An ecological resilience model for adolescents with type 1 diabetes: a cross-sectional study

BACKGROUND

Highly resilient adolescents with type 1 diabetes have been proved to achieve within-target glycemic outcomes and experience high quality of life. The ecological resilience model for adolescents with type 1 diabetes was developed in this study. It aims to increase our understanding of how resilience is both positively and negatively affected by internal and environmental ecological factors.

METHODS

This cross-sectional study surveyed 460 adolescents with type 1 diabetes from 36 cities in 11 provinces, China. Participants completed self-report questionnaires on resilience, family functioning, peer support, peer stress, coping style, and demographics. Standard glycated hemoglobin tests were performed on the adolescents. Structural equation modeling was applied to analyze the data.

RESULTS

The ecological resilience model for adolescents with type 1 diabetes was a good model with a high level of variance in resilience (62%). Family functioning was the most important predictor of resilience, followed by peer support, positive coping, and peer stress. Moreover, positive coping was the mediator of the relationship between family functioning and resilience. Positive coping and peer stress co-mediated the association between peer support and resilience.

CONCLUSIONS

Family functioning, peer relationships, and positive coping are interrelated, which may jointly influence resilience. The findings provide a theoretical basis for developing resilience-promotion interventions for adolescents with type 1 diabetes, which may lead to health improvements during a vulnerable developmental period.

Diagnosing Osteoporosis in Diabetes-A Systematic Review on BMD and Fractures

PURPOSE OF REVIEW

Recently, the American Diabetes Association updated the 2024 guidelines for Standards of Care in Diabetes and recommend that a T-score of - 2.0 in patients with diabetes should be interpreted as equivalent to - 2.5 in people without diabetes. We aimed to evaluate the most recent findings concerning the bone mineral density (BMD)-derived T-score and risk of fractures related to osteoporosis in subjects with diabetes.

RECENT FINDINGS

The dual-energy X-ray absorptiometry (DXA) scan is the golden standard for evaluating BMD. The BMD-derived T-score is central to fracture prediction and signifies both diagnosis and treatment for osteoporosis. However, the increased fracture risk in diabetes is not sufficiently explained by the T-score, complicating the identification and management of fracture risk in these patients. Recent findings agree that subjects with type 2 diabetes (T2D) have a higher T-score and higher fracture risk compared with subjects without diabetes. However, the actual number of studies evaluating the direct association of higher fracture risk at higher T-score levels is scant. Some studies support the adjustment based on the 0.5 BMD T-score difference between subjects with T2D and subjects without diabetes. However, further data from longitudinal studies is warranted to validate if the T-score treatment threshold necessitates modification to prevent fractures in subjects with diabetes.

Ensemble machine learning reveals key features for diabetes duration from electronic health records

Diabetes is a metabolic disorder that affects more than 420 million of people worldwide, and it is caused by the presence of a high level of sugar in blood for a long period. Diabetes can have serious long-term health consequences, such as cardiovascular diseases, strokes, chronic kidney diseases, foot ulcers, retinopathy, and others. Even if common, this disease is uneasy to spot, because it often comes with no symptoms. Especially for diabetes type 2, that happens mainly in the adults, knowing how long the diabetes has been present for a patient can have a strong impact on the treatment they can receive. This information, although pivotal, might be absent: for some patients, in fact, the year when they received the diabetes diagnosis might be well-known, but the year of the disease unset might be unknown. In this context, machine learning applied to electronic health records can be an effective tool to predict the past duration of diabetes for a patient. In this study, we applied a regression analysis based on several computational intelligence methods to a dataset of electronic health records of 73 patients with diabetes type 1 with 20 variables and another dataset of records of 400 patients of diabetes type 2 with 49 variables. Among the algorithms applied, Random Forests was able to outperform the other ones and to efficiently predict diabetes duration for both the cohorts, with the regression performances measured through the coefficient of determination R2. Afterwards, we applied the same method for feature ranking, and we detected the most relevant factors of the clinical records correlated with past diabetes duration: age, insulin intake, and body-mass index. Our study discoveries can have profound impact on clinical practice: when the information about the duration of diabetes of patient is missing, medical doctors can use our tool and focus on age, insulin intake, and body-mass index to infer this important aspect. Regarding limitations, unfortunately we were unable to find additional dataset of EHRs of patients with diabetes having the same variables of the two analyzed here, so we could not verify our findings on a validation cohort.

Trust-based health decision-making recruits the neural interoceptive saliency network which relates to temporal trajectories of Hemoglobin A1C in Diabetes Type 1

Experimental approaches in neuroeconomics generally involve monetary utility. Utility in the health domain is relevant in diabetes because constant daily life decisions are critical for self-consequential long-term outcomes. We used fMRI to investigate self-consequent decision-making in the health and economic domains in Type 1 Diabetes Mellitus and controls (N = 50). We focused on two critical phases of decision-making: Investment and Feedback (Positive or Negative). Patients showed larger BOLD activation of limbic, and reward/dopaminergic regions in particular in the health trust game. Importantly, the worse the trajectory of metabolic control (increasing HbA1C), the higher the BOLD activity in regions of the interoceptive saliency network. This was manifested by positive correlations between brain activity during investment in anterior cingulate cortex and insula and HbA1c blood level progression. We conclude that the neural correlates of health-consequent decision-making domain involve limbic and reward related dopaminergic regions in Type 1 Diabetes Mellitus. Furthermore, the temporal trajectory of HbA1C blood levels is correlated with neural risk processing in the saliency network. Evidence for differential risk processing in the health versus the neuroeconomic context, and the discovery of a role for the saliency interoceptive network in metabolic control trajectories suggests a new perspective on the development of personalized interventions.

Effectiveness of Faster Aspart versus Insulin Aspart in Children with Type 1 Diabetes: A Meta-Analysis

Background

Intensive insulin regimens are recommended to achieve glycemic goals in children and adolescents with type 1 diabetes. Fast-acting insulin aspart (faster aspart) is a new formulation of insulin aspart (IAsp) in which L-arginine and niacinamide are added to assure formulation stability, early absorption, and ultra-fast action. This meta-analysis compares faster aspart with IAsp for blood sugar control in children with type 1 diabetes. This study suggested treating diabetes with insulin, especially in children with type 1 diabetes.

Methods

PubMed, MEDLINE, Embase, Cochrane Library, Web of Science, and Google Scholar were searched from 2000 to 2023 without language restrictions. Blood glucose monitoring, HbA1c, care model, insulin aspart, IAsp, faster aspart, type 1 diabetes, and pediatrics are Mesh keywords. Cochrane Q statistics and index tested heterogeneity. To account for heterogeneity, Q=145.99 (P-value < 0.001) and =97.26%, and the random-effect model was used to aggregate primary study results. The meta-analysis of randomized-controlled trials was conducted in accordance with PRISMA standards.

Results

The overall estimate measure i.e. mean difference was found to be 5.44 [0.45, 10.44] and 7.71 [7.16, 8.26] which indicate significant reduction in the HbA1C level in the fast acting insulin aspart group as compared to the IAsp in T1D. However, the mean difference with respect to BMI was found to be -0.06 [-0.60, 0.48] which indicate non-significant reduction.

Conclusion

Faster aspart had faster onset and more early exposure than IAsp in children and adolescents with greater and more variable anti-insulin antibody levels than adults did. Hence fast-acting insulin aspart may provide better glucose control than IAsp in T1D.

Gestational diabetes mellitus and COVID-19: The epidemic during the pandemic

During the global coronavirus disease 2019 (COVID-19) pandemic, people worldwide have experienced an unprecedented rise in psychological distress and anxiety. In addition to this challenging situation, the prevalence of diabetes mellitus (DM), a hidden epidemic, has been steadily increasing in recent years. Lower-middle-income countries have faced significant barriers in providing accessible prenatal care and promoting a healthy diet for pregnant women, and the pandemic has made these challenges even more difficult to overcome. Pregnant women are at a higher risk of developing complications such as hyper-tension, preeclampsia, and gestational diabetes, all of which can have adverse implications for both maternal and fetal health. The occurrence of gestational diabetes has been on the rise, and it is possible that the pandemic has worsened its prevalence. Although data is limited, studies conducted in Italy and Canada suggest that the pandemic has had an impact on gestational diabetes rates, especially among women in their first trimester of pregnancy. The significant disruptions to daily routines caused by the pandemic, such as limited exercise options, indicate a possible link between COVID-19 and an increased likelihood of experiencing higher levels of weight gain during pregnancy. Notably, individuals in the United States with singleton pregnancies are at a significantly higher risk of excessive gestational weight gain, making this association particularly important to consider. Although comprehensive data is currently lacking, it is important for clinical researchers to explore the possibility of establishing correlations between the stress experienced during the pandemic, its consequences such as gestational gain weight, and the increasing incidence of gestational DM. This knowledge would contribute to better preventive measures and support for pregnant individuals during challenging times.

