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Prahalad P, Scheinker D, Desai M, Ding VY, Bishop FK, Lee MY, Ferstad J, Zaharieva DP, Addala A, Johari R, Hood K, Maahs DM. Equitable implementation of a precision digital health program for glucose management in individuals with newly diagnosed type 1 diabetes. Nat Med 2024; 30:2067-2075. [PMID: 38702523 DOI: 10.1038/s41591-024-02975-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 04/03/2024] [Indexed: 05/06/2024]
Abstract
Few young people with type 1 diabetes (T1D) meet glucose targets. Continuous glucose monitoring improves glycemia, but access is not equitable. We prospectively assessed the impact of a systematic and equitable digital-health-team-based care program implementing tighter glucose targets (HbA1c < 7%), early technology use (continuous glucose monitoring starts <1 month after diagnosis) and remote patient monitoring on glycemia in young people with newly diagnosed T1D enrolled in the Teamwork, Targets, Technology, and Tight Control (4T Study 1). Primary outcome was HbA1c change from 4 to 12 months after diagnosis; the secondary outcome was achieving the HbA1c targets. The 4T Study 1 cohort (36.8% Hispanic and 35.3% publicly insured) had a mean HbA1c of 6.58%, 64% with HbA1c < 7% and mean time in the range (70-180 mg dl-1) of 68% at 1 year after diagnosis. Clinical implementation of the 4T Study 1 met the prespecified primary outcome and improved glycemia without unexpected serious adverse events. The strategies in the 4T Study 1 can be used to implement systematic and equitable care for individuals with T1D and translate to care for other chronic diseases. ClinicalTrials.gov registration: NCT04336969 .
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Affiliation(s)
- Priya Prahalad
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA, USA.
- Stanford Diabetes Research Center, Stanford University, Stanford, CA, USA.
| | - David Scheinker
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA, USA
- Stanford Diabetes Research Center, Stanford University, Stanford, CA, USA
- Department of Management Science and Engineering, Stanford University, Stanford, CA, USA
- Clinical Excellence Research Center, Stanford University, Stanford, CA, USA
| | - Manisha Desai
- Department of Medicine, Quantitative Sciences Unit, Stanford University, Stanford, CA, USA
| | - Victoria Y Ding
- Department of Medicine, Quantitative Sciences Unit, Stanford University, Stanford, CA, USA
| | - Franziska K Bishop
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA, USA
- Stanford Diabetes Research Center, Stanford University, Stanford, CA, USA
| | - Ming Yeh Lee
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA, USA
| | - Johannes Ferstad
- Department of Management Science and Engineering, Stanford University, Stanford, CA, USA
| | - Dessi P Zaharieva
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA, USA
| | - Ananta Addala
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA, USA
- Stanford Diabetes Research Center, Stanford University, Stanford, CA, USA
| | - Ramesh Johari
- Stanford Diabetes Research Center, Stanford University, Stanford, CA, USA
- Department of Management Science and Engineering, Stanford University, Stanford, CA, USA
| | - Korey Hood
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA, USA
- Stanford Diabetes Research Center, Stanford University, Stanford, CA, USA
| | - David M Maahs
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA, USA
- Stanford Diabetes Research Center, Stanford University, Stanford, CA, USA
- Department of Health Research and Policy (Epidemiology), Stanford University, Stanford, CA, USA
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Prahalad P, Maahs DM. Roadmap to Continuous Glucose Monitoring Adoption and Improved Outcomes in Endocrinology: The 4T (Teamwork, Targets, Technology, and Tight Control) Program. Diabetes Spectr 2023; 36:299-305. [PMID: 37982062 PMCID: PMC10654131 DOI: 10.2337/dsi23-0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
Glucose monitoring is essential for the management of type 1 diabetes and has evolved from urine glucose monitoring in the early 1900s to home blood glucose monitoring in the 1980s to continuous glucose monitoring (CGM) today. Youth with type 1 diabetes struggle to meet A1C goals; however, CGM is associated with improved A1C in these youth and is recommended as a standard of care by diabetes professional organizations. Despite their utility, expanding uptake of CGM systems has been challenging, especially in minoritized communities. The 4T (Teamwork, Targets, Technology, and Tight Control) program was developed using a team-based approach to set consistent glycemic targets and equitably initiate CGM and remote patient monitoring in all youth with new-onset type 1 diabetes. In the pilot 4T study, youth in the 4T cohort had a 0.5% improvement in A1C 12 months after diabetes diagnosis compared with those in the historical cohort. The 4T program can serve as a roadmap for other multidisciplinary pediatric type 1 diabetes clinics to increase CGM adoption and improve glycemic outcomes.
