Pump It Up! A randomized clinical trial to optimize insulin pump self-management behaviors in adolescents with type 1 diabetes

Individuals with type 1 diabetes (T1D) must engage in a variety of complex and burdensome self-management behaviors daily to maintain near normal blood glucose levels and prevent complications. There is a need for interventions to improve use of sophisticated diabetes technologies, such as insulin pumps, during adolescence - a very high-risk developmental period for individuals with T1D. All diabetes devices, including insulin pumps, store large amounts of behavioral data that can be downloaded and analyzed to evaluate adherence to recommended T1D self-management behaviors. The overall objective of the present study, Pump it Up!, was to use objectively downloaded insulin pump data to inform and test two interventions to optimize insulin pump use in adolescents with T1D and their caregivers. Multiphase Optimization Strategy (MOST) was used to achieve the overall goal of this study - to separately test the main effect of the Pump It Up! Personalized T1D Self-Management Behaviors Feedback Report and the main effect of Pump It Up! Problem-Solving Skills intervention to improve T1D self-management behaviors using a 2 × 2 factorial design. The purpose of this paper is to describe the Pump It Up! study design and rationale, and participant baseline characteristics. Longitudinal data analyses will be conducted, and moderating effects of psychosocial factors will be examined in relation to primary (insulin pump self-management behaviors) and secondary (A1C) outcomes.

Blood Glucose Monitoring Before and After Type 1 Diabetes Clinic Visits

Objective

To determine patterns of blood glucose monitoring in children and adolescents with type 1 diabetes (T1D) before and after routine T1D clinic visits.

Methods

Blood glucose monitoring data were downloaded at four consecutive routine clinic visits from children and adolescents aged 5-18 years. Linear mixed models were used to analyze patterns of blood glucose monitoring in patients who had at least 28 days of data stored in their blood glucose monitors.

Results

In general, the frequency of blood glucose monitoring decreased across visits, and younger children engaged in more frequent blood glucose monitoring. Blood glucose monitoring increased before the T1D clinic visits in younger children, but not in adolescents. It declined after the visit regardless of age.

Conclusions

Members of the T1D care team need to consider that a T1D clinic visit may prompt an increase in blood glucose monitoring when making treatment changes and recommendations. Tailored interventions are needed to maintain that higher level of adherence across time.

Efficacy and safety of a fixed combination of insulin degludec/insulin aspart in children and adolescents with type 1 diabetes: A randomized trial

BACKGROUND

Insulin degludec/insulin aspart (IDegAsp) is a fixed soluble co-formulation of basal and bolus insulin.

OBJECTIVE

To evaluate efficacy and safety of IDegAsp in pediatric patients with type 1 diabetes (T1D).

SUBJECTS

Children and adolescents (aged 1 to <18 years) with T1D.

METHODS

A 16-week, phase 3b, treat-to-target, parallel-group, open-label, non-inferiority trial was conducted at 63 sites in 14 countries from October 2013 to November 2014. Patients were randomized 1:1 (age stratified: 1-<6 years; 6-<12 years; 12-<18 years) to IDegAsp once daily (OD) plus insulin aspart (IAsp) for remaining meals (IDegAsp + IAsp), or IDet OD or twice daily plus mealtime IAsp (IDet + IAsp). The primary end-point was HbA1c change from baseline at week 16.

RESULTS

A total of 362 participants were randomized to IDegAsp + IAsp (n = 182) or IDet + IAsp (n = 180). HbA1c decreased from baseline to week 16 by 0.3% in both groups (estimated treatment difference: -0.04%-points [-0.23; 0.15]_95%CI (-0.45 mmol/mol [-2.51; 1.60]_95%CI ), confirming non-inferiority. There were no significant differences between treatment groups in fasting or self-measured plasma glucose. Confirmed hypoglycemia rates did not significantly differ between groups. There was a significant reduction in basal and total insulin dose with IDegAsp + IAsp vs IDet + IAsp (post hoc analysis). Mean number of injections/day was 3.6 and 4.9 with IDegAsp + IAsp and IDet + IAsp, respectively (post hoc analysis). A non-significant higher rate of severe hypoglycemia was observed with IDegAsp + IAsp vs IDet + IAsp. The most frequent adverse events in both groups were hypoglycemia, headache, and nasopharyngitis.

CONCLUSIONS

IDegAsp + IAsp was non-inferior to IDet + IAsp regarding HbA1c, had similar hypoglycemia rates and required fewer injections.

A phase 3 multicenter, open-label, prospective study designed to evaluate the effectiveness and ease of use of nasal glucagon in the treatment of moderate and severe hypoglycemia in children and adolescents with type 1 diabetes in the home or school setting

OBJECTIVE

This multicenter, open-label study was designed to evaluate real-world effectiveness and ease of use of nasal glucagon (NG) in treating moderate or severe hypoglycemic events in children and adolescents with type 1 diabetes (T1D).

METHODS

Caregivers were trained to administer NG (3 mg) to the child/adolescent with T1D during spontaneous, symptomatic moderate or severe hypoglycemic events, observe treatment response (defined as awakening or returning to normal status within 30 minutes), and measure blood glucose (BG) levels every 15 minutes. Data regarding adverse events and ease of use were solicited using questionnaires.