Proof-of-concept Study of Using Supervised Machine Learning Algorithms to Predict Self-care and Glycemic Control in Type 1 Diabetes Patients on Insulin Pump Therapy

OBJECTIVE

Using supervised machine learning algorithms (SMLAs), we built models to predict the probability of type 1 diabetes mellitus (T1DM) patients on insulin pump therapy for meeting insulin pump self-management behavioral (IPSMB) criteria and achieving good glycemic response within six months.

METHODS

This was a single-center retrospective chart review of 100 adult T1DM patients on insulin pump therapy (>6 months). Three SMLAs were deployed: multivariable logistic regression (LR), random forest (RF), and K-nearest neighbor (k-NN); validated using repeated three-fold cross-validation. Performance metrics included AUC-ROC for discrimination and Brier scores for calibration.

RESULTS

Variables predictive of adherence with IPSMB criteria were baseline HbA1c, continuous glucose monitoring (CGM), and sex. The models had comparable discriminatory power (LR=0.74; RF=0.74; k-NN=0.72), with the random forest model showing better calibration (Brier=0.151). Predictors of the good glycemic response included baseline HbA1c, entering carbohydrates, and following the recommended bolus dose, with models comparable in discriminatory power (LR=0.81, RF=0.80, k-NN=0.78) but the random forest model being better calibrated (Brier=0.099).

CONCLUSION

These proof-of-concept analyses demonstrate the feasibility of using SMLAs to develop clinically relevant predictive models of adherence with IPSMB criteria and glycemic control within six months. Subject to further study, non-linear prediction models may perform better.

Age-period-cohort modelling of type 1 diabetes incidence rates among children included in the EURODIAB 25-year follow-up study

AIMS

Specific patterns in incidence may reveal environmental explanations for type 1 diabetes incidence. We aimed to study type 1 diabetes incidence in European childhood populations to assess whether an increase could be attributed to either period or cohort effects.

METHODS

Nineteen EURODIAB centres provided single year incidence data for ages 0-14 in the 25-year period 1989-2013. Case counts and person years were classified by age, period and cohort (APC) in 1-year classes. APC Poisson regression models of rates were fitted using restricted cubic splines for age, period and cohort per centre and sex. Joint models were fitted for all centres and sexes, to find a parsimonious model.

RESULTS

A total of 57,487 cases were included. In ten and seven of the 19 centres the APC models showed evidence of nonlinear cohort effects or period effects, respectively, in one or both sexes and indications of sex-specific age effects. Models showed a positive linear increase ranging from approximately 0.6 to 6.6%/year. Centres with low incidence rates showed the highest overall increase. A final joint model showed incidence peak at age 11.6 and 12.6 for girls and boys, respectively, and the rate-ratio was according to sex below 1 in ages 5-12.

CONCLUSION

There was reasonable evidence for similar age-specific type 1 diabetes incidence rates across the EURODIAB population and peaks at a younger age for girls than boys. Cohort effects showed nonlinearity but varied between centres and the model did not contribute convincingly to identification of environmental causes of the increase.

Biochemical and clinical markers of endothelial dysfunction do not outweigh traditional risk factors for the presence of diabetic retinopathy in patients with type 1 diabetes

BACKGROUND

This study aimed to evaluate whether soluble vascular cytoadhesive molecule-1 (sVCAM-1), intracellular cytoadhesive molecule-1 (sICAM-1), and endothelial function as assessed by EndoPat outweighed traditional risk factors for the presence of diabetic retinopathy (DR) in patients with type 1 diabetes (T1D).

METHODS

Patients aged ≥ 12 years completed a clinical-epidemiological questionnaire. Fasting venous blood samples were obtained (lipid profile, glycemic control, and C-reactive protein levels). Vascular reactivity was assessed via peripheral arterial tonometry performed by supplying the reactive hyperemia index (RHI) through the EndoPAT device. sVCAM-1 and sICAM-1 levels were measured using multiplex assays.

RESULTS

Data were obtained from 187 patients (51.3% female), aged 32 ± 13 years with a disease duration of 14 (6-15) years and mean hemoglobin A1c (HbA1c) of 9.1% ± 2.1%. After adjustments were made, age, HbA1c, arterial blood pressure, and use of drugs that could interfere with endothelial function were found to be associated with DR. No association was noted with sVCAM-1 and sICAM-1 levels and RHI.

CONCLUSIONS

In our sample, sVCAM-1, sICAM and EndoPAT did not outweigh the traditional DR risk factors, such as age, high HbA1c, arterial blood pressure, and use of drugs that could interfere with endothelial function and are significantly associated with DR. Further prospective studies should evaluate if markers of endothelial dysfunction could predict diabetes-related micro and macrovascular complications in T1D.

Prevalence of haplotype DQ2/DQ8 and celiac disease in children with type 1 diabetes

Type 1 diabetes (T1D) and celiac disease (CD) coexist very often. Identification of the human leukocyte antigen (HLA) DQ2/DQ8 can confirm the genetic predisposition to CD. Negative result of this test allows to exclude CD with a high probability. It was suggested that in individuals with higher risk of CD, including T1D patients, the implementation of genetic testing should reduce the number of patients requiring systematic immunological screening. The aim of this study was to analyze the prevalence of different haplotypes predisposing to CD in children and adolescents with previously diagnosed T1D.

MATERIAL AND METHODS

A retrospective analysis was performed on 166 T1D children (91 girls) in whom HLA DQ2/DQ8 alleles were tested. In 9.6% CD was also diagnosed.

RESULTS

In 12.7% both HLA DQ2/DQ8 were negative. In 87.3% patients HLA DQ2 and/or DQ8 was positive, including 27.7% patients with both haplotypes DQ2.5 and DQ8 positive. In all CD patients the disease predisposing alleles were positive, while none of the HLA DQ2/DQ8 negative children were diagnosed with CD.

CONCLUSIONS

The prevalence of HLA DQ2.5 and the HLA DQ2.5 / HLA DQ8 configuration is higher in patients with T1D, and CD compared to children with T1D alone. The combination of HLA DQ2 and HLA DQ8 most significantly increases the risk of developing CD. The group of HLA DQ2/DQ8 negative patients with improbable CD diagnosis, is relatively small. Most of T1D patients HLA DQ2/DQ8 positive need further regular antibody assessment. In patients with T1D, who are at high risk of developing CD, genetic testing may be considered to select those who require further systematic serological evaluation. Due to its retrospective nature, the study was not registered in the database of clinical trials and the Clinical trial registration number is not available.

Secretome effect of adipose tissue-derived stem cells cultured two-dimensionally and three-dimensionally in mice with streptozocin induced type 1 diabetes

Aims

To analyze therapeutic potential of the conditioned medium from adipose tissue-derived stem cells (ASC) cultivated in 2D (CM-2D) and 3D (CM-3D) models, in mice with Type 1 diabetes (T1D) induced by streptozotocin.

Main methods

Viability andCD105 expression of 2D and 3D ASC were analyzed by flow cytometry. T1D was induced in mice by multiple injections of streptozocin. On the 28th and 29th days after the first injection of streptozocin, diabetic animals received CM-2D or CM-3D. Pancreatic, CM-2D, and CM-3D cytokines were analyzed by cytometric bead array (CBA) and insulin and PDX-1 were observed and quantified by immunohistochemistry. Apoptosis-related proteins were quantified by Western Blotting.

Key findings

ASC in three-dimensional culture released increased levels of IL-6 and IL-2, while IL-4 was decreased. CM-2D induced pancreatic PDX-1 expression and was able to reduce glycemia in diabetic mice one week after injections but not CM-3D. On the other hand, CM-2D and CM-3D were not able to reverse apoptosis of pancreatic cells in diabetic mice nor to increase insulin expression.