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Affiliation(s)
- Priya Prahalad
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA
- Stanford Diabetes Research Center, Stanford University, Stanford, CA
| | - David M. Maahs
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA
- Stanford Diabetes Research Center, Stanford University, Stanford, CA
- Department of Health Research and Policy (Epidemiology), Stanford University, Stanford, CA
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3
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Tremblay ES, Bernique A, Garvey K, Astley CM. A Retrospective Cohort Study of Racial/Ethnic and Socioeconomic Disparities in Initiation and Meaningful Use of Continuous Glucose Monitoring among Youth With Type 1 Diabetes. J Diabetes Sci Technol 2023:19322968231183985. [PMID: 37394962 DOI: 10.1177/19322968231183985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
BACKGROUND Continuous glucose monitor (CGM) use improves type 1 diabetes (T1D) outcomes, yet children from diverse backgrounds and on public insurance have worse outcomes and lower CGM utilization. Using novel CGM data acquisition and analysis of two T1D cohorts, we test the hypothesis that T1D youth from different backgrounds experience disparities in meaningful CGM use following both T1D diagnosis and CGM uptake. METHODS Cohorts drawn from a pediatric T1D program were followed for one year beginning at diagnosis (n = 815, 2016-2020) or CGM uptake (n = 1392, 2015-2020). Using chart and CGM data, CGM start and meaningful use outcomes between racial/ethnic and insurance groups were compared using median days, one-year proportions, and survival analysis. RESULTS Publicly compared with privately insured were slower to start CGM (233, 151 days, P < .01), had fewer use-days in the year following uptake (232, 324, P < .001), and had faster first discontinuation rates (hazard ratio [HR] = 1.61, P < .001). Disparities were more pronounced among Hispanic and black compared with white subjects for CGM start time (312, 289, 149, P = .0013) and discontinuation rates (Hispanic HR = 2.17, P < .001; black HR = 1.45, P = .038), and remained even among privately insured (Hispanic/black HR = 1.44, P = .0286). CONCLUSIONS Given the impact of insurance and race/ethnicity on CGM initiation and use, it is imperative that we target interventions to support universal access and sustained CGM use to mitigate the potential impact of provider biases and systemic disadvantage and racism. By enabling more equitable and meaningful T1D technology use, such interventions will begin to alleviate outcome disparities between youth with T1D from different backgrounds.
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Affiliation(s)
- Elise Schlissel Tremblay
- Division of Endocrinology, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Allison Bernique
- Division of Endocrinology, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Katherine Garvey
- Division of Endocrinology, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Christina M Astley
- Division of Endocrinology, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Computational Epidemiology Lab, Boston Children's Hospital, Boston, MA, USA
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
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Boucsein A, Watson AS, Frewen CM, Sanders OJ, Haszard JJ, Jones SD, Milford-Hughes PJ, de Bock MI, Wheeler BJ. Impact of Advanced Hybrid Closed Loop on Youth With High-Risk Type 1 Diabetes Using Multiple Daily Injections. Diabetes Care 2023; 46:628-632. [PMID: 36689621 DOI: 10.2337/dc22-1971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 12/21/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To evaluate glycemic outcomes in youth (aged 13-25 years) with type 1 diabetes and high-risk glycemic control (HbA1c ≥8.5% [69 mmol/mol]) on multiple daily injection (MDI) therapy after transitioning to advanced hybrid closed loop (AHCL) therapy. RESEARCH DESIGN AND METHODS This prospective, 3-month, single-arm, dual-center study enrolled 20 participants, and all completed the study. RESULTS HbA1c decreased from 10.5 ± 2.1% (91.2 ± 22.8 mmol/mol) at baseline to 7.6 ± 1.1% (59.7 ± 11.9 mmol/mol), and time spent in target range 70-180 mg/dL (3.9-10.0 mmol/L) increased from 27.6 ± 13.2% at baseline to 66.5 ± 9.8% after 3 months of AHCL. Two episodes of diabetic ketoacidosis attributed to infusion set failure occurred. CONCLUSIONS AHCL has the potential to improve suboptimal glycemia in youth with type 1 diabetes previously on MDI therapy.
