. Insulin regimen, clinic volume and diabetes networks had a small or moderate impact on ICC.

CONCLUSIONS

Differences between diabetes clinics accounted for only a small portion of the total variation in glycaemic control because most of the variation was within clinics. This implies that national glycaemic improvements might best be achieved not only by targeting poor centres but also by shifting the whole distribution of clinics to higher levels of quality.

Diabetes knowledge in adolescents with type 1 diabetes and their parents and glycemic control

OBJECTIVE

To evaluate diabetes knowledge and skills (DKS) in adolescents (>10 year) with type 1 diabetes (T1D) and their parents, and its effect on glycemic control.

METHODS

A ready-to-use program and a standardized questionnaire comprising 50 true-false questions based on this program, were elaborated by a National Committee, to help dispensing education at diagnosis of T1D. The questionnaire was completed by 2933 T1D patients (49% girls, 51% boys; 14.1 ± 2.5 year), 2180 mothers and 798 fathers, in 115 pediatric centers. Associations between DKS score (number of correct answers), glycated hemoglobin (HbA1c) and sociofamilial characteristics were assessed.

RESULTS

DKS score increased with age, and was higher in girls than in boys and in mothers than in fathers; it correlated strongly between adolescents and their own parents; it was higher when adolescents had previously participated in diabetes camp and when parents had higher academic levels. HbA1c decreased significantly with parents' higher DKS score and academic level, and when both parents lived together. Mean adolescent DKS score was significantly higher in patients with HbA1c below 8% or 8.5% than for patients with HbA1c above these thresholds.

CONCLUSION

A large survey in T1D children and adolescents and their parents showed associations between DKS and glycemic control, and the major role of sociofamilial factors.

Accurate Carbohydrate Counting Is an Important Determinant of Postprandial Glycemia in Children and Adolescents With Type 1 Diabetes on Insulin Pump Therapy

BACKGROUND

Carbohydrate (CHO) counting is a key nutritional intervention utilized in the management of diabetes to optimize postprandial glycemia. The aim of the study was to examine the impact of accuracy of CHO counting on the postprandial glucose in children and adolescents with type 1 diabetes on insulin pump therapy.

METHODS

Children/adolescents with type 1 diabetes who were on insulin pump therapy for a minimum of 6 months are enrolled in the study. Patients were instructed to record details of meals consumed, estimated CHO count per meal, and 2-hour postprandial glucose readings over 3-5 days. Meals' CHO contents were recounted by an experienced clinical dietician, and those within 20% of the dietician's counting were considered accurate.

RESULTS

A total of 30 patients (21 females) were enrolled. Age range (median) was 8-18 (SD 13) years. Data of 247 meals were analyzed. A total of 165 (67%) meals' CHO contents were accurately counted. Of those, 90 meals (55%) had in-target postprandial glucose ( P < .000). There was an inverse relationship between inaccurate CHO estimates and postprandial glucose. Of the 63 underestimated meals, 55 had above-target glucose, while 12 of the 19 overestimated meals were followed by low glucose. There was no association between accuracy and meal size (Spearman's rho = .019).

CONCLUSION

Accuracy of CHO counting is an important determining factor of postprandial glycemia. However, other factors should be considered when advising on prandial insulin calculation. Underestimation and overestimation of CHO result in postprandial hyperglycemia and hypoglycemia, respectively. Accuracy does not correlate with meal size.

A Review of Interventions Aimed at Facilitating Successful Transition Planning and Transfer to Adult Care Among Youth with Chronic Illness

This article reviews studies that developed interventions aimed at facilitating the transition process and/or the transfer of youth with chronic illness to adult programs during the past decade. Three key intervention approaches have been studied. Data assessing the impact of transition coordinators suggest that the most successful outcomes occur when coordinators meet with patients prior to the transfer of care, support them as they negotiate the adult programs, and facilitate appointment keeping. Data assessing the impact of transition clinics suggest that the key to positive outcomes is helping patients develop a trusting relationship with the adult providers before fully transferring their care to the adult clinic. Similar conclusions can be drawn for transition programs, where it appears that the opportunity to discuss and plan transition with a pediatric provider over time and to meet with both the pediatric and adult providers simultaneously are beneficial for facilitating successful transfer to adult care. Although aspects of these care processes appear promising for improving transition success, this review identifies areas that need further study. We argue that studies are needed that examine individual patient and family-focused interventions as well as looking at other potential interventions in the health care system. [Pediatr Ann. 2017;46(5):e182-e187.].

Interaction of Pubertal Development and Metabolic Control in Adolescents with Type 1 Diabetes Mellitus

BACKGROUND

In T1DM, delayed pubertal development and reduced final height are associated with inadequate metabolic control.

OBJECTIVE

To assess whether T1DM affects pubertal growth spurt and whether metabolic control during puberty is gender-related.

METHODS

Using a large multicentre database, longitudinal data from 1294 patients were analysed. Inclusion criteria: complete records of height and HbA1c from the age of seven to 16 years. Exclusion criteria: other significant chronic diseases and medications, T1DM duration less than three months, and initial BMI < 3rd or >97th percentile.