Significance

Together, these results demonstrate that the 3D cell culture secretome was not able to improve diabetes type 1 symptoms at the times observed, while 2D cell secretome improved glycemic levels in T1D mice.

Assessing the association of rs7574865 STAT4 gene variant and type 1 diabetes mellitus among Egyptian patients

Background

Variants in the signal transducer and activator of transcription 4 (STAT4) gene have an important role in the incident of multiple autoimmune diseases including type 1 diabetes mellitus (T1D). It is a genetically related auto-immune disorder that resulted from T cell-mediated destruction of pancreatic cells that are in control for the production of insulin in the blood. The current study aimed to clarify the role of STAT4 (rs7574865) variant allelic and genotypic variations in the susceptibility to type 1 diabetes among Egyptians by using the real-time PCR.

Results

A total of 100 patients and 100 controls were genotyped for rs7574865, and the biochemical and anthropometric parameters were measured to show that type 1 diabetic patients had significantly higher levels of HbA1c and triglycerides compared to non-diabetic individuals (P < 0.05). And genetically, the T allele and GT genotype have a significant correlation with diabetes type 1.

Conclusion

It was confirmed by this study that the rs7574865 T allele and GT genotype have a significant correlation with diabetes type 1 incidence among Egyptian patients.

Effect of COVID-19 on management of type 1 diabetes: Pushing the boundaries of telemedical healthcare

The new coronavirus disease 2019 (COVID-19) pandemic posed a great burden on health care systems worldwide and is an enormous and real obstacle in providing needed health care to patients with chronic diseases such as diabetes. Parallel to COVID-19, there have been great advances in technology used for management of type 1 diabetes, primarily insulin pumps, sensors, integrated and closed loop systems, ambulatory glucose profile software, and smart phone apps providing necessary essentials for telemedicine implementation right at the beginning of the COVID-19 pandemic. The results of these remote interventions are reassuring in terms of glycemic management and hemoglobin A1c reductions. However, data on long-term outcomes and cost reductions are missing as well as proper technical infrastructure and government health policy support.

Bacterial strains colonizing the sensor electrodes of a continuous glucose monitoring system in children with diabetes

INTRODUCTION

The higher frequency of infections in diabetic patients is caused by a hyperglycemic environment, which promotes immune dysfunction. People with diabetes are more prone to skin infections. A continuous glucose monitoring (CGM) system provides information on changes in blood glucose (BG) levels throughout the day. Its use facilitates optimal therapeutic decisions for a diabetic patient. One of the factors limiting the use of CGM is inflammation at the insertion site.

AIM OF THE STUDY

The aim of the study was the microbiological identification of the bacterial strains which are found on CGM sensor electrodes.

MATERIAL AND METHODS

We performed microbiological tests on patients' CGM Enlite Medtronic electrodes, which were removed after 6 days of usage according to the manufacturer's instructions. 31 sensors were examined from 31 children (14 girls) aged from 0.5 to 14.6 years. The microbiological analysis was routinely performed at the Department of Children's Diabetology Medical University of Silesia in Katowice, Poland.

RESULTS

12 (39%) of the electrodes were colonized. In 11 (92%) cases the electrodes were colonized by one bacteria strain. 7 times methicillin-sensitive coagulase negative staphylococcus (MSCNS) was detected. We also found one case of Klebsiella pneumoniae, Ochrobactrum tritici, Bacillus sonorensis and methicillin-resistant coagulase-negative Staphylococci (MRCNS) colonization. One electrode was colonized by the mixed flora Enterococcus faecalis, methicillin-susceptible coagulase-negative Staphylococci (MSCNS), Pseudomonas stutzeri, methicillin-susceptible Staphylococcus aureus (MSSA). The median HbA1c in the group with colonization of electrodes was 6, 85% (6, 3-7, 6%) versus 6, 3% (5, 8-7, 5%) in the group without colonization. The median BMI in the group with colonization of the electrodes was 17.10 kg/m² (16.28-18.62 kg/m²) versus 15.98 kg/m² (15.14-17.96 kg/m²) in the group without colonization. Statistically, significantly more frequently electrodes are colonized in older children (median age in the group with colonization of electrodes 11.43 years (6.52-12.27 years), without colonization 8.42 years. (3.098-9.375 years); (p = 0.033).

CONCLUSIONS

It seems that older children are more likely to have their sensor electrode colonized by bacterial strains.

Coronavirus disease (Covid-19): How does the exercise practice in active people with type 1 diabetes change? A preliminary survey

AIMS

Coronavirus disease (Covid-19) could lead persons with pre-existing medical conditions to severe respiratory infections. The Italian Government introduced quarantine to limit viral transmission. This measure could lead people with type 1 diabetes (PWT1D) to disrupt daily care routine including PA practice with difficulties in glycemia management. This study aims to explore PA level in PWT1D before and during quarantine and to describe variation in glycemia values.

METHODS

An online survey investigating medical factors and the perceived and PA level in pre-established period before and after the introduction of quarantine was developed. Comparison between pre and post quarantine was assessed by Wilcoxon Signed Ranks test for continuous variables.

RESULTS

A total of 154 subjects satisfied the eligibility criteria (54.5% males, 44.8 ± 12.5 years). We found a decrease of PA level (Godin Scale Score 25 ± 1.7vs38.6 ± 1.7 points), steps number and minutes of exercise (respectively 12.606 ± 5026vs4.760 ± 3.145 and 66±4 vs 38±3) and an increase of glycemia values (142.1 ± 25.4 mg/dLvs150.8 ± 29.4 mg/dL).

CONCLUSIONS

PWT1D reported a decrease in exercise and worst glycemia. Although PWT1D tried to remain active, their PA level was inadequate to prevent glycemia rising. The difficult to maintain a glycemic control could expose patients to diabetes complications and to an higher risk to counteract infections.

Diabetes and fractures: new evidence of atypical femoral fractures?

Patients with diabetes have an increased risk of fractures. In this study, subtrochanteric and femoral shaft fractures were increased in patients with type 1 diabetes compared with the general population. In the light of this, more evidence points towards an association between diabetes and atypical femoral fractures.

INTRODUCTION

Patients with diabetes have an increased risk of femoral fractures, but little is known about the risk of atypical femoral fractures (AFFs). The aim of this study was to identify the risk of subtrochanteric and femoral shaft (ST/FS) fractures and estimate the risk of AFFs in patients with type 1 (T1D) and type 2 diabetes (T2D).

METHODS

From the nationwide Danish National Patient Register, we identified patients with T1D (n = 19,896), T2D (n = 312,188), and sex- and aged-matched controls without diabetes (n = 996,252) from the general population and all ST/FS fractures (n = 7509). Data were analyzed using a Cox proportional-hazards model and the incidence rate and rate ratio of ST/FS fractures were estimated.

RESULTS

The incidence rate of ST/FS fractures in T1D was 52.14 events per 100,000 person years and 73.21 per 100,000 person years in T2D. T1D was associated with an increased risk of ST/FS (HR 2.07 (95% CI 1.68-2.56)), whereas T2D was not (HR 0.99 (95% CI 0.94-1.10)). Previous ST/FS fractures were associated with an increased risk of subsequent ST/FS fractures (HR 6.95 (95% CI 6.00-8.05)) and the use of bisphosphonates with an increased risk of ST/FS fractures (HR 1.72 (95% CI 1.54-1.91)).

CONCLUSION

Patients with T1D have a higher risk of ST/FS fractures compared with sex- and age-matched controls. Since a proportion of ST/FS fractures are classified as AFFs, this could point towards the fact that AFFs also are increased in patients with T1D, but not T2D.

Drug Delivery Systems for Diabetes Treatment

BACKGROUND

Insulin is essential for the treatment of Type 1 diabetes mellitus (T1DM) and is necessary in numerous cases of Type 2 diabetes mellitus (T2DM). Prolonged administration of anti-diabetic therapy is necessary for the maintenance of the normal glucose levels and thereby preventing vascular complications. A better understanding of the disease per se and the technological progress contribute to the development of new approaches with the aim to achieve better glycemic control.