RESULTS

The analysis population included 14 patients who experienced 33 moderate hypoglycemic events with neuroglycopenic symptoms and BG level ≤70 mg/dL. Patients returned to normal status within 30 minutes of NG administration in all 33 events. Mean BG levels increased from 55.5 mg/dL (range 42-70 mg/dL) at baseline to 113.7 mg/dL (range 79-173 mg/dL) within 15 minutes of NG administration. In most hypoglycemic events (93.9%), caregivers reported that NG administration was easy or very easy; they could administer NG within 30 seconds in 60.6% of events. There were no serious adverse events.

CONCLUSIONS

A single 3-mg dose of NG was effective in treating moderate, symptomatic, hypoglycemic events in children and adolescents with T1D in a real-world setting. It was easy-to-use and reasonably well tolerated. NG shows promise as an effective, needle-free, and user-friendly alternative to injectable glucagon.

White Coat Adherence Occurs in Adolescents With Type 1 Diabetes Receiving Intervention to Improve Insulin Pump Adherence Behaviors

BACKGROUND

To assess the occurrence of white coat adherence, defined as an increase in adherence to treatment regimens prior to a study appointment, in adolescents with type 1 diabetes (T1D) using insulin pumps and participating in a randomized adherence intervention trial.

METHODS

Blood glucose monitoring (BGM) readings, carbohydrate inputs, and insulin boluses delivered were downloaded from the insulin pumps of adolescents, aged 10-18 years, at 3 consecutive T1D study visits. Linear mixed models were used to analyze patterns of BGM, carbohydrate inputs, and insulin boluses delivered in patients who had 40 consecutive days of data stored in their insulin pumps prior to the study visit.

RESULTS

Stratified linear mixed models revealed that adolescents randomized to the Tailored Feedback Intervention group increased their blood glucose monitoring ( P < .01), carbohydrate inputs ( P < .0001), and insulin bolusing ( P < .0001) prior to study appointments. In contrast, white coat adherence did not occur in adolescents randomized to the Treatment as Usual group ( Ps > .42).

CONCLUSIONS

White coat adherence may occur in adolescents participating in clinical trials. Meter and insulin pump data downloads representing the 1- to 2-week period prior to a study visit are likely to overestimate actual adherence during the time frame between study visits.

White Coat Adherence in Pediatric Patients With Type 1 Diabetes Who Use Insulin Pumps

BACKGROUND

The purpose was to assess the occurrence of white coat adherence, defined as an increase in adherence to treatment regimens prior to a clinic appointment, in children and adolescents with type 1 diabetes (T1D) who use insulin pumps.

METHODS

Blood glucose monitoring (BGM) data, carbohydrate inputs, and insulin boluses delivered were downloaded from the insulin pumps of children and adolescents, aged 7-19 years with T1D, at 2 consecutive routine diabetes clinic visits. Linear mixed models were used to analyze patterns of BGM, carbohydrate inputs, and insulin boluses delivered in patients who had ≥28 days of data stored in their insulin pumps.

RESULTS

In general, younger children engaged in more frequent BGM, carbohydrate inputs, and insulin boluses delivered than older children and adolescents. White coat adherence occurred with frequency of BGM, carbohydrate inputs, and insulin boluses delivered, but only in younger children.

CONCLUSIONS

Diabetes care providers need to be aware that white coat adherence may occur, particularly in young children. Providers routinely download meter and insulin pump data for the 1- to 2-week period before the clinic visit. For patients exhibiting white coat adherence, their data will overestimate the patient's actual adherence.

Are children with type 1 diabetes safe at school? Examining parent perceptions

OBJECTIVE

To describe parent perceptions of children's diabetes care at school including: availability of licensed health professionals; staff training; logistics of provision of care; and occurrence and treatment of hypo- and hyperglycemia; and to examine parents' perceptions of their children's safety and satisfaction in the school environment.

RESEARCH DESIGN AND METHODS

A survey was completed by parents of children with type 1 diabetes from permissive (trained, non-medical school personnel permitted to provide diabetes care; N = 237) and non-permissive (only licensed health care professionals permitted to provide diabetes care; N = 198) states.

RESULTS

Most parents reported that schools had nurses available for the school day; teachers and coaches should be trained; nurses, children, and parents frequently provided diabetes care; and hypo- and hyperglycemia occurred often. Parents in permissive states perceived children to be as safe and were as satisfied with care as parents in non-permissive states.

CONCLUSIONS

Training non-medical staff will probably maximize safety of children with diabetes when a school nurse is not available.

Importance of manually entering blood glucose readings when wireless-compatible meters are not being used with an insulin pump

BACKGROUND

The objective was to determine if there were differences in blood glucose monitoring (BGM) data downloaded from insulin pumps of patients who use meters that wirelessly transmit data to their insulin pumps (i.e., wireless group) and those who do not (i.e., nonwireless group).

METHODS

Blood glucose monitoring data were downloaded from the meters and insulin pumps of 47 children and adolescents with type 1 diabetes mellitus. Independent and paired t tests compared BGM data downloaded from meters and BGM data downloaded from insulin pumps.