RESULTS

Growth velocity (GV) was impaired with a significant reduction of peak GV by 1.2 cm in boys. HbA1c increase during male puberty was lower except for a period of 1.5 years. The highest HbA1c increase in boys coincided with maximum growth spurt. In girls, the highest HbA1c increase was observed during late puberty. Even though there is impaired GV, both sexes reach a height at 16 years of age which corresponds to the background population height.

CONCLUSION

Worsening of metabolic control is sex-discordant and associated with gender-specific alterations of GV. However, the vast majority of boys and girls with T1DM seems to reach normal height at the age of 16 years.

A randomized clinical trial aimed at preventing poor psychosocial and glycemic outcomes in teens with type 1 diabetes (T1D)

Adolescents with type 1 diabetes have an increased risk for a variety of emotional and behavioral challenges as well as negative diabetes outcomes. This study was designed to compare the effectiveness of a depression-prevention, resilience promotion program with an advanced diabetes education program. Each program consisted of 9 group-based sessions. There were 264 adolescents enrolled in this multi-site randomized clinical trial. The primary outcomes were depressive symptoms and glycemic control; secondary outcomes included resilience skills, diabetes management and adherence, and diabetes-specific distress. The goal of the present paper is to describe the study design, the intervention, and the baseline characteristics of the sample. Preliminary data suggests that enrollment, randomization and retention were successful. Longitudinal follow-up and examination of mechanisms of action as they relate to psychosocial and glycemic outcomes will be explored in the future.

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.

Early Hospital Readmission After Simultaneous Pancreas-Kidney Transplantation: Patient and Center-Level Factors

Early hospital readmission is associated with increased morbidity, mortality, and cost. Following simultaneous pancreas-kidney transplantation, rates of readmission and risk factors for readmission are unknown. We used United States Renal Data System data to study 3643 adult primary first-time simultaneous pancreas-kidney recipients from December 1, 1999 to October 31, 2011. Early hospital readmission was any hospitalization within 30 days of discharge. Modified Poisson regression was used to determine the association between readmission and patient-level factors. Empirical Bayes statistics were used to determine the variation attributable to center-level factors. The incidence of readmission was 55.5%. Each decade increase in age was associated with an 11% lower risk of readmission to age 40, beyond which there was no association. Donor African-American race was associated with a 13% higher risk of readmission. Each day increase in length of stay was associated with a 2% higher risk of readmission until 14 days, beyond which each day increase was associated with a 1% reduction in the risk of readmission. Center-level factors were not associated with readmission. The high incidence of early hospital readmission following simultaneous pancreas-kidney transplant may reflect clinical complexity rather than poor quality of care.

The Stricter the Better? The Relationship between Targeted HbA1c Values and Metabolic Control of Pediatric Type 1 Diabetes Mellitus

INTRODUCTION

It remains unclear how HbA1c recommendations influence metabolic control of paediatric patients with type 1 diabetes mellitus. To evaluate this we compared reported HbA1c with guideline thresholds.

MATERIALS AND METHODS

We searched systematically MEDLINE and EMBASE for studies reporting on HbA1c in children with T1DM and grouped them according to targeted HbA1c obtained from regional guidelines. We assessed the discrepancies in the metabolic control between these groups by comparing mean HbA1c extracted from each study and the differences between actual and targeted HbA1c.

RESULTS

We included 105 from 1365 searched studies. The median (IQR) HbA1c for the study population was 8.30% (8.00%-8.70%) and was lower in "6.5%" than in "7.5%" as targeted HbA1c level (8.20% (7.85%-8.57%) versus 8.40% (8.20%-8.80%); p = 0.028). Median difference between actual and targeted HbA1c was 1.20% (0.80%-1.70%) and was higher in "6.5%" than in "7.5%" (1.70% (1.30%-2.07%) versus 0.90% (0.70%-1.30%), resp.; p < 0.001).

CONCLUSIONS

Our study indicates that the 7.5% threshold results in HbA1c levels being closer to the therapeutic goal, but the actual values are still higher than those observed in the "6.5%" group. A meta-analysis of raw data from national registries or a prospective study comparing both approaches is warranted as the next step to examine this subject further.

Validation of a contemporary adherence measure for children with Type 1 diabetes: the Diabetes Management Questionnaire

AIMS

To evaluate the psychometric properties of the Diabetes Management Questionnaire, a brief, self-report measure of adherence to contemporary diabetes management for young people with Type 1 diabetes and their caregivers.

METHODS

A total of 273 parent-child dyads completed parallel versions of the Diabetes Management Questionnaire. Eligible children (aged 8-18 years) had Type 1 diabetes for ≥1 year. A multidisciplinary team designed the Diabetes Management Questionnaire as a brief, self-administered measure of adherence to Type 1 diabetes management over the preceding month; higher scores reflect greater adherence. Psychometrics were evaluated for the entire sample and according to age of the child.