OBJECTIVE

Current therapies for DM are faced with some challenges. The purpose of this review is to analyze in detail the current trends for insulin delivery systems for diabetes treatment.

RESULTS

Contemporary ways have been proposed for the management of both types of diabetes by adequate application of drug via subcutaneous, buccal, oral, ocular, nasal, rectal and pulmonary ways. Development of improved oral administration of insulin is beneficial regarding mimicking physiological pathway of insulin and minimizing the discomfort of the patient. Various nanoparticle carriers for oral and other ways of insulin delivery are currently being developed. Engineered specific properties of nanoparticles (NP): controlling toxicity of NP, stability and drug release, can allow delivery of higher concentration of the drug to the desired location.

CONCLUSIONS

The successful development of any drug delivery system relies on solving three important issues: toxicity of nanoparticles, stability of nanoparticles, and desired drug release rate at targeted sites. The main goals of future investigations are to improve the existing therapies by pharmacokinetic modifications, development of a fully automatized system to mimic insulin delivery by the pancreas and reduce invasiveness during admission.

The importance of insulin donations for children in 43 low- and middle-income countries

Diabetes mellitus is rapidly becoming one of the major diseases affecting people's health globally. Over half of 100 million diabetes patients who need insulin to survive, especially in low- and middle-income countries (LMIC), are not able to get this medicine and die prematurely. Since 2000, insulin-producing companies have started support programmes with a component of insulin donations to children and youth with type 1 diabetes in 43 LMIC. Based on their experiences we conclude, contrary to common belief, that the diagnosis, treatment, and prevention of fatal complications in children with type 1 diabetes in LMIC are very possible in practice, with large improvements in survival, mean body weight, mean glucose levels, and frequency of complications. Medicine donations can never offer a sustainable solution and we now propose a ten-step transition process towards a fully sustainable national diabetes care and prevention programme for children and youth with diabetes type 1.

Coronary plaque characteristics and epicardial fat tissue in long term survivors of type 1 diabetes identified by coronary computed tomography angiography

OBJECTIVES

The aim was to assess coronary atherosclerosis, plaque morphology and associations to cardiovascular risk factors and epicardial adipose tissue (EAT) in patients with long duration of type 1 diabetes mellitus (T1DM).

MATERIALS AND METHODS

Eighty-eight patients with ≥ 45 year T1DM duration and 60 controls underwent coronary CT angiography (CCTA) for evaluation of coronary artery plaque volume (total, calcified or mixed/soft), coronary artery calcification score (CAC) and EAT.

RESULTS

Plaques were detected in 75 (85%) T1DM patients and 28 (47%) controls, p < 0.01. Median (interquartile range) plaque volume (mm³) in T1DM vs. controls was: 21.0 (1.0-66.0) vs. 0.2 (0.0-7.1), p < 0.01 for calcified, 0.0 (0.0-8.7) vs. 0.0 (0.0-0.0), p < 0.01 for soft/mixed and 29.5 (3.9-95.8) vs. 0.4 (0.0-7.4), p < 0.01 for total plaque volume. Median CAC was 128 (13-671) vs. 1 (0.0-39.0), p < 0.01 in T1DM vs. controls. Median EAT volume did not differ between the groups; 52.3 (36.1-65.5) cm³ vs. 55 (38.3-79.6), p = 0.20. No association between CAC or plaque volumes and EAT were observed. Low time-weighted LDL-cholesterol and HbA1c for 30 years were associated with having plaque volume < 25th percentile, OR (95% CI) 0.18 (0.05-0.70), p = 0.01 and 0.45 (0.20-1.00), p < 0.05, respectively. Time-weighted LDL-c was linearly associated with CAC (beta 0.82 (95% CI 0.03-1.62), p = 0.04) and total plaque volume (beta 0.77 (95% CI 0.19-1.36), p = 0.01).

CONCLUSION

Long-term survivors of T1DM have a higher prevalence of coronary atherosclerosis compared to controls. Low LDL-cholesterol and HbA1c over time have a protective effect on coronary atherosclerosis. EAT volume was not associated with coronary atherosclerosis in T1DM patients.

Being mothers and fathers of a child with type 1 diabetes aged 1 to 7 years: a phenomenological study of parents' experiences

Purpose: The diagnosis of diabetes in pre-school children poses a number of unique challenges related to everyday responsibility, and the continuous need for supervision and caregiving. This may affect both the child’s and the parents’ perceived burden caused by the condition. The aim of the study was to explore the lived experience of being mothers and fathers of a child with type 1 diabetes aged 1 to 7 years.

Methods: The study is rooted in an interpretive phenomenological methodology as described by van Manen. In-depth interviews were carried out to collect data.

Findings. We were able to identify one essential theme across the interviews: Striving to live an ordinary family life, yet feeling and living very differently—with interrelated sub-themes: A life-changing situation, Always on guard, and Struggling to let go.

Conclusion: Parents described a profoundly changed situation, and they were indeed striving to live like a “normal” family. They were in need of support from health care professionals at the outpatient clinic, not only support and supervision in regard to practical tasks, but also concerning handling a changed life situation and emotional reactions, especially in the first year after diagnosis.

Being Facilitators in a Challenging Context-School Personnel's Experiences of Caring for Youth with Diabetes Type 1

PURPOSE

The purpose of the study was to describe school personnel's experiences of caring for youth with diabetes type 1.

DESIGN AND METHODS

A qualitative design was chosen for this study. Data were collected with individual interviews that were subjected to inductive qualitative content analysis. The sample consisted of 24 school personnel (teachers, principals and school nurses) from Swedish schools. All had experience with youth aged 6 to 18 years old with diabetes type 1.

RESULTS

School personnel experienced caring for youth with diabetes type 1 as "Being facilitators in a challenging context" and described establishing trusting relationships, finding strategies to support self-care, feeling uncertain and incapable in need of education, and dealing with unclear responsibility.

CONCLUSIONS

School personnel (teachers, principals and school nurses) are key professionals supporting youth with diabetes type 1 and self-care in school. Lack of education and unclear responsibility created feelings of uncertainty and insecurity for school personnel and a need for mandatory education of school personnel regarding T1DM and self-care, including legislation was identified.

IMPLICATIONS

Mandatory education should be provided for all school personnel regarding diabetes type 1, self-care and current legislation. A liason position in form of a nurse specialist should manage the education.

Impaired cognitive processing speed in type 1 diabetic patients who had severe/recurrent hypoglycaemia

AIMS

To detect whether adults with type 1 diabetes mellitus (T1DM) have lower cognitive performance than healthy individuals and to detect risk factors for low cognitive performance.

METHODS

Twenty-six adults with T1DM and twenty-six healthy subjects matched for age, gender and educational level were compared for cognitive performance by a chronometric computerized test measuring visuo-spatial working memory (N-Back) and by two validated neuropsychological tests (Mini Mental State Examination, Animal Naming Test). Clinical data about diabetes duration, average daily insulin dosage, glycated haemoglobin, retinopathy, urine albumin-creatinine ratio, previous hypoglycaemic coma and awareness of hypoglycaemia were obtained from medical records. Basal pre-test glycemia and blood pressure were measured for each patient.

RESULTS

No differences were found between patients (n = 26) and healthy controls (n = 26) in neuropsychological tests. Within diabetic patients, those with impaired awareness of hypoglycaemia (n = 7) or history of coma in the recent 1-3 years (n = 5) had psychomotor slowing at the N-Back test (592 ± 35 vs. 452 ± 21 ms and 619 ± 40 vs. 462 ± 19 ms, respectively; both p < 0.01). The variables related to diabetic severity did not show a relationship with reaction times of the N-Back test.

CONCLUSION

Psychomotor speed slowing is detectable in patients with T1DM who have a history of previous hypoglycaemic episodes or coma.