RESULTS

There were significant differences in BGM data downloaded from the insulin pumps of patients using wireless meters compared to those using nonwireless meters. Wireless patients appeared to engage in more BGM, had more low and in-range BG readings and fewer very high BG readingss than nonwireless patients. However, a comparison of BGM data downloaded from meters and insulin pumps of nonwireless patients indicated that their insulin pump data significantly underestimated the number of BGM readings conducted, as well as the number of low and in-range readings, while overestimating the number of very high BGM readings.

CONCLUSIONS

Because patients who use nonwireless-compatible meters do not manually enter their low and in-range BGM readings into the insulin pump, BGM data downloaded only from pumps may provide an incomplete representation of BGM frequency or results. It is recommended that patients use meters that directly communicate with pumps or perform bolus calculations. Patients should be educated about the importance of manually entering all BGM readings if they do not use a wireless-compatible meter with their insulin pump.

Insulin bolusing software: the potential to optimize health outcomes in type 1 diabetes mellitus

BACKGROUND

Insulin bolusing calculators alleviate the burden of having to calculate insulin bolus doses for patients with type 1 diabetes mellitus (T1DM). Three important pieces of information are needed: a blood glucose monitoring (BGM) result, carbohydrates to be consumed, and the amount of insulin bolus delivered. The purpose of this study was to describe insulin pump adherence behaviors associated with the use of bolus calculators in youth who use Medtronic insulin pumps.

METHODS

Data were downloaded from the MiniMed Paradigm insulin pumps (Medtronic) of 31 youth with T1DM. Areas of adherence that were evaluated included fundamental insulin pump adherence behaviors (e.g., BGM, carbohydrate entry, and insulin bolusing), decisions about Wizard® recommendations, and three Wizard steps: BGM result-carbohydrate input-insulin bolus.

RESULTS

On average, patients conducted BGM ≥4 times/day on 69% of days, inputted carbohydrates ≥3 times/day on 63% of days, and insulin bolused ≥3 times/day on 85% of days. Participants generally followed Wizard recommendations. Finally, participants completed all three Wizard steps (BGM, carbohydrate input, insulin bolus) within 30 min for an average of 29% of boluses. Almost 3% of boluses that were preceded by Wizard use were delivered without conducting BGM or inputting carbohydrates.

CONCLUSION

There was substantial variability in insulin pump adherence behaviors (e.g., days when no BGM occurred, reliance on basal insulin). Interventions targeting insulin pump adherence behaviors have the potential to optimize diabetes health outcomes and glycemic control. Improving insulin pump software reports is one promising avenue for improving adherence.

Impact of a telemedicine system with automated reminders on outcomes in women with gestational diabetes mellitus

BACKGROUND

Health information technology has been proven to be a successful tool for the management of patients with multiple medical conditions. The purpose of this study was to examine the impact of an enhanced telemedicine system on glucose control and pregnancy outcomes in women with gestational diabetes mellitus (GDM).

SUBJECTS AND METHODS

We used an Internet-based telemedicine system to also allow interactive voice response phone communication between patients and providers and to provide automated reminders to transmit data. Women with GDM were randomized to either the telemedicine group (n=40) or the control group (n=40) and asked to monitor their blood glucose levels four times a day. Women in the intervention group transmitted those values via the telemedicine system, whereas women in the control group maintained paper logbooks, which were reviewed at prenatal visits. Primary outcomes were infant birth weight and maternal glucose control. Data collection included blood glucose records, transmission rates for the intervention group, and chart review.

RESULTS

There were no significant differences between the two groups (telemedicine vs. controls) in regard to maternal blood glucose values or infant birth weight. However, adding telephone access and reminders increased transmission rates of data in the intervention group compared with the intervention group in our previous study (35.6±32.3 sets of data vs.17.4±16.9 sets of data; P<0.01).

CONCLUSIONS

Our enhanced telemedicine monitoring system increased system utilization and contact between women with GDM and their healthcare providers but did not impact upon pregnancy outcomes.

Does blood glucose monitoring increase prior to clinic visits in children with type 1 diabetes?

OBJECTIVE

To assess the occurrence of white coat adherence in families with children who have type 1 diabetes.

RESEARCH DESIGN AND METHODS

Blood glucose data were downloaded from meters of 72 children, aged 2-11 years, with type 1 diabetes at four consecutive clinic visits. Generalized estimating equations were used to analyze patterns of blood glucose monitoring (BGM) during the 28 days before each clinic visit.

RESULTS

More frequent BGM was associated with better glycemic control. Evidence of a white coat adherence effect, with BGM frequency increasing before a clinic visit, was found only among children with low A1C levels.

CONCLUSIONS

Highly motivated families who frequently monitor their child's blood glucose increased the frequency of BGM before the child's clinic visit. The additional monitoring may benefit the child by providing the physician with a wealth of blood glucose information to guide recommendations.