RESULTS

The children (49% female) had a mean ± sd (range) age 13.3 ± 2.9 (8-18) years and their mean ± sd HbA1c was 71 ± 15 mmol/mol (8.6 ± 1.4%). Internal consistency was good for parents (α = 0.83) and children (α = 0.79). Test-retest reliability was excellent for parents (intraclass correlation coefficient =0.83) and good for children (intraclass correlation coefficient = 0.65). Parent and child scores had moderate agreement (intraclass correlation coefficient = 0.54). Diabetes Management Questionnaire scores were inversely associated with HbA1c (parents: r = -0.41, P < 0.0001; children: r = -0.27, P < 0.0001). Psychometrics were stronger in the children aged ≥13 years compared with those aged < 13 years, but were acceptable in both age groups. Mean ± sd Diabetes Management Questionnaire scores were higher among children who were receiving insulin pump therapy (n = 181) than in children receiving multiple daily injections (n = 92) according to parent (75.9 ± 11.8 vs. 70.5 ± 15.5; P = 0.004) and child report (72.2 ± 12.1 vs. 67.6 ± 13.9; P = 0.006).

CONCLUSIONS

The Diabetes Management Questionnaire is a brief, valid self-report measure of adherence to contemporary diabetes self-management for people aged 8-18 years who are receiving either multiple daily injections or insulin pump therapy.

Prevalence and predictors of severe hypoglycemia in Danish children and adolescents with diabetes

OBJECTIVE

To investigate the prevalence of severe hypoglycemia in Danish children and adolescents with type 1 diabetes and to pinpoint predictors of this acute complication in children on modern treatment modalities.

RESEARCH DESIGN AND METHODS

The study is based on data from DanDiabKids, a national diabetes register for children and adolescents. The register contains data on patients with type 1 diabetes with an ascertainment rate of 99%. Data from 3320 patients aged 0-18 yr was included in the study period from 1998 to 2009 and analyzed using a negative binomial model.

RESULTS

One thousand nine hundred and ninety-nine episodes of severe hypoglycemia in 867 patients were registered conferring an overall incidence of severe hypoglycemia of 15.1 [95% confident interval (CI): 13.8; 16.4] per 100 patient years. This remained unchanged during the study period. Duration of diabetes, age and treatment in centers managing less than 100 patients significantly increased the risk of severe hypoglycemia (p < 0.001). Patients on insulin pump therapy had a 42% reduced risk of severe hypoglycemia compared with pen treated patients (p = 0.01). Patients treated with five or more daily insulin injections had a 31% (95% CI: 17; 49) reduced risk of severe hypoglycemia compared to patients on fewer daily injections (p = 0.015).

CONCLUSIONS

Despite improvements in metabolic control over a decade the prevalence of severe hypoglycemic events remained unchanged. More intensive treatments such as insulin pump therapy and multiple daily injections on a national level seems to be a protective factor for developing severe hypoglycemia up to 2009.

Glycaemic control of Type 1 diabetes in clinical practice early in the 21st century: an international comparison

AIMS

Improving glycaemic control in people with Type 1 diabetes is known to reduce complications. Our aim was to compare glycaemic control among people with Type 1 diabetes using data gathered in regional or national registries.

METHODS

Data were obtained for children and/or adults with Type 1 diabetes from the following countries (or regions): Western Australia, Austria, Denmark, England, Champagne-Ardenne (France), Germany, Epirus, Thessaly and Thessaloniki (Greece), Galway (Ireland), several Italian regions, Latvia, Rotterdam (The Netherlands), Otago (New Zealand), Norway, Northern Ireland, Scotland, Sweden, Volyn (Ukraine), USA and Wales) from population or clinic-based registries. The sample size with available data varied from 355 to 173 880. Proportions with HbA1c < 58 mmol/mol (< 7.5%) and ≥ 75 mmol/mol (≥ 9.0%) were compared by age and sex.

RESULTS

Data were available for 324 501 people. The proportions with HbA1c 58 mmol/mol (< 7.5%) varied from 15.7% to 46.4% among 44 058 people aged < 15 years, from 8.9% to 49.5% among 50 766 people aged 15-24 years and from 20.5% to 53.6% among 229 677 people aged ≥ 25 years. Sex differences in glycaemic control were small. Proportions of people using insulin pumps varied between the 12 sources with data available.

CONCLUSION

These results suggest that there are substantial variations in glycaemic control among people with Type 1 diabetes between the data sources and that there is room for improvement in all populations, especially in young adults.

Challenges of optimizing glycaemic control in children with Type 1 diabetes: a qualitative study of parents' experiences and views

AIMS

To explore the difficulties parents encounter in trying to achieve clinically recommended blood glucose levels and how they could be better supported to optimize their child's glycaemic control.

METHODS

In-depth interviews were conducted with 54 parents of children with Type 1 diabetes (≤ 12 years). Data were analysed thematically.

RESULTS

Parents described being reluctant and finding it difficult to keep their child's blood glucose levels consistently within clinically recommended ranges. As well as worrying about their child's ability to detect/report hypoglycaemia, parents highlighted a multitude of factors that had an impact on their child's blood glucose levels and over which they could exercise little control. These included: leaving their child with other caregivers who could not be trusted to detect hypoglycaemia; difficulties remotely monitoring and regulating their child's food consumption and activity; and physical and social changes accompanying childhood development. Most parents used two sets of blood glucose targets, with clinically recommended targets employed when their child was in their immediate care and higher targets when in the care of others. Parents described health professionals as lacking understanding of the difficulties they encountered keeping blood glucose within target ranges and needing more empathetic, tailored and realistic advice.