T Helper 22 Pathway Evaluation in Type 1 Diabetes and Its Complications

A subset of CD4+ T cells named T helper (Th)22 cells play some pathogenic roles in some autoimmune disorders such as type 1 diabetes (T1D). We aimed to study the correlation between the circulatory number of these cells and serum levels of its related cytokines with T1D as well as diabetic complications including metabolic control, atherosclerosis, and nephropathy. Fortynine patients with T1D and 43 healthy controls underwent the assessment of circulatory number of Th22 cells (by flow cytometry), serum level of Th22 related cytokines including Interleukin-22 (IL-22), Interleukin-10 (IL-10), Transforming growth factor-β (TGF-β), Tumor necrosis factor-α (TNF-α) (by ELISA) and carotid intima-media thickness (cIMT) measurement (by doppler ultrasonography). In addition, fasting blood and urine samples were taken to measure levels of hemoglobin A1C, lipid profile, cell blood count (CBC), serum and urine creatinine and urine protein in all participants. Th22 frequency and serum levels of IL-22 and TNF-α in patients were significantly higher than those in controls (p<0.001). Serum levels of IL-10 and TGF-β in healthy individuals were higher than those in patients (p<0.001). None of the Th22 related markers had a significant correlation with diabetic complications. There was only a significant effect of IL-22 on HbA1C variations. Th22 pathway has a significant correlation with T1D but not with its complications of cIMT and Urine Albumin/Creatinine Ratio (UACR). We report that Th22 pathway is not a good prognostic as well as diagnostic marker of early macrovascular complications in T1D.

The role of telenursing in the management of Diabetes Type 1: A randomized controlled trial

BACKGROUND

Diabetes Mellitus type 1 (T1DM) is a chronic disease that requires patients' self-monitoring and self-management to achieve glucose targets and prevent complications. Telenursing implicates technology in the interaction of a specialized nurse with patients with chronic diseases in order to provide personalized care and support.

OBJECTIVE

To evaluate the effect of telenursing on T1DM patients' compliance with glucose self-monitoring and glycemic control.

DESIGN

Randomized controlled study.

SETTINGS

Outpatient Department of Diabetes, Endocrinology and Metabolism of a University Hospital in Northern Greece.

METHODS

Ninety-four T1DM patients were recruited and randomized in two groups by a random number generator. The intervention group (N = 48) was provided with telenursing services. A specialized nurse made a weekly contact via telephone motivating patients to frequently measure blood glucose and adopt a healthy lifestyle. The control group (N = 46) received standard diabetes advice and care in the clinic. The primary outcome was the effect of the intervention in glucose control and glucose variability. The secondary outcome was the effect on frequency of self-monitoring. SPSS 20.0 was used for data analysis.

RESULTS

The two groups did not differ in age, sex, physical activity or initial HbA1c. In the intervention group, blood glucose significantly decreased at the end of the study in all predefined measurements, compared to control group: morning (93.18 ± 13.30 mg/dl vs. 105.17 ± 13.74 mg/dl, p < 0.005), pre-prandial (114.76 ± 9.54 mg/dl vs. 120.84 ± 4.05 mg/dl, p < 0.005), post-prandial (193.35 ± 25.36 mg/dl vs. 207.84 ± 18.80 mg/dl, p < 0.005), and HbA1c decreased significantly over time in the intervention group (8.3 ± 0.6% at the beginning of the study vs. 7.8 ± 1% at the end of the study, p = 0.03). In the intervention group there were also fewer omitted glucose measurements than in the control group.

CONCLUSIONS

Patients in the intervention group achieved better glucose control and more frequent self-monitoring than patients in routine care in the clinic. The findings of our study indicate that telenursing can motivate T1DM patients to better control their disease.

Comparison of MDRD, CKD-EPI, and Cockcroft-Gault equation in relation to measured glomerular filtration rate among a large cohort with diabetes

AIMS

To analyze the performance of Modification of Diet in Renal Disease (MDRD), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), Cockcroft-Gault (CG), and CG calculated with ideal bodyweight (CG-IBW) equations to estimate glomerular filtration rate (eGFR) based on serum creatinine in a large diabetic population.

METHODS

24,516 adults with type-1-diabetes or type-2-diabetes from the multicenter diabetes prospective follow-up registry DPV were analyzed. We compared eGFR and measured GFR (mGFR) based on 24-h urine collection by calculating mean bias (difference), precision (SD of this difference), accuracy (proportion of eGFR within ±10% of mGFR), Bland-Altman-plots.

RESULTS

CG overestimates, whereas MDRD, CKD-EPI, and CG-IBW underestimate. Smallest mean bias and highest accuracy (75.3%) were observed for MDRD compared to the other equations (p<0.0001). MDRD and CKD-EPI estimated most accurately in stages 1 (MDRD:57.7%, CKD-EPI:57.3%) and 2 (MDRD:80.2%, CKD-EPI:80.7%). In stages 3 to 5, highest accuracy was observed for the MDRD (stage 3:82.3%, stage 4:77.8%, stage 5:71.0%). Among younger subjects, accuracy was higher using the CKD-EPI (18-<40years:63.7%, 40-<60years:72.8%). Above age 60years, MDRD estimated most accurately (60-<70years:77.3%, ≥70years:78.8%). In males and females, MDRD estimated most accurately (males:75.3%, females:75.3%).

CONCLUSION

In this large diabetic cohort, smallest bias and highest accuracy were observed for the MDRD.

Cost-effectiveness analysis of insulin degludec compared with insulin glargine u100 for the management of type 1 and type 2 diabetes mellitus - from the Spanish National Health System perspective

BACKGROUND

The objective of this study was to assess the cost-effectiveness of insulin degludec versus insulin glargine, from the Spanish NHS in three groups of patients.

METHODS

A short-term cost utility model was developed to estimate effectiveness results in terms of the total number of hypoglycaemic events and their disutility impact throughout the year on the initial level of quality of life for patients in each treatment.

RESULTS

Degludec was the dominant strategy for T2DM BOT and exhibited an incremental cost-effectiveness ratio of 52.70€/QALY and 11,240.88€/QALY for T1DM B/B and T2DM B/B, respectively. Lower costs are primarily driven by lower nocturnal and severe hypoglycaemic events, which were reduced versus IGlar. Improvements in clinical outcomes in all three patient groups are result of the reduced number of hypoglycaemic events showing 0.0211, 0.0328 and 0.0248 QALYs gained when compared to IGlar for T1DM B/B, T2DM BOT and T2DM B/B, respectively. Different scenario analyses showed that the ICERS were stable to plausible variations in the analysed parameters, except when the same number of SMBG for both treatments is used, with T2DM B/B showing an ICER over the accepted threshold.

CONCLUSION

This analysis demonstrates that degludec is a cost-effective option in the Spanish NHS, when used in patients currently treated with long-acting insulin.

Risks of asphyxia-related neonatal complications in offspring of mothers with type 1 or type 2 diabetes: the impact of maternal overweight and obesity

AIMS/HYPOTHESIS

We aimed to compare the risks of severe asphyxia-related neonatal complications in the offspring of mothers with type 1 or type 2 diabetes, and to assess the impact of maternal overweight/obesity on these risks.

METHODS

This was a population-based study of 1,343,751 live-born singleton infants in Sweden between 1997 and 2011, including 5941 and 711 infants of mothers with type 1 and type 2 diabetes, respectively. ORs with 95% CIs were calculated for low Apgar score (0-6) at 5 min after birth, hypoxic ischaemic encephalopathy and neonatal seizures.

RESULTS

The rates of a low Apgar score were 0.9%, 2.6% and 2.1% in the offspring of mothers without diabetes or with type 1 or type 2 diabetes, respectively. After controlling for maternal confounders (including BMI), the risk of a low Apgar score increased in the offspring of mothers with type 1 diabetes (OR 2.67, 95% CI 2.23, 3.20) but not in the offspring of mothers with type 2 diabetes (OR 1.25, 95% CI 0.66, 2.35). The ORs of hypoxic ischaemic encephalopathy or neonatal seizures were increased in the offspring of mothers with type 1 diabetes (OR 3.41, 95% CI 2.58, 4.49) and type 2 diabetes (OR 2.54, 95% CI 1.13, 5.69). Maternal overweight/obesity was a risk factor for asphyxia-related neonatal complications and low Apgar scores in the offspring of mothers with type 1 diabetes and mothers without diabetes.

CONCLUSIONS/INTERPRETATION

The risks of a low Apgar score and severe asphyxia-related neonatal complications are increased in the offspring of mothers with type 1 or type 2 diabetes. Maternal overweight/obesity is an important contributing factor.