International Forum for the Advancement of Diabetes Research and Care, April 29-30, 2011, Athens, Greece

The International Forum for the Advancement of Diabetes Research and Care brought together distinguished international experts in diabetes to discuss diverse trends and emerging issues in diabetes therapy and management. The plenary sessions on the first day focused on trends in insulin therapy, the role of glucagon-like peptide-1 receptor agonists in diabetes treatment, the relationship between diabetes and cardiovascular risk, and the challenges associated with the development of clinically relevant treatment guidelines. Interactive breakout sessions addressed the following topics: microvascular complications of diabetes; the need for a team approach to patient education; optimal management of Asian people with diabetes; the role of continuous glucose monitoring in assessing glucose variability; and lessons learned from biosimilar drugs. The plenary sessions on the second day covered self-monitoring of blood glucose, treatment and prevention of type 1 diabetes, and future directions for diabetes therapy. The meeting represented an excellent forum for the presentation of new research and the exchange of ideas aimed at improving outcomes for people with diabetes.

Performance of the DIDGET blood glucose monitoring system in children, teens, and young adults

BACKGROUND

This study evaluated the performance of the DIDGET® blood glucose monitoring system (BGMS) in the hands of its intended users: children, teens, and young adults with diabetes.

METHODS

Finger stick capillary blood samples were tested in duplicate by subjects (with parent/guardian assistance, if needed) and health care professionals using the DIDGET BGMS, and results were compared with those obtained using a Yellow Springs Instruments (YSI) glucose analyzer. Modified venous blood samples (i.e., glycolyzed or spiked with glucose) were used to analyze meter performance under extreme glucose concentrations. Accuracy was assessed using International Organization for Standardization (ISO) 15197:2003 guidelines (i.e., 95% of meter results within ±15 mg/dl or ±20% of reference values).

RESULTS

A total of 123 subjects aged 4 to 24 years with type 1 or type 2 diabetes were enrolled. The DIDGET meter achieved accuracy according to ISO 15197:2003 criteria: >97% of meter results were within ±15 mg/dl or ±20% of reference values. Regression analyses showed a high degree of correlation between meter and YSI results: coefficient of determination (R(2)) = 98.2% for all samples combined and 97.2% for capillary samples only. Clinical accuracy for combined samples was demonstrated by Parkes consensus error grid analyses; 100% of meter results were in zone A (98.5%) or zone B (1.5%). There was no difference in performance or accuracy across age subsets. Hematocrit values did not affect meter blood glucose results.

CONCLUSION

The DIDGET BGMS provided accurate test results across all age ranges in children, teens, and young adults with diabetes.

Ease of use and preference for a new disposable self-injection pen compared with a reusable pen for administering recombinant human growth hormone: A multicenter, 2-month, single-arm, open-label clinical trial in patient-caregiver dyads

BACKGROUND

Improved ease of use of drug-delivery devices may enhance compliance. Development of an easier-to-use device for administration of recombinant human growth hormone (rhGH) may thus be beneficial for patients and their caregivers.

OBJECTIVE

This study compared ease of use and preference for a new disposable rhGH injection pen relative to previous experience with the currently available reusable pen in standard practice. Both pens deliver the same formulation of rhGH.

METHODS

This multicenter, single-arm, open-label study assessed ease of use and preference for the 2 injection pens in patient-caregiver dyads. Eligible children were aged 8 through 18 years, were currently being treated with rhGH, and had been compliant with use of the current reusable pen for ≥ 3 months before study entry. A validated self-reported Injection Pen Assessment Questionnaire was administered twice during the study-at baseline (to assess perceptions of the reusable pen) and after 2 months of use of the new disposable pen-to assess ease of use of the individual pens (rated on a 5-point Likert-type scale), the comparative ease of use of the 2 pens, and pen preference. The primary end point was the proportion of dyads who rated the new pen as no different or easier to use than the current pen. Regardless of treatment or suspected causal relationship to the investigational product, all observed or volunteered adverse events (AEs) were recorded and rated as mild, moderate, or severe.

RESULTS

Of 137 screened dyads, 136 (91 boys, 45 girls) were included in the safety population and 133 were included in the efficacy population. The children had a mean age of 12.3 years, a mean weight of 42.2 kg, a mean height of 145.9 cm, and a mean body mass index of 19.3 kg/m(2); 84.6% of the children were white. The majority (82.4%) of adult dyad members were subjects' mothers. The adult dyad members were more likely than the child members to be responsible for preparing the injection (82.0%) and administering the injection (72.9%). Overall, 73.7% of dyads rated the new disposable pen no different or easier to use than the reusable pen (95% CI, 66.2%-81.2%), and 65.2% rated the disposable pen no different or preferable to the reusable pen (95% CI, 57.0%-73.3%). Overall, 60 all-causality AEs occurred in 28 subjects (20.6%), most of them (93.3%) either mild or moderate in intensity. Eight device-related AEs occurred in 7 subjects (5.1%) (injection-site hematoma in 3 and injection-site pain in 5). The most common AEs were headache (7 events), injection-site pain (5), upper respiratory tract infection (4), and pyrexia (4). No deaths or serious AEs were reported.

CONCLUSIONS

Nearly three quarters of patients and caregivers reported that the new disposable pen was no different or easier to use than the reusable pen, and nearly two thirds preferred the disposable pen. No safety concerns were identified. The findings suggest that the improvements in the new pen were recognized by patients and caregivers.