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Affiliation(s)
- Alisa Boucsein
- 1Department of Women's and Children's Health, University of Otago, Dunedin, New Zealand
| | - Antony S Watson
- 2Department of Paediatrics, University of Otago, Christchurch, New Zealand
| | - Carla M Frewen
- 1Department of Women's and Children's Health, University of Otago, Dunedin, New Zealand
| | - Olivia J Sanders
- 2Department of Paediatrics, University of Otago, Christchurch, New Zealand
| | | | - Shirley D Jones
- 1Department of Women's and Children's Health, University of Otago, Dunedin, New Zealand
| | | | - Martin I de Bock
- 2Department of Paediatrics, University of Otago, Christchurch, New Zealand
- 4Te Whatu Ora-Health New Zealand, Christchurch
| | - Benjamin J Wheeler
- 1Department of Women's and Children's Health, University of Otago, Dunedin, New Zealand
- 5Te Whatu Ora-Health New Zealand, Dunedin
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Due-Christensen M, Bruun LD, Joensen LE, Norgaard O, Andersen TH. Psychosocial aspects and perspectives of adult-onset type 1 diabetes: A systematic scoping review. Diabet Med 2023; 40:e15073. [PMID: 36807612 DOI: 10.1111/dme.15073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 12/21/2022] [Accepted: 02/17/2023] [Indexed: 02/22/2023]
Abstract
AIM To map existing research on psychosocial aspects of adult-onset type 1 diabetes (T1D), including psychosocial health status, ways psychosocial aspects may affect management of T1D in everyday life, and interventions targeting management of adult-onset T1D. METHODS We conducted a systematic search in MEDLINE, EMBASE, CINAHL and PsycInfo. Search results were screened with predefined eligibility criteria, followed by data extraction of the included studies. Charted data were summarized in narrative and tabular form. RESULTS We included 10 reports describing nine studies from the 7302 identified in the search. All studies were conducted in Europe. Participant characteristics were missing in several studies. Five of the nine studies incorporated psychosocial aspects as the main aim of the study. Limited information on psychosocial aspects was available in the remaining studies. We identified three overarching themes related to psychosocial aspects: (1) the impact of the diagnosis on everyday life, (2) the influence of psychosocial health on metabolic levels and adaptation, and (3) provision of self-management support. CONCLUSIONS Research focussing on psychosocial aspects of the adult-onset population is scarce. Future research should involve participants across the adult life age span and from a wider geographical area. Sociodemographic information should be collected to explore different perspectives. Further exploration of suitable outcome measures considering adults' limited experience of living with the condition is needed. This would help to better understand how psychosocial aspects may affect management of T1D in everyday life and thus enable healthcare professionals to provide appropriate support to adults with new-onset T1D.
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Affiliation(s)
- Mette Due-Christensen
- Department of Health Promotion, Copenhagen University Hospital-Steno Diabetes Center Copenhagen, Herlev, Denmark
- Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - L D Bruun
- Danish Diabetes Knowledge Center, Department of Education, Copenhagen University Hospital - Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - L E Joensen
- Department of Health Promotion, Copenhagen University Hospital-Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - O Norgaard
- Danish Diabetes Knowledge Center, Department of Education, Copenhagen University Hospital - Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - T H Andersen
- Danish Diabetes Knowledge Center, Department of Education, Copenhagen University Hospital - Steno Diabetes Center Copenhagen, Herlev, Denmark
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Suh J, Choi Y, Oh JS, Song K, Choi HS, Kwon A, Chae HW, Kim HS. Association between early glycemic management and diabetes complications in type 1 diabetes mellitus: A retrospective cohort study. Prim Care Diabetes 2023; 17:60-67. [PMID: 36609067 DOI: 10.1016/j.pcd.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 12/20/2022] [Accepted: 12/26/2022] [Indexed: 01/06/2023]
Abstract
AIMS To investigate the association between early HbA1c levels near diagnosis and future glycemic management, and analyzed risk factors of complications in people with T1DM. METHODS This retrospective cohort study included 201 children and adolescents with T1DM. Patient data including sex, age at diagnosis, duration of disease, HbA1c levels, HbA1c variability during the follow-up period, and diabetes complications and comorbidities were collected. RESULTS The mean follow-up period of patients was 16.4 years. HbA1c levels in all three examined time points after diagnosis (first year, second year, and first two years) were significantly associated with recent HbA1c level, and second-year HbA1c was most closely correlated with recent HbA1c level. Elevated second-year HbA1c was a risk factor of diabetic ketoacidosis (DKA) and retinopathy, and increased variability of HbA1c was significantly related to various microvascular complications. When HbA1c is stratified into quartiles, the subjects of each quartile trend to stay within that quartile over the follow-up period. CONCLUSIONS Early HbA1c levels were closely associated with recent HbA1c levels and diabetes complications in patients with T1DMs. Strict glucose management after diagnosis and reducing variability of HbA1c may prevent future diabetes complications and comorbidities.
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Affiliation(s)
- Junghwan Suh
- Department of Pediatrics, Severance Children's Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Youngha Choi
- Department of Pediatrics, Severance Children's Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Jun Suk Oh
- Department of Pediatrics, Severance Children's Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Kyungchul Song
- Department of Pediatrics, Severance Children's Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Han Saem Choi
- Department of Pediatrics, Severance Children's Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Ahreum Kwon
- Department of Pediatrics, Severance Children's Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyun Wook Chae
- Department of Pediatrics, Severance Children's Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Ho-Seong Kim
- Department of Pediatrics, Severance Children's Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, South Korea.