CONCLUSION

It is not parents' fear of hypoglycaemia in isolation that leads to decisions to raise their child's blood glucose but, rather, parental fear in conjunction with other factors and considerations. Hence, to improve diabetes management in children, these factors may need to be addressed; for instance, by training others in diabetes management and using new technologies. Changes to consultations are also recommended.

Glycemic Control, Self-Efficacy and Fear of Hypoglycemia Among Iranian Children with Type 1 Diabetes

OBJECTIVE

This study was designed to test the reliability of a Persian version of 2 questionnaires to assess the level of fear of hypoglycemia (FoH) and self-efficacy in diabetes management and their association with glycated hemoglobin (A1C) and parents' demographic characteristics in a sample of children with type 1 diabetes.

DESIGN

We assessed 61 children with type 1 diabetes (35 boys and girls, 6.0 to 12.7 years of age) using the Hypoglycemia Fear Survey-Child version (HFS-C) and Self-Efficacy for Diabetes Scale-Child version (SED-C). Their glycemic control was evaluated by A1C levels.

RESULTS

The internal consistency of the Persian version of HFS-C and SED-C were very good. Our results showed that children older than 10 years of age report lower levels of FoH, which are related to higher levels of self-efficacy (r=-.30, p=0.025 and r=-.30, p=0.02, respectively). Of the children, 42.3% of girls and 31.4% of boys reported that low blood sugar is a big problem for them. These findings suggest that FoH is a significant concern for this target group. Only 19.7% of children had controlled diabetes based on A1C levels. There was no significant association between higher A1C levels and other variables, including HFS-C, SED-C and parents' demographic characteristics.

CONCLUSIONS

The Persian version of HFS-C and SED-C are reliable and valid measures of the fear of hypoglycemia and of self-efficacy in children with type 1 diabetes, and these questionnaires could be used in our country for identifying those children who may need diabetes education and other supports. The association between greater self-efficacy and lower fear of hypoglycemia suggests that addressing self-efficacy in diabetes education courses may be effective in helping to overcome FoH.

Equal access to health care may diminish the differences in outcome between native and immigrant patients with type 1 diabetes

BACKGROUND/OBJECTIVE

Previous studies have found that ethnicity influences glycemic control. We hypothesized that differences between Nordic and non-Nordic patients are less pronounced for children with type 1 diabetes in high incidence countries in Northern Europe.

RESEARCH DESIGN AND METHODS

We investigated patients aged 0-15 yr in national pediatric registers in Denmark (D), Iceland (I), Norway (N), and Sweden (S) (2006-2009). Ethnic origin was defined by maternal country of birth as being Nordic or non-Nordic (other countries).

RESULTS

The cohort (n = 11,908, 53.0% boys, onset age 7.7 (3.9) yr, diabetes duration 6.1 (3.6) yr, [mean, (SD)]) comprised 921 (7.7%) non-Nordic patients. The frequencies of non-Nordic patients according to country of residence were: 5.7% (D), 2.7% (I), 5.5% (N), and 9.4% (S). Sex distribution and BMI z-score did not differ between Nordic and non-Nordic patients, but non-Nordic patients were 0.5 yr younger at onset than Nordic patients (p < 0.0006). Non-Nordic patients had a lower number of daily insulin bolus injections and higher daily insulin doses compared to their Nordic peers. Patients of non-Nordic origin had slightly higher HbA1c levels (0.6-2.9 mmol/mol, p < 0.001) and, with the exception of Norway, were less frequently treated with CSII (p = 0.002) after adjusting for confounders.

CONCLUSIONS

The reported differences in glycemic regulation between Nordic and non-Nordic type 1 diabetes children and adolescents in four Nordic countries are diminutive, but persist after accounting for treatment intensity.

Executive function, adherence, and glycemic control in adolescents with type 1 diabetes: a literature review

The aim of the present review was to examine and report findings from published research to date that has examined associations between executive function (EF), adherence, and glycemic control in youth with type 1 diabetes. A review of the published research is presented with the objectives of reporting the following: (1) the associations between EF and adherence, (2) the associations between EF and glycemic control, (3) proposed methodological considerations needed to advance related research, (4) recommendations for future research, and (5) clinical recommendations. The major conclusions of this review support the presence of an association between EF, adherence, and glycemic control. Additional prospective and controlled studies are necessary to fully understand the impact of EF on the ability of youth to independently manage type 1 diabetes.

Secondary diabetic ketoacidosis and severe hypoglycaemia in patients with established type 1 diabetes mellitus in China: a multicentre registration study

BACKGROUND

Diabetic ketoacidosis (DKA) and severe hypoglycaemia are common acute complications of type 1 diabetes mellitus (T1DM). This study aimed to determine the incidence of, and risk factors for, these complications in Chinese patients with established T1DM.

METHODS

This cross-sectional study recruited patients with established T1DM from 16 centres in Guangdong Province, China. Incidence rates were expressed as episodes/100 patient-years. Regression models identified risk factors for the occurrence and recurrence of secondary DKA and severe hypoglycaemia.