Risk factors associated with depressive symptoms in caregivers of children with type 1 diabetes or cystic fibrosis

OBJECTIVE

Evaluate depressive symptoms in caregivers of children with type 1 diabetes (T1D) or cystic fibrosis (CF) and identify associated risk factors.

METHODS

A total of 195 caregivers completed demographic, stress, and depressive symptoms questionnaires. Children's health status was obtained from medical records.

RESULTS

Approximately 33% of caregivers reported elevated symptoms of depression (i.e., exceeded clinical cutoff of 16 on the Center for Epidemiological Studies-Depression Scale). For caregivers of children with T1D, elevations were associated with less caregiver education, more family stress, older child age, and worse glycemic control. For caregivers of children with CF, more family stress and lack of employment outside of the home were associated with elevated depressive symptoms.

CONCLUSIONS

Many caregivers of children with T1D or CF experience depressive symptoms, although risk factors may differ in these two populations. Screening of caregiver depressive symptoms as part of routine clinic visits may provide opportunities for needed intervention.

Parent reactions to a school-based body mass index screening program

BACKGROUND

This study assessed parent reactions to school-based body mass index (BMI) screening.

METHODS

After a K-8 BMI screening program, parents were sent a letter detailing their child's BMI results. Approximately 50 parents were randomly selected for interview from each of 4 child weight-classification groups (overweight, at risk of overweight, normal weight, underweight) to assess parent recall of the letter, reactions to BMI screening, and actions taken in response to the child's BMI results.

RESULTS

Most parents found the BMI screening letter easy to read and had poor recall of numerical information (eg, the child's BMI percentile) but good recall of the child's weight classification (eg, normal weight or overweight). Most parents, and ethnic-minority parents in particular, supported school-based BMI screening. Parents of children whose weight was outside of the normal range were more likely to recall receiving the letter and talking to the child and the child's doctor about it. Parents who recalled their child as being overweight were more likely to report changing the child's diet and activity level. Most parents, and ethnic-minority parents in particular, wanted their child to participate in an after-school exercise program. An overweight condition in parents, but not children, was associated with an interest in family-based cooking and exercise classes.

CONCLUSIONS

Most parents, and ethnic-minority parents in particular, viewed school-based BMI screening and after-school exercise programs favorably. Parents reported taking action in response to a BMI result outside of the normal range. Parents who were overweight themselves were particularly interested in family cooking and exercise classes.

Prevalence of overweight in north Florida elementary and middle school children: effects of age, sex, ethnicity, and socioeconomic status

BACKGROUND

The number of overweight children has been rapidly increasing, although its prevalence varies by age, sex, ethnicity, and socioeconomic (SES) status.

METHODS

Height and weight assessments were used to calculate body mass index (BMI) and BMI percentile on more than 17,000 children in 1 north Florida school district's elementary and middle schools. Based on the child's BMI percentile, each child was placed into 1 of 4 groups: underweight, normal, at risk for overweight, and overweight. Logistic regression was used to test the relative contribution of sex, ethnicity, school (elementary vs middle), age, and SES (indicated by free/reduced vs full-pay lunch status) to a child's weight classification.

RESULTS

Overall, 36.2% of the children were either overweight (18.9%) or at risk for overweight (17.4%). Approximately 30% of the kindergarten children were overweight (14.0%) or at risk for overweight (15.5%). African American children were most likely to begin kindergarten overweight. The prevalence of overweight increased for all ethnic groups during the elementary school years. However, African American girls and Hispanic boys were more likely to be overweight than any other ethnic group; Asian girls were least likely to be overweight. These findings could not be readily explained by the effects of SES. Higher SES appeared to be protective but only for white and Hispanic children.

CONCLUSIONS

These results confirm the increasing prevalence of overweight in US school children, especially among African American girls and Hispanic boys.

Type 2 diabetes mellitus among Florida children and adolescents, 1994 through 1998

OBJECTIVES

This study was undertaken to examine the trends in the diagnosis of Type 2 diabetes mellitus among children and adolescents with new-onset diabetes seen from 1994 through 1998 at the three university-based diabetes centers in Florida.

METHODS

Data were abstracted from medical records and patients were categorized as having Type 1 or Type 2 diabetes.

RESULTS

There were 569 patients classified with Type 1 diabetes and 92 with Type 2 diabetes. The proportion of patients diagnosed with Type 2 diabetes increased over the five years from 9.4% in 1994 to 20.0% in 1998 (chi-square test for trend = 8.2; p=0.004). There was not an associated net increase in the total number of new diabetes patients referred over time (chi-square test for trend = 0.6, p=0.4). Those with Type 2 diabetes were more likely to have a body mass index in the 85th-94th percentile [odds ratio (OR) = 8.5; 95% confidence interval (CI) 2.5, 28.8], have a body mass index >or=95th percentile (OR = 6.8; 95% CI 2.6, 17.7), Hispanic ethnicity (OR = 6.2; 95% CI 2.2, 17.9), black race (OR = 2.8; 95% CI 1.3, 6.2), female gender (OR = 2.2; 95% CI 1.2, 4.3), and older age (OR = 1.4 for each one-year increment in age; 95% CI 1.3, 1.6), compared with those having Type 1 diabetes.