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de Bock M, Codner E, Craig ME, Huynh T, Maahs DM, Mahmud FH, Marcovecchio L, DiMeglio LA. ISPAD Clinical Practice Consensus Guidelines 2022: Glycemic targets and glucose monitoring for children, adolescents, and young people with diabetes. Pediatr Diabetes 2022; 23:1270-1276. [PMID: 36537523 PMCID: PMC10107615 DOI: 10.1111/pedi.13455] [Citation(s) in RCA: 52] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/11/2022] [Indexed: 12/24/2022] Open
Affiliation(s)
- Martin de Bock
- Department of Paediatrics, University of Otago, Christchurch, New Zealand
| | - Ethel Codner
- Institute of Maternal and Child Research (IDMI), School of Medicine, Universidad de Chile, Santiago, Chile
| | - Maria E Craig
- Institute of Endocrinology and Diabetes, Children's Hospital at Westmead, Sydney, Australia.,Discipline of Child and Adolescent Health, University of Sydney, Sydney, Australia.,Discipline of Paediatrics & Child Health, School of Clinical Medicine, University of New South Wales Medicine & Health, Sydney, Australia
| | - Tony Huynh
- Department of Endocrinology & Diabetes, Queensland Children's Hospital, South Brisbane, Queensland, Australia.,Department of Chemical Pathology, Mater Pathology, South Brisbane, Queensland, Australia.,School of Clinical Medicine, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - David M Maahs
- Department of Pediatrics, Division of Endocrinology, Lucile Salter Packard Children's Hospital, Stanford University, Stanford, California, USA.,Stanford Diabetes Research Center, Stanford University, Stanford, California, USA.,Department of Epidemiology, Stanford University, Stanford, California, USA
| | - Farid H Mahmud
- Division of Endocrinology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Loredana Marcovecchio
- Department of Paediatrics, University of Cambridge and Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Linda A DiMeglio
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetology, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Dupenloup P, Pei RL, Chang A, Gao MZ, Prahalad P, Johari R, Schulman K, Addala A, Zaharieva DP, Maahs DM, Scheinker D. A model to design financially sustainable algorithm-enabled remote patient monitoring for pediatric type 1 diabetes care. Front Endocrinol (Lausanne) 2022; 13:1021982. [PMID: 36440201 PMCID: PMC9691757 DOI: 10.3389/fendo.2022.1021982] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 10/21/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Population-level algorithm-enabled remote patient monitoring (RPM) based on continuous glucose monitor (CGM) data review has been shown to improve clinical outcomes in diabetes patients, especially children. However, existing reimbursement models are geared towards the direct provision of clinic care, not population health management. We developed a financial model to assist pediatric type 1 diabetes (T1D) clinics design financially sustainable RPM programs based on algorithm-enabled review of CGM data. Methods Data were gathered from a weekly RPM program for 302 pediatric patients with T1D at Lucile Packard Children's Hospital. We created a customizable financial model to calculate the yearly marginal costs and revenues of providing diabetes education. We consider a baseline or status quo scenario and compare it to two different care delivery scenarios, in which routine appointments are supplemented with algorithm-enabled, flexible, message-based contacts delivered according to patient need. We use the model to estimate the minimum reimbursement rate needed for telemedicine contacts to maintain revenue-neutrality and not suffer an adverse impact to the bottom line. Results The financial model estimates that in both scenarios, an average reimbursement rate of roughly $10.00 USD per telehealth interaction would be sufficient to maintain revenue-neutrality. Algorithm-enabled RPM could potentially be billed for using existing RPM CPT codes and lead to margin expansion. Conclusion We designed a model which evaluates the financial impact of adopting algorithm-enabled RPM in a pediatric endocrinology clinic serving T1D patients. This model establishes a clear threshold reimbursement value for maintaining revenue-neutrality, as well as an estimate of potential RPM reimbursement revenue which could be billed for. It may serve as a useful financial-planning tool for a pediatric T1D clinic seeking to leverage algorithm-enabled RPM to provide flexible, more timely interventions to its patients.
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Affiliation(s)
- Paul Dupenloup
- Department of Management Science and Engineering, Stanford University, Stanford, CA, United States
| | - Ryan Leonard Pei
- Department of Management Science and Engineering, Stanford University, Stanford, CA, United States
| | - Annie Chang
- Department of Management Science and Engineering, Stanford University, Stanford, CA, United States
| | - Michael Z. Gao
- Department of Management Science and Engineering, Stanford University, Stanford, CA, United States
| | - Priya Prahalad
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA, United States
- Stanford Diabetes Research Center, Stanford University, Stanford, CA, United States
| | - Ramesh Johari
- Department of Management Science and Engineering, Stanford University, Stanford, CA, United States
- Stanford Diabetes Research Center, Stanford University, Stanford, CA, United States
| | - Kevin Schulman
- Clinical Excellence Research Center, Stanford University, Stanford, CA, United States
- Graduate School of Business, Stanford University, Stanford, CA, United States
| | - Ananta Addala
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA, United States
| | - Dessi P. Zaharieva
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA, United States
| | - David M. Maahs
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA, United States
- Stanford Diabetes Research Center, Stanford University, Stanford, CA, United States
| | - David Scheinker
- Department of Management Science and Engineering, Stanford University, Stanford, CA, United States
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA, United States
- Clinical Excellence Research Center, Stanford University, Stanford, CA, United States
- Department of Medicine, Division of Biomedical Informatics Research, Stanford University, Stanford, CA, United States
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9
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Patton SR, Maahs D, Prahalad P, Clements MA. Psychosocial Needs for Newly Diagnosed Youth with Type 1 Diabetes and Their Families. Curr Diab Rep 2022; 22:385-392. [PMID: 35727439 PMCID: PMC9211050 DOI: 10.1007/s11892-022-01479-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/07/2022] [Indexed: 11/23/2022]
Abstract
PURPOSE OF REVIEW To synthesize findings from studies published within the last 5 to 10 years and recruiting families of children with new-onset type 1 diabetes (T1D). RECENT FINDINGS Children can establish glycated hemoglobin (HbA1c) trajectories in the new-onset period that may persist for up to a decade. Demographic factors, family conflict, and diabetic ketoacidosis at the time of diagnosis may be risk factors for sub-optimal child HbA1c, while new immune modulating therapies and a treatment approach that combines advanced technologies and remote patient monitoring may improve child HbA1c. Nonetheless, recent trials in the new-onset period have largely overlooked how treatments may impact families' psychosocial functioning and longitudinal observational studies have been limited. The new-onset period of T1D is an important time for research and clinical intervention, though gaps exist specific to families' psychosocial needs. Filling these gaps is essential to inform clinical management and standard of care guidelines and improve outcomes.