RESULTS

A total of 611 patients with established T1DM (53.7% women) were recruited. The incidence of secondary DKA and severe hypoglycaemia was 26.4 (22.4, 31.0) and 68.8 (62.2, 76.0)/100 patient-years, respectively. Significant risk factors for secondary DKA were female gender [relative risk (RR) = 2.12], medical reimbursement rate <50% (RR = 1.84), uncontrolled diet (RR = 1.76), smoking (RR = 2.18) and poor glycaemic control [glycated haemoglobin A1c (HbA1c)/1.0% increase; RR = 1.15]. Overweight/obesity was a protective factor (RR = 0.57). Significant risk factors for severe hypoglycaemia included male gender (RR = 1.71), medical reimbursement rate < 50% (RR = 1.36), longer duration of T1DM (per 5-year increase, RR = 1.22), underweight (RR = 1.44), uncontrolled diet ('never controlled' or 'sometimes controlled' vs. 'usually controlled', RR = 2.09 or 2.02, respectively), exercise <150 min/week (RR = 1.66), presence of neuropathy (RR = 1.89), smoking (RR = 1.48) and lower HbA1c values (per 1.0% decrease, RR = 1.46). Overweight/obesity was a protective factor (RR = 0.62). Additionally, 34.4% of secondary DKA and 81.1% of severe hypoglycaemia episodes occurred in 3.8% and 16.2% patients with recurrent events (≥two episodes), respectively.

CONCLUSIONS

The results indicate that secondary DKA and severe hypoglycaemia occur at high rates in Chinese patients with established T1DM and that recurrence is likely to occur in high-risk patients. Comprehensive management of T1DM should include recommendations to control modifiable risk factors.

Changes in insulin therapy regimens over 10 yr in children and adolescents with type 1 diabetes attending diabetes camps

OBJECTIVE

To describe the changes in insulin therapy regimens of children and adolescents with type 1 diabetes over 10 yr and their correlation with hemoglobin A1c (HbA1c).

RESEARCH DESIGN AND METHODS

The study included 7206 children and adolescents (age 12.8 ± 2.7 yr, more than 1 yr of diabetes duration) admitted in summer camps between 1998 and 2007 (707-896/yr). Based on injection times (breakfast, lunch, afternoon, dinner, bedtime) and insulin types (short, long and premixed; human or analog), 786 different therapeutic combinations were classified in six main types of regimens. The distribution of the different regimens and their correlation with HbA1c were evaluated as a function of year and age.

RESULTS

Over 10 yr, basal bolus increased from 13 to 52% and the pump from <1 to 13%, regimens with two to three injections per day decreased from 50 to 25%, those with only premixed insulins from 33 to 7%, and diverse regimens from 9 to 1%. HbA1c was significantly higher with premixed insulin only, but there were no differences between the other regimens throughout the follow-up. Mean yearly HbA1c (8.21-8.45%) did not show any significant decrease, but the percentage of patients with HbA1c > 9 and 10% decreased significantly, in those treated with two to three injections and the pump, not with basal bolus or premixed only regimens.

CONCLUSION

A major trend in intensifying insulin treatment in children and adolescents with type 1 diabetes was accompanied by modest improvements in HbA1c. No insulin regimen has shown any better results, except over premixed insulins.

Teaming up: feasibility of an online treatment environment for adolescents with type 1 diabetes

OBJECTIVE

To evaluate the feasibility of an online interactive treatment environment for adolescents with type 1 diabetes, called Sugarsquare, to supplement usual care.

RESEARCH DESIGN AND METHODS

Sugarsquare provides easily accessible contact with the diabetes team, peer support, and treatment overview. Of 120 eligible patients, 62 adolescents aged 11-21 (M = 15.23, SD = 2.00) were assigned to a usual-care group (n = 31) or a usual-care + intervention group (n = 31). Feasibility was assessed in terms of acceptability, demand, practicability, integration, and efficacy in a 9-month study-period.

RESULTS

Assessment of acceptability and demand revealed that 20 adolescents in the intervention group (65%) logged in at least once; 16 adolescents (52%) logged in repeatedly. Usage resulted in 5795 page-views, 3580 chat-messages, 427 forum-messages, and in 40 private interactions between 11 adolescents (35%) and professionals. Assessment of practicability revealed that all 13 professionals (100%) accessed the intervention. Slow processing speed and security procedures formed obstacles for usage. Assessment of integration showed that international standards for diabetes care (International Diabetes Federation/International Society for Pediatric and Adolescent Diabetes/American Diabetes Association) were met. Assessment of efficacy revealed improvement in the intervention group in evaluation of care (Patients' Evaluation of Quality of Diabetes), F(1,30) = 5.35, p < 0.05, and quality of life, communication (PedsQL), F(1,30) = 11.65, p <0.05. The latter was correlated with posted chat-messages (r = 0.42, p < 0.05). No between-group differences were found.

CONCLUSIONS

This study shows that Sugarsquare is feasible in adolescents with type 1 diabetes. It meets a demand in adolescents and can support professionals when organizing on-going care according to international standards. Results are promising and next steps are a full-scale randomized controlled trial and subsequent implementation in daily care.