CONCLUSIONS

From 1994 through 1998, there was a significant overall increase in the percentage of children referred with new-onset diabetes who were considered to have Type 2 diabetes. Factors associated with the diagnosis of Type 2 diabetes relative to Type 1 diabetes include body mass index >/=85th percentile, Hispanic ethnicity, black race, female gender, and older age.

Insulin lispro lowers postprandial glucose in prepubertal children with diabetes

OBJECTIVE

This study compared the glucose-lowering effect of insulin lispro, given before or after meals, with regular human insulin given before meals in prepubertal children with diabetes.

RESEARCH DESIGN AND METHODS

A 3-way crossover, open-label study involving 61 prepubertal children (ages 2.9-11.4 years) with type 1 diabetes. The children were randomly assigned to receive regular human insulin 30 to 45 minutes before meals, insulin lispro within 15 minutes before or immediately after meals, combined with basal insulin. Each treatment lasted 3 months. Hemoglobin A(1c) levels and home glucose monitoring profiles were measured at the end of each treatment period.

RESULTS

Treatment with insulin lispro before breakfast resulted in lower 2-hour postprandial glucose values than regular human insulin (11.7 +/- 4.4 mmol/L vs 15.0 +/- 5.4 mmol/L). Similarly, insulin lispro given before dinner resulted in lower blood glucose values 2 hours postprandially (8.8 +/- 5.0 mmol/L vs 10.8 +/- 5.4 mmol/L) than regular human insulin. When insulin lispro was administered after meals, the 2-hour glucose levels were between those seen with either insulin lispro or regular human insulin given before meals. The number and types of adverse events, the rates of hypoglycemia, and the HbA(1c) levels did not differ among the 3 therapies.

CONCLUSIONS

In prepubertal children, insulin lispro given before meals is safe and significantly lowers postprandial glucose levels after breakfast and dinner compared with regular human insulin, and insulin lispro given after the meal provides similar benefits as regular human insulin before the meal.

Multisite evaluation of a new diabetes self-test for glucose and glycated protein (fructosamine)

BACKGROUND

In diabetes management, the true average blood glucose is best obtained using glycated protein tests that give the average blood glucose over a previous time window of either weeks (fructosamine tests) or months (glycated hemoglobin tests). Until now, glycated protein tests have only been available as laboratory tests and have therefore been underutilized in diabetes management. Recently, a fructosamine self-test for use by diabetes patients at home was cleared for marketing by the U.S. Food and Drug Administration (FDA). We have studied the performance of this test in three geographically distinct diabetes clinics to confirm the performance and accuracy of both glucose and fructosamine testing with this device. This new self-testing system has the potential to improve glycemic control dramatically in patients with diabetes, including those patients with type 2 diabetes using oral drug therapy.

METHODS

Three geographically different sites (San Diego, CA, Tallahassee, FL, and Minneapolis, MN) were selected for the study. Sixty male and 56 female adult patients, with both type 1 (59) and type 2 (57) diabetes, were selected for participation in the study (total patients = 116). Fingerstick puncture capillary blood glucose was tested using the YSI Model 1500 and the Duet Glucose test. A fingerstick puncture capillary blood test was also tested with the Duet GlucoProtein (fructosamine) test strip in duplicate. For fructosamine comparison, a venipuncture blood sample of ethylene diaminetetraacetic acid (EDTA) plasma was collected and tested using the Roche Unimate laboratory test.

RESULTS

The glucose test gave excellent correlation to the reference laboratory method (r = 0.98) and the GlucoProtein test gave a correlation of 0.72 compared to the laboratory method. The bias of both tests compared to the laboratory tests was 10% or less at all concentrations. Error grid analysis of the glucose test showed that 97.5% of test results were in the accurate zone and 2.5% were in the clinically neutral or benign errors zone. Analysis of fructosamine test results using a two-by-two grid yielded sensitivity of 100%, specificity of 92% and accuracy of 94%.

CONCLUSIONS

The Duet Glucose Control System is accurate for both measuring glucose and GlucoProtein (fructosamine) using a fingerstick blood sample. This new testing system has the potential to provide useful information to both healthcare specialists in their office and also to patients at home to help them achieve better long-term glucose control and avoid the potential acute and chronic complications of diabetes.

Staged diabetes management. Toward an integrated model of diabetes care

This paper introduces a new and innovative approach to diabetes management in the primary-care setting. Staged diabetes management (SDM) represents a four-year effort to develop and test a data-based approach to diabetes management that could be easily adapted to a variety of health-care settings in which diabetes management is principally under the direction of primary-care physicians was limited access to specialists. After testing under controlled circumstances at the International Diabetes Center (Minneapolis, MN), SDM was subjected to substantial field trials under conditions that represent the scope and variety of primary-care practices in diabetes. The following represents the work of several investigators who independently undertook a review of SDM.

Insulin availability among International Diabetes Federation member associations. Report of the Task Force on Insulin Distribution

OBJECTIVE

To assess the availability of insulin and diabetes supplies among International Diabetes Federation (IDF) member associations.