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Affiliation(s)
- Susana R. Patton
- grid.472715.20000 0000 9331 5327Center for Healthcare Delivery Science, Nemours Children’s Health, 807 Children’s Way, Jacksonville, FL 32207 USA
| | - David Maahs
- grid.168010.e0000000419368956Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA 94304 USA
- grid.168010.e0000000419368956Stanford Diabetes Research Center, Stanford University, Stanford, CA 94304 USA
- grid.168010.e0000000419368956Department of Health Research and Policy (Epidemiology), Stanford University, Stanford, CA 94304 USA
| | - Priya Prahalad
- grid.168010.e0000000419368956Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA 94304 USA
- grid.168010.e0000000419368956Stanford Diabetes Research Center, Stanford University, Stanford, CA 94304 USA
| | - Mark A. Clements
- grid.239559.10000 0004 0415 5050Department of Pediatrics, Division of Endocrinology and Diabetes, Children’s Mercy Kansas City, 2401 Gilham Road, Kansas City, MO 64108 USA
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Moshage Y, Rodrigues F, White M, Cameron F. A pragmatic real-world trial examining the impact of an alteration of prescribing practice at diagnosis in paediatric type 1 diabetes mellitus. Diabet Med 2022; 39:e14849. [PMID: 35426172 DOI: 10.1111/dme.14849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 04/12/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Y Moshage
- Department of Medicine, University of Groningen, Groningen, Netherlands
- Diabetes Research, Murdoch Children's Research Institute, Melbourne, Australia
| | - Farrah Rodrigues
- Department of Endocrinology and Diabetes, Royal Children's Hospital Melbourne, Melbourne, Australia
- Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Australia
| | - Mary White
- Department of Endocrinology and Diabetes, Royal Children's Hospital Melbourne, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- Health Services Research Unit, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Fergus Cameron
- Department of Endocrinology and Diabetes, Royal Children's Hospital Melbourne, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
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11
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Prahalad P, Ding VY, Zaharieva DP, Addala A, Johari R, Scheinker D, Desai M, Hood K, Maahs DM. Teamwork, Targets, Technology, and Tight Control in Newly Diagnosed Type 1 Diabetes: the Pilot 4T Study. J Clin Endocrinol Metab 2022; 107:998-1008. [PMID: 34850024 PMCID: PMC8947228 DOI: 10.1210/clinem/dgab859] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Youth with type 1 diabetes (T1D) do not meet glycated hemoglobin A1c (HbA1c) targets. OBJECTIVE This work aimed to assess HbA1c outcomes in children with new-onset T1D enrolled in the Teamwork, Targets, Technology and Tight Control (4T) Study. METHODS HbA1c levels were compared between the 4T and historical cohorts. HbA1c differences between cohorts were estimated using locally estimated scatter plot smoothing (LOESS). The change from nadir HbA1c (month 4) to 12 months post diagnosis was estimated by cohort using a piecewise mixed-effects regression model accounting for age at diagnosis, sex, ethnicity, and insurance type. We recruited 135 youth with newly diagnosed T1D at Stanford Children's Health. Starting July 2018, all youth within the first month of T1D diagnosis were offered continuous glucose monitoring (CGM) initiation and remote CGM data review was added in March 2019. The main outcomes measure was HbA1c. RESULTS HbA1c at 6, 9, and 12 months post diagnosis was lower in the 4T cohort than in the historic cohort (-0.54% to -0.52%, and -0.58%, respectively). Within the 4T cohort, HbA1c at 6, 9, and 12 months post diagnosis was lower in those patients with remote monitoring than those without (-0.14%, -0.18% to -0.14%, respectively). Multivariable regression analysis showed that the 4T cohort experienced a significantly lower increase in HbA1c between months 4 and 12 (P < .001). CONCLUSION A technology-enabled, team-based approach to intensified new-onset education involving target setting, CGM initiation, and remote data review statistically significantly decreased HbA1c in youth with T1D 12 months post diagnosis.