Development and Evaluation of a Pediatric Diabetes Program by a Single Provider

PURPOSE

Although the use of a team approach is ideal for a pediatric population, such an approach is expensive, with programs running at a negative balance of $400,000 to $800,000 per year. To address the problem, a "state of the art" pediatric diabetes program was implemented that was cost neutral and did not compromise patient care.

METHODS

Four years after starting a pediatric diabetes program run by a single provider, diabetes goals were evaluated by checking A1C levels while keeping costs in check. A1C levels were obtained every 2 to 3 months and analyzed over several months. Two hundred patients with type 1 diabetes were managed in the program. The cost of the program was analyzed on the basis of rental fees, staff salaries, and basic equipment and supplies required. A1C levels were performed using the Siemens HbA1c DCA Vantage Analyzer. Patients are able to call, fax, text, and e-mail between visits. This has resulted in excellent control and high satisfaction.

RESULTS

The mean A1C level was 7.2% to 7.4%. The pediatric diabetes program is now cost neutral. Survey results indicated that patients were satisfied with the care they received.

CONCLUSIONS

Children with type 1 diabetes can be managed by a single provider and achieve treatment goals that far exceed those obtained in most pediatric diabetes programs. This can be done at a fiscally responsible cost.

The PILGRIM study: in silico modeling of a predictive low glucose management system and feasibility in youth with type 1 diabetes during exercise

BACKGROUND

Predictive low glucose management (PLGM) may help prevent hypoglycemia by stopping insulin pump delivery based on predicted sensor glucose values.

MATERIALS AND METHODS

Hypoglycemic challenges were simulated using the Food and Drug Administration-accepted glucose simulator with 100 virtual patients. PLGM was then tested with a system composed of a Paradigm(®) insulin pump (Medtronic, Northridge, CA), an Enlite™ glucose sensor (Medtronic), and a BlackBerry(®) (Waterloo, ON, Canada)-based controller. Subjects (n=22) on continuous subcutaneous insulin infusion (five females, 17 males; median [range] age, 15 [range, 14-20] years; median [range] diabetes duration, 7 [2-14] years; median [range] glycated hemoglobin, 8.0% [6.7-10.4%]) exercised until the PLGM system suspended insulin delivery or until the reference blood glucose value (HemoCue(®); HemoCue GmbH, Großostheim, Germany) reached the predictive suspension threshold setting.

RESULTS

PLGM reduced hypoglycemia (<70 mg/dL) in silico by 26.7% compared with no insulin suspension, as opposed to a 5.3% reduction in hypoglycemia with use of low glucose suspend (LGS). The median duration of hypoglycemia (time spent <70 mg/dL) with PLGM was significantly less than with LGS (58 min vs. 101 min, respectively; P<0.001). In the clinical trial the hypoglycemic threshold during exercise was reached in 73% of the patients, and hypoglycemia was prevented in 80% of the successful experiments. The mean (±SD) sensor glucose at predictive suspension was 92±7 mg/dL, resulting in a postsuspension nadir (by HemoCue) of 77±22 mg/dL. The suspension lasted for 90±35 (range, 30-120) min, resulting in a sensor glucose level at insulin resumption of 97±19 mg/dL.

CONCLUSIONS

In silico modeling and early feasibility data demonstrate that PLGM may further reduce the severity of hypoglycemia beyond that already established for algorithms that use a threshold-based suspension.

Improved results in paediatric diabetes care using a quality registry in an improvement collaborative: a case study in Sweden

BACKGROUND

Several studies show that good metabolic control is important for children and adolescents with type 1 diabetes. In Sweden, there are large differences in mean haemoglobin A1c (HbA1c) in different hospitals and difficulties implementing national guidelines in everyday practice. This study shows how the participation in an improvement collaborative could facilitate improvements in the quality of care by paediatric diabetes teams. The Swedish paediatric diabetes quality registry, SWEDIABKIDS was used as a tool and resource for feedback and outcome measures.

METHODS

Twelve teams at paediatric diabetes centres, caring for 30% (2302/7660) of patients in Sweden, participated in an 18-month quality improvement program. Each team defined treatment targets, areas needing improvement, and action plans. The main outcome was the centre patients' mean HbA1c levels, but other clinical variables and change concepts were also studied. Data from the previous six months were compared with the first six months after starting the program, and the long-term follow up after another eleven months.

RESULTS

All centres reduced mean HbA1c during the second and third periods compared with the first. The mean reduction for all was 3·7 mmol/mol (p<0.001), compared with non-participating centres who improved their mean HbA1c with 1·7 mmol/mol during the same period. Many of the participating centres reduced the frequency of severe hypoglycaemia and/or ketoacidosis, and five centres reached their goal of ensuring that all patients had some sort of physical activity at least once weekly. Change concepts were, for example, improved guidelines, appointment planning, informing the patients, improving teamwork and active use of the registry, and health promotion activities.

CONCLUSIONS

By involving paediatric diabetes teams in a quality improvement collaborative together with access to a quality register, the quality of paediatric diabetes care can improve, thereby contributing to a reduced risk of late complications for children and adolescents with diabetes.