RESEARCH DESIGN AND METHODS

A mail survey of IDF member associations asked about the following issues: 1) diabetes prevalence and insulin use, 2) availability and cost of insulin and supplies, 3) availability of glycemic monitoring supplies, 4) cost of insulin and supplies to patients, and 5) availability of oral hypoglycemic agents.

RESULTS

Of 85 member associations, 60 responded. The mean prevalence of diabetes was 3.7%. Of the 39 with a population-based survey data, the prevalence was 3.9%. Insulin use was reported for 19.2% of diabetes patients and, for the 15 with population-based data, the proportion using insulin was 16.1%. Of the respondents, 47 (78%) reported insulin was always available, 11 (18%) reported insulin was available from 25 to 99% of the time, and 2 (Uganda and Tanzania) reported insulin was available < 25% of the time. Insulin is free to patients in 39 (65%) of the countries. The average cost of the least expensive insulin was U.S. $9.62 per vial. Fifteen countries imposed a mean 13% customs charge. Disposable syringes were available in 42 (72%) of countries all of the time. Glucose meters were in use in 49 countries. The most common oral agent was glyburide, which was available in 57 countries.

CONCLUSIONS

Insulin is in reasonable supply in IDF member countries. Cost and customs charges are an impediment to universal access. IDF now can recommend programs based on this data.

Stroke mortality and its socioeconomic, racial, and behavioral correlates in Florida

Stroke mortality is associated both with being black and with having low socioeconomic status. However, it is uncertain to what extent that increased risk is related to rates of behavior-related risk factors, such as hypertension, cigarette smoking, obesity, or alcohol consumption. The investigators performed an ecologic analysis to estimate the contributions of behavioral risks, socioeconomic status, and black race to regional variations in stroke mortality rates among persons 55-84 years of age in Florida. They used data from the 1980 census and from the Behavioral Risk Factor Surveillance System (BRFSS) for 1986 through 1988. Weighted multiple linear regression models indicated that regions in Florida with high stroke mortality rates were characterized by high prevalences of poverty, obesity, and hypertension. Although limited by its ecologic design, this study suggests that socioeconomic status and prevalence of behavioral risks contribute independently to interregional disparities in stroke mortality rates in Florida. BRFSS data, now available for more than 45 States, can be used to help clarify the relative contributions of behavioral and other risks to population-based mortality rates.

North Florida is part of the stroke belt

Florida is the only State in the southeastern United States that is not part of the "stroke belt." The National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health, defines the stroke belt as those States with an age-adjusted stroke mortality rate for the years 1979 to 1981 that is more than 10 percent above the national annual rate of 40.3 per 100,000 population. By reproducing at the county level the methods that were used at the State level to describe the stroke belt, the authors identified a group of 34 contiguous northern Florida counties (population exceeds 2 million) with an age-adjusted stroke mortality rate of 47.2 per 100,000--higher than 3 of the 11 stroke belt States. They concluded that north Florida is part of the stroke belt and should be included as a priority region for stroke prevention programs. County-level analyses that are methodologically comparable with those used by NHLBI to describe the stroke belt may be a useful technique for identifying high stroke-rate regions within States which might be missed when needs assessment is based only on State-level data.

Infant mortality by cause: A comparison of underlying and multiple cause designations

The extent of variability in the social, economic, and demographic characteristics of infant deaths when grouped by detailed cause is analyzed using health statistics data for Florida for the period 1980-1982. "The analysis first compares cause-of-death-specific infant, neonatal, and postneonatal mortality between each of the four cause-of-death models. Next, interest shifts to an examination of the variability among decedents, specific to cause of death, in a range of background, proximate, and immediate determinants of infant health and survival. Variability is evident in cause-specific mortality rates as well as in decedent characteristics across the cause-of-death models. These findings suggest that more attention be given to the mode of identifying cause of death in studies of infant mortality." (SUMMARY IN FRE)

Interventions among primary-care practitioners to improve care for preventable complications of diabetes

The National Diabetes Advisory Board recommends that diabetes prevention and control programs focus on the preventable complications of diabetes, i.e., visual impairment, lower-extremity problems, renal problems, ketoacidosis, and adverse outcomes of pregnancy. The Florida Diabetes Control Program chose to focus its efforts on the first three of these complications at the federal- and state-funded primary-care programs in Florida because these programs had access to targeted, public-sector patients and because of fiscal restraints that make the care provider the logical source of entry to the health-care system. This study sought to document the current level of care for complications of diabetes in primary-care settings, provide state-of-the-art professional education along with patient education, and evaluate changes in practice habits. Three intervention and three control primary-care centers were selected. Medical records in each center were reviewed over a 2-yr period. At intervention sites, retinopathy referrals increased from 9 to 43% (P less than .001), urinalyses increased from 69 to 94% (P less than .001), and examinations of lower extremities increased from 66 to 94% (P less than .001). There were no such changes in the control sites. Hypertension was diagnosed in nearly two-thirds of patients, and a last blood pressure of greater than 140 mmHg systolic or greater than 90 mmHg diastolic was present in 64% of the intervention group at yr 1 and declined to 56% at yr 2 (P less than .05).(ABSTRACT TRUNCATED AT 250 WORDS)