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Affiliation(s)
- Priya Prahalad
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, California 94304, USA
- Stanford Diabetes Research Center, Stanford University, Stanford, California 94304, USA
- Correspondence: Priya Prahalad, MD, PhD, Department of Pediatrics, Division of Pediatric Endocrinology, Center for Academic Medicine, 453 Quarry Rd, Palo Alto, CA 94304, USA.
| | - Victoria Y Ding
- Department of Medicine, Division of Biomedical Informatics Research, Stanford University, Stanford, California 94304, USA
| | - Dessi P Zaharieva
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, California 94304, USA
| | - Ananta Addala
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, California 94304, USA
| | - Ramesh Johari
- Stanford Diabetes Research Center, Stanford University, Stanford, California 94304, USA
- Department of Management Science and Engineering, Stanford University, Stanford, California 94304, USA
| | - David Scheinker
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, California 94304, USA
- Stanford Diabetes Research Center, Stanford University, Stanford, California 94304, USA
- Department of Management Science and Engineering, Stanford University, Stanford, California 94304, USA
- Clinical Excellence Research Center, Stanford University, Stanford, California 94304, USA
| | - Manisha Desai
- Department of Medicine, Division of Biomedical Informatics Research, Stanford University, Stanford, California 94304, USA
| | - Korey Hood
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, California 94304, USA
- Stanford Diabetes Research Center, Stanford University, Stanford, California 94304, USA
| | - David M Maahs
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, California 94304, USA
- Stanford Diabetes Research Center, Stanford University, Stanford, California 94304, USA
- Department of Health Research and Policy (Epidemiology) Stanford University, Stanford, California 94304, USA
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12
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Quinn LM, Thayakaran R, Thomas N, Nirantharakumar K, Narendran P. Comment on Lachin et al. The Beneficial Effects of Earlier Versus Later Implementation of Intensive Therapy in Type 1 Diabetes. Diabetes Care 2021;44:2225-2230. Diabetes Care 2022; 45:e70-e71. [PMID: 35245356 PMCID: PMC8918199 DOI: 10.2337/dc21-2372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Lauren M Quinn
- Institute of Immunology and Immunotherapy, Research College of Medical and Dental Sciences, University of Birmingham, Birmingham, U.K
| | - Rasiah Thayakaran
- Public Health, Epidemiology, and Biostatistics, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, U.K
| | - Neil Thomas
- Public Health, Epidemiology, and Biostatistics, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, U.K
| | - Krishnarajah Nirantharakumar
- Public Health, Epidemiology, and Biostatistics, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, U.K
| | - Parth Narendran
- Institute of Immunology and Immunotherapy, Research College of Medical and Dental Sciences, University of Birmingham, Birmingham, U.K.,Department of Diabetes, University Hospitals of Birmingham NHS Foundation Trust, Birmingham, U.K
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13
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Champakanath A, Akturk HK, Alonso GT, Snell-Bergeon JK, Shah VN. Continuous Glucose Monitoring Initiation Within First Year of Type 1 Diabetes Diagnosis Is Associated With Improved Glycemic Outcomes: 7-Year Follow-Up Study. Diabetes Care 2022; 45:750-753. [PMID: 35018417 DOI: 10.2337/dc21-2004] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 12/03/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate long-term glycemic outcomes of continuous glucose monitoring (CGM) initiation within the first year of type 1 diabetes diagnosis. RESEARCH DESIGN AND METHODS Patients with type 1 diabetes (N = 396) were divided into three groups: 1) CGM (CGM use within 1 year of diabetes diagnosis and continued through the study), 2) no-CGM (no CGM use throughout the study), and 3) new-CGM (CGM use after 3 years since diabetes diagnosis). Patients were followed up to 7 years. RESULTS A1c was significantly lower in the CGM compared with the no-CGM group throughout 7 years of follow-up (least squares mean A1c values: 6 months, 7.3% vs. 8.1%; 1 year, 7.4% vs. 8.6%; 2 years, 7.7% vs. 9.1%; 3 years, 7.6% vs. 9.3%; 4 years, 7.4% vs. 9.6%; 5 years, 7.6% vs. 9.7%; 6 years, 7.5% vs. 10.0%; and 7 years, 7.6% vs. 9.8%; for all, P < 0.001) adjusting for age at diagnosis, sex, and insulin delivery method. CONCLUSIONS CGM initiation within first year of type 1 diabetes diagnosis results in long-term improvement in A1c.