A 3-year prospective study of parent-child communication in early adolescents with type 1 diabetes: relationship to adherence and glycemic control

OBJECTIVE

To examine changes in parent-child communication patterns and their relation to glycemic control and treatment adherence using observational data in a 3-year prospective multisite study of youth with type 1 diabetes aged 9-11 years at baseline and their families (n = 217).

METHODS

Adolescents and caregivers participated in a diabetes problem-solving discussion. Families were rated on negative and positive communication and interactions using the Interaction Behavior Code.

RESULTS

Maternal and paternal negative communication decreased over time, whereas adolescent and maternal positive communication and positive reciprocity increased. Baseline preadolescent youth and maternal positive communication predicted adherence 3 years later. Changes in family communication did not predict changes in glycemic control or adherence.

CONCLUSIONS

During the transition to adolescence, family communication changed in unexpected and positive ways. Additionally, the relationship of baseline family communication to subsequent adherence suggests the need to assess family communication concerning diabetes-related management during preadolescence.

Family perceptions of insulin pump adverse events in children and adolescents

BACKGROUND

Insulin pumps (for continuous subcutaneous insulin infusion [CSII]) are used widely in type 1 diabetes mellitus. Although there has been considerable study of outcomes, there are few recent data on CSII-associated adverse events and no data on family perceptions of adverse events and their confidence in dealing with them.

SUBJECTS AND METHODS

We approached all families of children and adolescents ≤ 19 years of age on CSII attending the diabetes clinic over a 16-week clinic cycle. Participants completed a retrospective questionnaire examining issues over the previous 12 months. Data on pump adverse events as well as answers to questions pertaining to education and confidence were collected.

RESULTS

Our survey received a response rate of 99%, with 235 of the 238 families approached participating. In the preceding 12 months, 104 of 230 (45%) had reported at least one pump-related adverse event (either mechanical or set-related), with an associated 52 of 229 (23%) resulting in pump replacement. This equated to a minimum incidence density of 53 adverse events/100 person-years. Additionally, 18 of 230 (8%) reported a hospital admission or emergency department attendance as a consequence. Pump malfunction and infusion set/site failures were the most common events reported, with one or more events in 58 of 104 (56%) and 47 of 104 (45%), respectively. Adverse events, excluding set/site failures, were associated with older age (13.1 ± 3.4 years vs. 11.9 ± 4 years; P = 0.02).

CONCLUSIONS

This is the first study to look at family perceptions of adverse events while using modern CSII. It highlights a high self-reported rate of CSII-related adverse events, pump replacement, and subsequent presentation to the hospital. Potential areas for additional targeted education are identified. Further prospective study examining pump adverse event characteristics and incidence is warranted.

Longitudinal evaluation of endothelial function in children and adolescents with type 1 diabetes mellitus: a long-term follow-up study

BACKGROUND

Type 1 diabetes (T1DM) predisposes to cardiovascular disease, increasing the risk to develop atherosclerosis. In the pediatric population, the cardiovascular risk may be evaluated examining endothelial function by a non-invasive ultrasound technique, namely flow-mediated dilation (FMD) of the brachial artery. The aims of this study were the longitudinal evaluation of the potential change in the endothelium-dependent vasomotor function in children and adolescents with T1DM and the identification of clinical and laboratory data correlated to modifications.

METHODS

We studied 39 T1DM patients (20 girls and 19 boys; aged 11.2 ± 3.72 years). FMD and blood samples were obtained from all patients at baseline (time 0) and after a follow up of at least 1 year (time 1). FMD was also evaluated in 45 healthy controls (22 boys, 23 girls) aged 10.2 ± 3.05 years.

RESULTS

At time 0, 43.6% of T1DM patients presented an impaired FMD. FMD at time 1 revealed a dramatic impairment of endothelial function: altered FMD values were shown in 61.5% of patients and it got worse in 74.3% of them. Longitudinally, boys had a greater impairment of FMD than girls. At baseline, multivariate analysis identified only sex as significant predictor of FMD (β = 0.470, P = 0.029).

CONCLUSIONS

Because endothelial dysfunction appears earlier in diabetic children, they are at higher risk to develop atherosclerosis. Our results suggest the usefulness of FMD as a tool to stratify pediatric T1DM patients according to their cardiovascular risk and to follow them up longitudinally.

Quarterly visits with glycated hemoglobin monitoring: the sweet spot for glycemic control in youth with type 1 diabetes

OBJECTIVE

To evaluate the association between the frequency of visits and glycated hemoglobin (GHb) measurements on glycemic control in youth with type 1 diabetes.

RESEARCH DESIGN AND METHODS

A retrospective longitudinal cohort study of 1,449 youth with type 1 diabetes (mean age 11.4 years, 50% female, 74% Caucasian, 24% with Medicaid) followed at five pediatric endocrinology clinics from the years 2008-2011 was conducted. By hierarchical cluster analysis, three homogeneous groups of patients were generated: those with a relative increase in GHb (worsened [n = 237]), no change in GHb (stable [n = 842]), and a decrease in GHb (improved [n = 370]) over the study period. The number of visits and GHb measurements per year were compared among the three groups by multinomial logistic regression analysis using one visit or GHb test per year as a reference and controlling for patient demographic and baseline characteristics.