Surveillance in Florida of continuous subcutaneous insulin infusion use in cohort

Because of concerns about safety and expense associated with continuous subcutaneous insulin infusion (CSII), all people who had used CSII as of July 1982 were identified. Annual follow-up has resulted in data for up to 61 mo. Of the 92 nonpregnant registrees, 31 were less than 20 yr old, 36 were 20-29, and 25 were 30 yr or older. Two deaths occurred in 1780 person-months of pump use. The cumulative proportion on the pump (CPOP) or actuarial CSII continuance proportion was 11%. There was no significant difference between sexes or between ages for men, but despite eliminating pregnant women, those greater than or equal to 30 yr old had a CPOP of 0.22, compared with 0.11 for those less than 30 yr (P = .03). Continuance curves were no different for those beginning CSII with or without complications or for those with or without good glucose control. Those who began at patient request did have better CPOP than those who began at physician request (P = .05). Physician perception of clinical, mechanical, or psychosocial problems while on the pump was not predictor of continuance curves as measured by CPOP. Of the 17 physicians queried at the latest update, 9 physicians have 16 current CSII users; these 9 have only 14% of their patients in the original cohort currently on CSII. This is compared with the 3 physicians who have 34 current users and 60% of their original cohort on CSII. Four physicians no longer use CSII. Devices for CSII cost +131/person-month of use.(ABSTRACT TRUNCATED AT 250 WORDS)

Cushing's disease. A cause of delayed growth and development

An adolescent male with a typical cushingoid appearance presented to his physician with failure of linear growth and sexual development. Although his neuroradiologic workup was negative, his endocrinologic assessment pointed to the pituitary gland as the diseased organ. Selective transsphenoidal adenomectomy has thus far resulted in normalization of cortisol and growth hormone levels and furthered linear and sexual growth.

Characteristics of recipients in Florida's long-term program of insulin distribution

Since 1935 the State health agency has provided insulin to medically indigent diabetics in Florida. During 1980, data were collected on 9,429 recipients regarding their age, race, sex, height, weight, and type and dosage of insulin. The mean age was 55 years; 47 percent were white and 52 percent were black. Seventy-two percent of the recipients were females and 28 percent were males. The utilization rate was much greater for blacks than for whites in all age-sex groups. Seventy-two percent of the estimated number of insulin-requiring black females used insulin supplied by the health agency, compared with 9 percent of insulin-requiring white females in the State. For black males, the proportion was 37 percent and for the white males, it was 5 percent. Obesity was defined as a Body Mass Index (BMI) of greater than 25 for females and greater than 27 for males. The mean BMIs were 30.9 for females and 27.7 for males. In all age groups, women were more obese than men, and blacks were more obese than whites except for the oldest age group, those 65 and older. The mean total daily dosage of insulin was 46 units, and 95 percent of recipients used NPH or Lente insulin. Insulin dosage per kilogram of body weight showed some decrease as weight increased. The authors concluded that the Florida program reaches a significant proportion of its target population.

Diabetes and pregnancy in South Carolina: prevalence, perinatal mortality, and neonatal morbidity in 1978

Through retrospective analysis of vital records and hospital discharge data, this study examines the prevalence of diabetes in pregnancy and diabetes-related perinatal mortality and neonatal morbidity in South Carolina in 1978. Diabetes was observed in 5.9/1000 deliveries. Diabetic natality rates for whites and nonwhites were 5.1/1000 and 6.9/1000, respectively. In comparison with comprehensive screening programs, these rates suggest that more than half of all diabetic pregnancies in South Carolina are unrecognized. The overall diabetic perinatal mortality rate was 102 deaths/1000 deliveries, in contrast to the nondiabetic perinatal mortality rate of 25 deaths/1000 deliveries. The risk of perinatal mortality is greater for nonwhites (153 deaths/1000 deliveries) and for women on insulin (182 deaths/1000 deliveries). One-fourth of the pregnancies among nonwhite women on insulin resulted in fetal or neonatal death. Observed neonatal morbidity was high, with respiratory distress syndrome, hypoglycemia, infections, and congenital anomalies the most frequent complications reported. Documentation of assessment for other common neonatal complications was limited.

Surgical management of islet-cell adenoma in infancy

Persistent neonatal hypoglycemia is a potentially serious condition which should be recognized promptly, investigated thoroughly, and treated expeditiously. Islet-cell adenoma causing hypoglycemia in infancy is very unusual. Only 23 cases have been reported in the literature. This report documents eight cases of our own and summarizes diagnostic methods, proper medical preparation, and fundamental surgical management. Prompt surgical intervention is emphasized, as this will relieve hypoglycemia and may be important in preventing irreversible central nervous system damage. We are of the opinion that any infant with unremitting hypoglycemia, a high corrected insulin/glucose ratio, and failure to respond to maximum diazoxide therapy will require partial pancreatectomy. Identification of the adenoma at the time of operation is unlikely, and blind pancreatectomy and/or reoperation is not unusual.