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14
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Prahalad P, Schwandt A, Besançon S, Mohan M, Obermannova B, Kershaw M, Bonfanti R, Lyckå AP, Hanas R, Casteels K. Hemoglobin A1c trajectories in the first 18 months after diabetes diagnosis in the SWEET diabetes registry. Pediatr Diabetes 2022; 23:228-236. [PMID: 34779090 DOI: 10.1111/pedi.13278] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 10/26/2021] [Accepted: 11/03/2021] [Indexed: 11/30/2022] Open
Abstract
AIM A majority of youth with type 1 diabetes do not meet recommended hemoglobin A1c (HbA1c) targets. The SWEET diabetes registry is a multi-national registry of youth with diabetes. We used data from this registry to identify characteristics associated with glycemic control. METHODS Patients in the SWEET diabetes registry with at least one HbA1c value within 10 days of diagnosis and three follow up measurements in the first 18 months of diagnosis were included (~10% of the SWEET diabetes registry). Locally weighted scatterplot smoothing was used to generate curves of HbA1c. Wilcoxon, Kruskal-Wallis, or χ2-tests were used to calculate differences between groups. RESULTS The mean HbA1c of youth in the SWEET diabetes registry is highest at diagnosis and lowest between months 4 and 5 post-diabetes diagnosis. HbA1c continues to increase steadily through the first 18 months of diagnosis. There are no differences in HbA1c trajectories based on sex or use of diabetes technology. Youth in North America/Australia/New Zealand had the highest HbA1c throughout the first 18 months of diagnosis. The trajectory of youth from countries with nationalized health insurance was lower than those countries without nationalized health insurance. Youth from countries with the highest gross domestic product (GDP) had the highest HbA1c throughout the first 18 months of diagnosis. CONCLUSIONS In this subset of patients, the trajectory of youth from countries with nationalized health insurance was lower than those countries without nationalized health insurance. High GDP and high use of technology did not seem to protect from a higher trajectory.
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Affiliation(s)
- Priya Prahalad
- Division of Pediatric Endocrinology, Stanford University, Stanford, California, USA.,Stanford Diabetes Research Center, Stanford, California, USA
| | - Anke Schwandt
- Institute of Epidemiology and Medical Biometry, ZIBMT, Ulm University, Ulm, Germany.,German Centre for Diabetes Research (DZD), Neuherberg, Germany
| | - Stéphane Besançon
- NGO Santé Diabète Headquarter France and Delegation in Mali, Grenoble, France
| | - Meena Mohan
- Department of Endocrinology, PSG Super Speciality Hospitals, Coimbatore, India
| | - Barbora Obermannova
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Melanie Kershaw
- Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Riccardo Bonfanti
- Pediatric Diabetes, Diabetes Research Institute, Ospedale San Raffaele Milano, Milan, Italy
| | - Auste Pundziute Lyckå
- Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ragnar Hanas
- Department of Pediatrics, NU Hospital Group, Uddevalla, Sweden.,Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Kristina Casteels
- Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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15
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Lai CW, Lipman TH, Willi SM, Hawkes CP. Early Racial/Ethnic Disparities in Continuous Glucose Monitor Use in Pediatric Type 1 Diabetes. Diabetes Technol Ther 2021; 23:763-767. [PMID: 34143673 DOI: 10.1089/dia.2021.0120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Racial-ethnic disparities in technology use have been described in children with type 1 diabetes (T1D). It is not known whether these emerge early in disease management. This single-center retrospective study examined disparities in continuous glucose monitor (CGM) initiation and durability in the first-year after diagnosis of T1D in children. Of 345 eligible children, 46% started CGM within their first year. In non-Hispanic white (NHW) children, 51% started using CGM versus 28% of non-Hispanic black (NHB) children (P = 0.006). After stratifying by commercial/government insurance, a proxy for socioeconomic status, this difference persisted among those with commercial insurance. One-year post-CGM initiation, 96% (125/130) of NHW children were using CGM versus 73% (11/15) of NHB children (P = 0.003). Disparities in CGM use emerge early in care of children with T1D, with lower rates of initiation and sustained use of CGM in NHB children. Strategies addressing causes of these disparities should begin early in T1D management.
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Affiliation(s)
- Charlene W Lai
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Terri H Lipman
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Steven M Willi
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Colin P Hawkes
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
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16
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Lam A, Dayan C, Herold KC. A little help from residual β cells has long-lasting clinical benefits. J Clin Invest 2021; 131:143683. [PMID: 33529163 PMCID: PMC7843219 DOI: 10.1172/jci143683] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Following type 1 diabetes (T1D) diagnosis, declining C-peptide levels reflect deteriorating β cell function. However, the precise C-peptide levels that indicate protection from severe hypoglycemia remain unknown. In this issue of the JCI, Gubitosi-Klug et al. studied participants from the landmark and ongoing Diabetes Control and Complications Trial (DCCT) and the Epidemiology of Diabetes Interventions and Complications (EDIC) study that had long-standing (about 35 years) T1D. The authors correlated severe hypoglycemia and other disease outcomes with residual C-peptide levels. While C-peptide secretion failed to associate with hemoglobin A1c (HbA1c) or microvascular complications, C-peptide levels greater than 0.03 nmol/L were linked with fewer episodes of severe hypoglycemia. These findings suggest that efforts to preserve finite β cell function early in T1D can have meaningful, long-standing health benefits for patients.