The greater omentum as a site for pancreatic islet transplantation

The greater omentum is a highly vascularized anatomical structure in the peritoneal cavity. Its main components are connective, adipose and vascular cells, along with specialized immune cells. The omentum functions as a site for fat accumulation, it has adhesive properties to control traumatized and inflamed tissues, and a function in local hemostasis, immune responses, and revascularization. Other functions include the absorption of fluids, the phagocytosis of particulate matter, and foreign body reaction. The omentum is catalyzing significant interest for its potential as a site for pancreatic islet and cell transplantation. Our knowledge about this structure, its functions, and its potential as a site for transplantation is poised to grow in the coming years.

Bifidobacteria-derived lipoproteins inhibit infection with coxsackievirus B4 in vitro

The aim of the present study was to investigate the potential of bifidobacteria in protecting cells from coxsackievirus B4 (CV-B4) infection. Bifidobacterial screening identified two of five strains that protected human epithelial type 2 (HEp-2) cell viability when bifidobacteria were incubated with viral particles prior to inoculation. In contrast, no effect was shown by incubating HEp-2 cells with bifidobacteria prior to CV-B4 inoculation. Cell wall lipoprotein aggregates (LpAs) secreted by the selected strains were assayed for their antiviral activity. The two LpAs exhibited antiviral activity when they were incubated with viral particles prior to inoculation of HEp-2 cells. Recombinant LpA-derived protein exhibited identical antiviral activity. To identify the peptide sequences interacting with the virus particles, LpA proteins were aligned with the peptide sequences of the north canyon rim and puff footprint onto coxsackievirus and adenovirus receptor (CAR). The in silico molecular docking study using CV-B3 as template showed low-energy binding, indicating a stable system for the selected peptides and consequently a likely binding interaction with CV-B. Bifidobacterium longum and Bifidobacterium breve peptides homologous to the viral north rim footprint onto CAR sequence formed hydrogen bonds with several viral residues in the north rim of the canyon, which were already predicted as interacting with CAR. In conclusion, proteins from bifidobacterial LpAs can inhibit infection with CV-B4, likely through binding to the capsid amino acids that interact with CAR.

IL-33 improves the suppressive potential of regulatory T cells in patients with type 1 diabetes

AIMS

The presented study was aimed to analyze the influence of IL-33 on regulatory T cells (Tregs) suppressive potential in patients with type 1 diabetes.

METHODS

We analyzed the ability of IL-33 treated Tregs to inhibit the production of IFN-γ by effector T lymphocytes in an in vitro co-culture. The study group consisted of 22 patients with type 1 diabetes and 12 age and sex-matched healthy individuals.

RESULTS

Our findings revealed that in vitro IL-33 treatment of Tregs derived from patients with type 1 diabetes resulted in quantitative as well as qualitative changes in this cell population, confirming immunoregulatory features of IL-33.

CONCLUSION

IL-33 could be considered as a potential therapeutic tool in adoptive therapies of type 1 diabetes.

Item analysis using Rasch models confirms that the Danish versions of the DISABKIDS® chronic-generic and diabetes-specific modules are valid and reliable

Background

Type 1 Diabetes (T1D) has a negative impact on psychological and overall well-being. Screening for Health-related Quality of Life (HrQoL) and addressing HrQoL issues in the clinic leads to improved well-being and metabolic outcomes. The aim of this study was to translate the generic and diabetes-specific validated multinational DISABKIDS® questionnaires into Danish, and then determine their validity and reliability.

Methods

The questionnaires were translated using a validated translation procedure and completed by 99 children and adolescents from our diabetes-department; all diagnosed with T1D and were aged between 8 and 18 years old. The Rasch and the graphical log linear Rasch model (GLLRM) were used to determine validity. Monte Carlo methods and Cronbach’s α were used to confirm reliability.

Results

The data did not fit a pure Rasch model but did fit a GLLRM when item six in the independence scale is excluded. The six subscales measure different aspects of HrQoL indicating that all the subscales are necessary. The questionnaire shows local dependency between items and differential item functioning (DIF). Therefore age, gender, and glycated hemoglobin (HbA1c) levels must be taken into account when comparing HrQoL between groups.

Conclusions

The Danish versions of the DISABKIDS® chronic-generic and diabetes-specific modules provide valid and objective measurements with adequate reliability. These Danish versions are useful tools for evaluating HrQoL in Danish patients with T1D. However, guidelines on how to manage DIF and local independence will be required, and item six should be rephrased.

Electronic supplementary material

The online version of this article (doi:10.1186/s12955-017-0618-8) contains supplementary material, which is available to authorized users.

Disenrollment from general practitioners among chronic patients: a register-based longitudinal study of Norwegian claims data

Background

Norwegian general practitioners (GPs) consult on a variety of conditions with a mix of patient types. Patients with chronic diseases benefit from appropriate continuity of care and generally visit their GPs more often than the average patient. Our aim was to study disenrollment patterns among patients with chronic diseases in Norway, because such patterns could indicate otherwise unobserved GP quality. For instance, higher quality GPs could have both a greater share of patients with chronic diseases and lower disenrollment rates.

Methods

Data on 384,947 chronic patients and 3,974 GPs for the years 2009–2011 were obtained from national registers, including patient and GP characteristics, disenrollment data, and patient list composition. The birth cohorts from 1940 and 1970 (146,906 patients) were included for comparison. Patient and GP characteristics, comorbidity, and patient list composition were analyzed using descriptive statistics. Patients’ voluntary disenrollment was analyzed using logistic regression models.

Results

The GPs’ proportion of patients with a given chronic disease varied more than expected when the allocation was purely random. The proportions of patients with different chronic diseases were positively correlated, partly due to comorbidity. Patients tended to have lower disenrollment rates from GPs who had higher shares of patients with the same chronic disease. Disenrollment rates were generally lower from GPs with higher shares of patients with arthritis or depression, and higher from GPs who had higher shares of patients with diabetes type 1 and schizophrenia. This was the same in the comparison group.

Conclusion

Patients with a chronic disease appeared to prefer GPs who have higher shares of patients with the same disease. High shares of patients with some diseases were also negatively associated with disenrollment for all patient groups, while other diseases were positively associated. These findings may reflect the GPs’ general quality, but could alternatively result from the GPs’ specialization in particular diseases. The supportive findings for the comparison group make it more plausible that high shares of chronic patients could indicate GP quality.

Factors affecting long-term efficacy of T regulatory cell-based therapy in type 1 diabetes

Background

Recent studies suggest that immunotherapy using T regulatory cells (Tregs) prolongs remission in type 1 diabetes (T1DM). Here, we report factors that possibly affect the efficacy of this treatment.

Methods

The metabolic and immune background of 12 children with recently diagnosed T1DM, as well as that of untreated subjects, during a 2-year follow-up is presented. Patients were treated with up to 30 × 10⁶/kg b.w. of autologous expanded CD3⁺CD4⁺CD25^highCD127⁻ Tregs.

Results

The disease progressed and all patients were insulin-dependent 2 years after inclusion. The β-cell function measured by c-peptide levels and the use of insulin were the best preserved in patients treated with two doses of Tregs (3/6 in remission), less so after one dose (1/6 in remission) and the worst in untreated controls (no remissions). Increased levels of Tregs could be seen in peripheral blood after their adoptive transfer together with the shift from naïve CD62L⁺CD45RA⁺ to memory CD62L⁺CD45RA⁻ Tregs. Increasing serum levels of proinflammatory cytokines were found: IL6 increased in all subjects, while IL1 and TNFα increased only in untreated group. Therapeutic Tregs were dependent on IL2, and their survival could be improved by other lymphocytes.

Conclusions

The disease progression was associated with changing proportions of naïve and memory Tregs and slowly increasing proinflammatory activity, which was only partially controlled by the administered Tregs. The therapeutic cells were highly dependent on IL2. We conclude that the therapy should be administered at the earliest to protect the highest possible mass of islets and also to utilize the preserved content of Tregs in the earlier phases of T1DM.

Trial registrationhttp://www.controlled-trials.com/ISRCTN06128462; registered retrospectively

Electronic supplementary material

The online version of this article (doi:10.1186/s12967-016-1090-7) contains supplementary material, which is available to authorized users.