RESULTS

Patients with quarterly visits were least likely to have worsened glycemic control (odds ratio 0.33, P < 0.05) and were most likely to have improved glycemic control (3.48, P < 0.01). Patients with four GHb tests a year (0.53, P < 0.05) were least likely to have worsened glycemic control.

CONCLUSIONS

Quarterly visits and GHb testing are associated with glycemic control in youth with type 1 diabetes.

Autonomy support and responsibility-sharing predict blood glucose monitoring frequency among youth with diabetes

OBJECTIVE

Adolescence poses a number of special challenges for youth and their families managing the Type 1 diabetes medical regimen. Little is known on how family and youth factors and management of the regimen change over the course of early adolescence and predict adherence to the regimen during this developmental period.

METHODS

Youth with Type 1 diabetes (n = 239) and their maternal caregivers completed measures of diabetes-specific autonomy support, diabetes-related family conflict, regimen responsibility, and blood glucose monitoring frequency (BGMF) at 4 timepoints over a 3-year period.

RESULTS

Autonomy support and BGMF significantly decreased over time and responsibility for the diabetes regimen shifted from the caregiver toward youth over time. Significant changes in perceived family conflict over time differed depending on the reporter. Baseline BGMF, changes in caregiver autonomy support, and changes in responsibility for the regimen significantly predicted changes in BGMF over time.

CONCLUSIONS

This study documents changes in autonomy support, youth responsibility for the diabetes regimen, and BGMF during the transition into early adolescence. Higher levels of caregiver autonomy support preserve BGMF during a developmental period in which BGMF typically deteriorates.

A randomized trial comparing the rate of hypoglycemia--assessed using continuous glucose monitoring--in 125 preschool children with type 1 diabetes treated with insulin glargine or NPH insulin (the PRESCHOOL study)

BACKGROUND

Avoidance of hypoglycemia is a key consideration in treating young children with type 1 diabetes (T1DM).

KEY OBJECTIVE

To evaluate hypoglycemia with insulin glargine vs. neutral protamine Hagedorn (NPH) insulin in young children, using continuous glucose monitoring (CGM).

SUBJECTS

Children of 1 to <6 yr treated with once-daily glargine vs. once- or twice-daily NPH, with bolus insulin lispro/regular human insulin provided to all.

METHODS

Twenty-four week, multicenter, randomized, open-label study. Primary endpoint was event rate of composite hypoglycemia [symptomatic hypoglycemia, low CGM excursions (<3.9 mmol/L) or low fingerstick blood glucose (FSBG; <3.9 mmol/L)]. Noninferiority of glargine vs. NPH was assessed for the primary endpoint.

RESULTS

One hundred and twenty-five patients (mean age, 4.2 yr) were randomized to treatment (glargine, n = 61; NPH, n = 64). At baseline, mean HbA1c was 8.0 and 8.2% with glargine and NPH, respectively. Composite hypoglycemia episodes/100 patient-yr was 1.93 for glargine and 1.69 for NPH; glargine noninferiority was not met. Events/100 patient-yr of symptomatic hypoglycemia were 0.26 for glargine vs. 0.33 for NPH; low CGM excursions 0.75 vs. 0.72; and low FSBG 1.93 vs.1.68. There was a slight difference in between-group severe/nocturnal/severe nocturnal hypoglycemia and glycemic control. All glargine-treated patients received once-daily injections; on most study days NPH-treated patients received twice-daily injections.

CONCLUSIONS

While glargine noninferiority was not achieved, in young children with T1DM, there was a slight difference in hypoglycemia outcomes and glycemic control between glargine and NPH. Once-daily glargine may therefore be a feasible alternative basal insulin in young populations, in whom administering injections can be problematic.

Identification and prediction of group-based glycemic control trajectories during the transition to adolescence

OBJECTIVE

To identify trajectories of glycemic control over a period of 3 years in a pediatric sample of youth diagnosed with Type 1 diabetes transitioning to adolescence. A second aim was to examine a set of modifiable individual and family level baseline predictors of glycemic control group membership.

METHODS

This multisite, prospective study included 239 children and adolescents (ages 9-11 years at baseline) diagnosed with Type 1 diabetes and their caregivers. Glycemic control was based on hemoglobin A1c (HbA1c) collected at 6-month intervals over a period of 3 years. Predictors of glycemic control membership included baseline global executive functioning, diabetes self-management, diabetes-specific family conflict, blood glucose monitoring frequency, and relevant individual and family level covariates.

RESULTS

Group-based trajectory analyses were used to describe patterns of glycemic control from baseline to 36 months and 3 trajectories were identified: low risk (42.9%), elevated risk (44.6%), and high risk (12.1%) subgroups. Baseline maternal-reported family conflict, blood glucose monitoring frequency, and gender were significant predictors of glycemic control group membership. Higher levels of baseline family conflict, lower frequency of blood glucose monitoring, and female gender were associated with elevated and high-risk group membership.

CONCLUSIONS

These findings underscore the importance of examining trajectories of HbA1c across time. These results suggest that problematic trajectories of glycemic control are evident during the transition to adolescence. Furthermore, there are modifiable individual and family level characteristics that predict group membership and hence could be targeted in interventions to ensure adequate glycemic control is maintained over time and that risks for diabetes-related complications are reduced.