Maternal overweight and obesity and risk of pre-eclampsia in women with type 1 diabetes or type 2 diabetes

AIMS/HYPOTHESIS

Women with type 1 or type 2 diabetes are at increased risk of pre-eclampsia. Overweight and obesity are associated with an increased risk of pre-eclampsia in women without diabetes. The aim of the study was to investigate the impact of maternal overweight and obesity on the risk of pre-eclampsia in women with type 1 diabetes or type 2 diabetes.

METHODS

In a population-based cohort study including singleton births in Sweden, we estimated the risk of pre-eclampsia among women with type 1 diabetes (n = 7062) and type 2 diabetes (n = 886), and investigated whether maternal overweight (BMI 25-29.9 kg/m(2)) and obesity (BMI ≥30.0 kg/m(2)) modified the risk. Logistic regression analyses were used to estimate crude and adjusted ORs with 95% CIs, using women without diabetes as the reference group (n = 1,509,525).

RESULTS

Compared with women without diabetes, the adjusted ORs for pre-eclampsia in women with type 1 and type 2 diabetes were 5.74 (95% CI 5.31, 6.20) and 2.11 (95% CI 1.65, 2.70), respectively. The corresponding risks of pre-eclampsia combined with preterm birth were even higher. Risks of pre-eclampsia increased with maternal overweight (BMI 25-29.9 kg/m(2)) and obesity (BMI ≥30.0 kg/m(2)), foremost in women without diabetes, to a lesser extent in women with type 1 diabetes but not in women with type 2 diabetes.

CONCLUSIONS/INTERPRETATION

Maternal overweight and obesity increased risks of pre-eclampsia in women with type 1 diabetes but not in women with type 2 diabetes. Even so, considering associations between maternal BMI and overall maternal and offspring risk, all women (with and without diabetes) should aim for a normal weight before pregnancy.

Use of cross-reactivity immunoassay to orient insulin replacement in diabetic patients with high levels of insulin antibodies

The prevalence and high levels of anti-insulin antibodies (IA) have frequently been associated with brittle diabetes, lipodystrophy in the areas where the insulin is injected and/or poor metabolic control. When this happens the usual criterion adopted is the empirical change of insulin type and/or formulation intending to diminish the IA level and then to decrease the undesirable side-effects. Here, we present a rational two step radiometric method consisting in: A) a first-line radioligand binding assay (RBA) to assess IA in sera of these patients and detecting those with high levels. B) applying a displacement assay (RIA) to determine the in vitro cross-reactivity parameters (affinity constants and selectivity ratios) that quantify the relative degree of interaction between antibodies and alternative insulin analogs. From these results we conclude that conventional criteria for selection of insulin analogs, in terms of pharmacokinetic and pharmacodinamic parameters, should be complemented with an appropriate test to assess affinity parameters when high IA title is demonstrated. •This manuscript introduces a rational method to determine the appropriated insulin replacement when high insulin antibodies levels are present.•This protocol provides instructions and details in mathematical tools and laboratory processes for the analysis of serum samples.•This method proved to be successful in a single case and requires confirmation using a large group of patients.

Zinc transporter 8 autoantibodies assessment in daily practice

OBJECTIVES

Zinc transporter 8 (ZnT8) is specifically expressed in the pancreatic β-cell and is more restricted in its tissue distribution than other auto-antigens as glutamic acid decarboxylase 65 (GAD₆₅) and insulinoma-associated antigen-2 (IA2). ZnT8 autoantibodies (ZnT8A) assessment allows identifying rapid progression to clinical onset of the disease. We evaluated the prevalence of ZnT8A in adults of different ethnic and phenotypic groups and analyzed its potential utility as additional marker of autoimmunity in daily practice.

METHODS

ZnT8A, GADA and IA2A were assessed using enzyme-linked immune-sorbent assay (ELISA) in 160 controls and 216 diabetic subjects. 105 were of type 1 diabetes (T1D), 17 had Latent Autoimmune Diabetes of Adults (LADA), 38 were type 2 diabetic (T2D) and 56 had ketosis-prone diabetes (KPD). 82 patients were newly diagnosed cases.

RESULTS

ZnT8A were detected in 1% of controls and were not found in any of our 38 T2D subjects or 56 KPD subjects. In contrast, ZnT8A were detected in 18% of LADA subjects and in 38% of T1D subjects. A slight difference of percentage of ZnT8A positivity was found among our T1D ethnic groups. ZnT8A were positive in 41% of patients positive for GADA and 67% of patients positive for IA2A. The percentage of stratification achieved 91% when GADA, IA2A and ZnT8A were assessed simultaneously.

CONCLUSIONS

Results obtained for ZnT8A measurement using ELISA were consistent with previous data. Such investigation could improve the risk stratification and would be integrated in our daily practice.

Hypoglycemic episodes are associated with inflammatory status in patients with type 1 diabetes mellitus

BACKGROUD

Glycemic control may be associated with inflammatory status in type 1 diabetes (T1DM). We examined the association between glucose control parameters and circulating inflammation markers in T1DM.

METHODS

The study included 101 T1DM patients treated with personal insulin pumps (T1DM duration 15.2 + 7.3 years). The analysed glycemic parameters included HbA1c, mean glucose level, standard deviation and number of hypoglycemic episodes (glucose <55 mg/dL) from the last 7 days. Blood was collected for testing inflammatory markers (IL-6, VCAM, ICAM, E-selectin).

RESULTS

The T1DM cohort had good glycemic control (HbA1c 7.1 ± 0.8%, mean daily glucose 141.5 ± 27.1 mg/dL and the mean number of hypoglycemic episodes was 5.6 ± 4.0/week). In a forward stepwise multiple linear regression analysis the number of hypoglycemic episodes predicted the levels of the investigated markers (sICAM p = 0.0019, sVCAM p = 0.021, sE-selectin p = 0.048, and IL-6 p = 0.049). None of the other glycemic parameters was shown to be an independent predictor.

CONCLUSIONS

For the first time, we report an association between the number of mild hypoglycemic episodes, recorded in a real life setting, and the level of inflammatory markers in T1DM patients with good glycemic control.

The Effects of Transition from Bedtime to Morning Glargine Administration in Patients with Poorly Regulated Type 1 Diabetes Mellitus: Croatian Pilot Study

INTRODUCTION

The objective of this study was to compare differences in glucoregulation, frequency of hypoglycemic episodes, glucose variability and lipid profiles of inpatients with poorly regulated type 1 diabetes mellitus (T1DM) after evening versus morning glargine application.

METHODS

Eighteen patients with poorly regulated T1DM, glycated hemoglobin (Hba1c) levels ≥7% and frequent nocturnal and/or morning hypoglycemic episodes were included in this study. There was a 12-week screening phase where patients continued their usual insulin regimen and were encouraged to achieve optimal glycemic control; however, all patients maintained HbA1c values ≥7% and continued to have frequent nocturnal and/or morning hypoglycemic events and were therefore transitioned to morning application of insulin glargine for 12 weeks. The primary outcome was to investigate changes in HbA1c values 12 weeks after the transition. The secondary outcome was to evaluate the effect of transition on glucose variability, incidence of hypoglycemic episodes, insulin doses, lipid profile and weight. Data were analyzed using paired Student's t test and Pearson correlation.

RESULTS

After the transition, there was no significant change in total daily dose of basal insulin (p 0.114) and the average body weight remained unchanged, while significant reduction of HbA1c was present (8.02 ± 0.5 vs. 7.4 ± 0.3%) (p < 0.01) resulting in a decrease in nocturnal and daytime hypoglycemic episodes per month per person (p < 0.01). Parameters of glucose variability (glycemic standard deviations and J-index) were also improved after transition period (p < 0.01). As for the lipid profile, increase of high-density lipoprotein cholesterol and decrease of triglycerides (p < 0.01) were noticed, while other lipid parameters remained unaffected. Furthermore, insignificant association of basal insulin dose with HbA1c values regardless of the time of administration was observed.

CONCLUSION

In patients with poorly regulated T1DM, transition to morning application of glargine improved glucoregulation (including a decrease in HbA1c, glucose variability and number of nocturnal hypoglycemic episodes), followed by favorable changes in lipid profile without affecting body weight. These effects were associated with the time of application, but not with the insulin dose.

Challenges and Opportunities in the Management of Cardiovascular Risk Factors in Youth With Type 1 Diabetes: Lifestyle and Beyond

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in persons with type 1 diabetes (T1D). Specific risk factors associated with diabetes, such as hyperglycemia and kidney disease, have been demonstrated to increase the incidence and progression of CVD. Nevertheless, few data exist on the effects of traditional risk factors such as dyslipidemia, obesity, and hypertension on CVD risk in youth with T1D. Improvements in understanding and approaches to the evaluation and management of CVD risk factors, specifically for young persons with T1D, are desirable. Recent advances in noninvasive techniques to detect early vascular damage, such as the evaluation of endothelial dysfunction and aortic or carotid intima-media thickness, provide new tools to evaluate the progression of CVD in childhood. In the present review, current CVD risk factor management, challenges, and potential therapeutic interventions in youth with T1D are described.

Influence of remission and its duration on development of early microvascular complications in young adults with type 1 diabetes

INTRODUCTION

Prevalence of partial remission ranges between 20% and 80% in the initial course of type 1 diabetes. In this phase of the disease, a substantial insulin secretion contributes to good metabolic control. The aim of the study was to determine the association between presence of partial remission and occurrence of microangiopathy complications in type 1 diabetes.

MATERIAL AND METHODS

Ninety-eight consecutive patients with newly diagnosed type 1 diabetes were asked to participate in a cohort study. Partial remission was defined as the time in which all of the following criteria were met: HbA1c below 6.5% (48mmol/mol), daily insulin requirement below 0.3 U/kg body weight and serum Cpeptide concentration above 0.5ng/ml. Patients were divided into those who were in remission at any time during follow-up (remitters) and non-remitters. After 7years of follow-up, the occurrence of microangiopathy complications was analyzed. In statistical analysis, Mann-Whitney test, chi(2) test and Fisher test were used for analysis between groups. We applied a Cox's multivariate regression model and univariate regression method. P<0.05 was considered statistically significant.

RESULTS

In univariate logistic regression, a significant association was found between absence of remission and occurrence of at least one microvascular complication. In the Cox proportional hazards regression model that included clinically significant parameters at diagnosis (presence of ketoacidosis, cigarette smoking and HbA1c value) as covariates, absence of remission was associated with occurrence of chronic complications of diabetes at 7years [HR: 3.65 (95% CI 1.23-4.56), p=0.04]. In non-remitters, higher incidence of at least one microvascular complication (46.4% vs. 7.6%), higher incidence of retinopathy (42.8% vs. 5.7%), and neuropathy (21.4% vs. 1.9%) was found.

CONCLUSIONS

Occurrence of partial remission of diabetes is associated with a reduced risk of chronic microvascular complications at 7-year follow-up.

High expression of OX40 (CD134) and 4-1BB (CD137) molecules on CD4(+)CD25(high) cells in children with type 1 diabetes

PURPOSE

Despite the rapidly rising incidence of diabetes in children, with the highest rise in children<5 years of age, data on mechanisms that trigger severe beta-cells damage are limited. The aim of the study was to assess the frequency of OX40 (CD134) or 4-1BB (CD137) positive cells in the peripheral blood of children with newly diagnosed type 1 diabetes (T1D) in comparison to healthy controls.

MATERIAL/METHODS

The study included 33 children (mean age 7.3 ± 5.4 years) with newly diagnosed T1D and 39 age-matched healthy controls. Separate analysis was performed in children<5 years. Flow cytometric analysis was performed using the following markers: CD4, CD25, CD137, and CD134. Fasting C-peptide level was assessed as well.

RESULTS

The frequency of CD4(+)CD25(high)OX40(+) was higher in T1D children than in controls (median value 3.58% vs. 1.1%, respectively; p=0.003). Moreover, T1D children had higher frequency of CD4(+)CD25(high)4-1BB(+) cells than healthy subjects (median value 5.76% vs. 3.74%, respectively; p=0.037). A significant correlation was noted between the age of diabetic children and the C-peptide level (r=0.54, 95% CI [0.19-0.77], p=0.004). In comparison with age-matched controls, children<5 years had higher frequency of CD4(+)CD25(high)OX40(+) (p=0.004) and CD4(+)CD25(high)4-1BB(+) cells (p=0.079).

CONCLUSIONS

Our study showed higher frequency of both OX40 and 4-1BB positive cells in T1D children in comparison to controls. It seems that observed differences might be more pronounced in children<5 years of age than in older subjects. Further clinical studies are needed to determine the age-related differences in the immune system, in the pathogenesis of T1D.

Shared Medical Appointments marginally enhance interaction between patients: an observational study on children and adolescents with type 1 diabetes

OBJECTIVE

To examine informational and emotional patient-provider and patient-patient communication sequences (i.e. cues and subsequent responses) during Shared Medical Appointments (SMAs) for children and adolescents with type 1 Diabetes Mellitus (T1DM) and their parents.

METHODS

57 children/adolescents with T1DM and 36 healthcare providers participated in ten SMAs in seven Dutch hospitals. Parents were present in six SMAs. Video-recordings were made. Communication sequences, including informational and emotional cues and responses were rated using an adaptation of the Medical Interview Aural Rating Scale.

RESULTS

143 patient-initiated cues were identified, followed by 140 provider responses and 30 patient responses. Patients gave more informational than emotional cues. Informational cues were mostly medical-related. Subsequent responses provided by providers and patients contained mostly appropriate information. We identified 17 patient and four parent cues with multiple responses.

CONCLUSIONS

Almost all cues were identified by healthcare providers and responded to in an appropriate manner. Cues not followed by a provider's response were picked up by other patients. Providers acted as mediator between a patient cue and another patient's response, thereby stimulating the interaction during SMAs.

PRACTICE IMPLICATIONS

Professionals could more explicitly invite all participants to interact with each other, and enable them to have their share in the communication process.

Insulin degludec: a long-acting modern insulin analogue with a predictable pharmacokinetic/pharmacodynamic profile

Insulin degludec is, like insulin detemir, a product of coupling of Des-B30 threonine insulin to fatty acid side chains. After injection, degludec self associates, precipitating in subcutaneous tissue. There is a continuous and highly predictable slow dissociation of insulin monomers from this depot; insulin levels rise immediately reaching tmax at 10-12 hours, followed by a slow decline with a t½ of 17-21 hours, roughly double the duration of action of insulin glargine. An important property of degludec not shared by glargine is miscibility with rapid-acting insulin. Although the effect of coadministered insulin aspart is somewhat blunted by coformulation with degludec, a preparation of 70% degludec and 30% aspart has predictable pharmacodynamics. Daily administration of degludec has glucose-lowering benefits not different from those of glargine, with purportedly less hypoglycemia. Although degludec is approved and marketed in Europe under the brand name Tresiba®, the U.S. Food and Drug Administration, in a surprising development, challenged the assertion of lower tendency to hypoglycemia with degludec, and, more importantly, raised concerns that degludec may have a higher cardiovascular risk than glargine. Only a long-term study in a large patient population can resolve these questions. However, release of degludec for marketing to appropriate patients should proceed while awaiting the results of such a study.

The action of aminoguanidine on the liver of trained diabetic rats

Background

This study evaluated the effect of aminoguanidine on liver of diabetic rats subject to physical exercises using histological and histochemical techniques.

Methods

The rats used in this study were divided into five groups: sedentary control, sedentary diabetic, trained diabetic, sedentary diabetic and treated with aminoguanidine, trained diabetic and treated with aminoguanidine.

Results

The results showed no effect of aminoguanidine on the liver tissue, although there was improvement with exercise training showing cytological, morpho-histological and histochemical alterations in liver cells of animals from groups trained diabetic and/or treated diabetic compared to those individuals in the sedentary control and sedentary diabetic. These changes included: hepatocytes hypertrophy, presence and distribution of polysaccharides in the hepatocytes cytoplasm and, especially, congestion of the liver blood vessels.

Conclusion

Our results suggest that aminoguanidine is not hepatotoxic, when used at dosage of 1 g/L for the treatment of diabetes complications, and confirmed that the practice of moderate physical exercise assuaged the damage caused by diabetes without the use of insulin.

Electronic supplementary material

The online version of this article (doi:10.1186/2251-6581-12-40) contains supplementary material, which is available to authorized users.