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Affiliation(s)
- Anna Lam
- University of Alberta, Edmonton, Alberta, Canada
| | - Colin Dayan
- Cardiff University School of Medicine, Cardiff, United Kingdom
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17
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Siller AF, Tosur M, Relan S, Astudillo M, McKay S, Dabelea D, Redondo MJ. Challenges in the diagnosis of diabetes type in pediatrics. Pediatr Diabetes 2020; 21:1064-1073. [PMID: 32562358 DOI: 10.1111/pedi.13070] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/07/2020] [Accepted: 06/10/2020] [Indexed: 12/11/2022] Open
Abstract
The incidence of diabetes, both type 1 and type 2, is increasing. Health outcomes in pediatric diabetes are currently poor, with trends indicating that they are worsening. Minority racial/ethnic groups are disproportionately affected by suboptimal glucose control and have a higher risk of acute and chronic complications of diabetes. Correct clinical management starts with timely and accurate classification of diabetes, but in children this is becoming increasingly challenging due to high prevalence of obesity and shifting demographic composition. The growing obesity epidemic complicates classification by obesity's effects on diabetes. Since the prevalence and clinical characteristics of diabetes vary among racial/ethnic groups, migration between countries leads to changes in the distribution of diabetes types in a certain geographical area, challenging the clinician's ability to classify diabetes. These challenges must be addressed to correctly classify diabetes and establish an appropriate treatment strategy early in the course of disease for all. This may be the first step in improving diabetes outcomes across racial/ethnic groups. This review will discuss the pitfalls in the current diabetes classification scheme that is leading to increasing overlap between diabetes types and heterogeneity within each type. It will also present proposed alternative classification schemes and approaches to understanding diabetes type that may improve the timely and accurate classification of pediatric diabetes type.
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Affiliation(s)
- Alejandro F Siller
- Diabetes and Endocrinology Section, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Mustafa Tosur
- Diabetes and Endocrinology Section, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Shilpi Relan
- Diabetes and Endocrinology Section, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Marcela Astudillo
- Diabetes and Endocrinology Section, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Siripoom McKay
- Diabetes and Endocrinology Section, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Dana Dabelea
- Lifecourse Epidemiology of Adiposity and Diabetes (LEAD) Center, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Maria J Redondo
- Diabetes and Endocrinology Section, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
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18
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Johnson A, Hill NE, Godsland I, Oliver NS. Glycemic Tracking Before and After Insulin Pump Initiation. J Diabetes Sci Technol 2020; 14:970-971. [PMID: 32146846 PMCID: PMC7753865 DOI: 10.1177/1932296820910506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Agnes Johnson
- Imperial College Healthcare NHS Trust, Endocrinology & Diabetes, Charing Cross Hospital, London, UK
| | - Neil E. Hill
- Imperial College Healthcare NHS Trust, Endocrinology & Diabetes, Charing Cross Hospital, London, UK
- Neil E. Hill, MRCP, PhD, Consultant Diabetes & Endocrinology, Imperial College Healthcare NHS Trust, Endocrinology & Diabetes, Charing Cross Hospital, London W6 8RF, UK.
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19
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Ji H, Godsland I, Oliver NS, Hill NE. Loss of association between HbA1c and vascular disease in older adults with type 1 diabetes. PLoS One 2020; 15:e0234319. [PMID: 32542057 PMCID: PMC7295188 DOI: 10.1371/journal.pone.0234319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 05/22/2020] [Indexed: 11/21/2022] Open
Abstract
Aims Robust evidence supports intensive glucose control in those with recently diagnosed type 1 diabetes to reduce the risk of developing micro- and macrovascular complications. Data to support longitudinal glycaemic targets is lacking. We aimed to explore if longer duration of diabetes and greater age might reduce the impact of glycaemia on the risk of vascular complications. Research and design methods Data for adults age 20 years or more, was extracted from a clinical database of people with type 1 diabetes cared for at a London teaching hospital. The presence or absence of micro- and macro-vascular complications was recorded. Multivariable logistic regression analysis was performed using HbA1c as independent variable, diabetes duration and age as continuous variable and obesity, hypertension, hypercholesterolaemia, low HDL cholesterol and hypertriglyceridaemia as categorical variables. Results Data from 495 patients was used. HbA1c above 60 mmol/mol (7.6%) was associated with increased microvascular complications in patients aged 20–44 years, independent of age and duration of diabetes. In older people with T1DM duration of diabetes was the major risk factor. Conclusions Our study suggests that increased age and greater duration of diabetes reduce the impact of glycaemia on the risk of vascular complications. Intensive blood glucose management in patients aged ≥45 years may have limited benefits in terms of reducing the risk of complications although this does not dismiss the benefits of good glycaemic control in older people with T1DM.
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Affiliation(s)
- HaEun Ji
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Ian Godsland
- Division of Diabetes, Department of Metabolism, Endocrinology and Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Nick S. Oliver
- Imperial College Healthcare NHS Trust, London, United Kingdom
- Division of Diabetes, Department of Metabolism, Endocrinology and Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Neil E. Hill
- Imperial College Healthcare NHS Trust, London, United Kingdom
- * E-mail:
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20
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Mazarello Paes V, Barrett JK, Dunger DB, Gevers EF, Taylor‐Robinson DC, Viner RM, Stephenson TJ. Factors predicting poor glycemic control in the first two years of childhood onset type 1 diabetes in a cohort from East London, UK: Analyses using mixed effects fractional polynomial models. Pediatr Diabetes 2020; 21:288-299. [PMID: 31782879 PMCID: PMC7028081 DOI: 10.1111/pedi.12950] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 10/15/2019] [Accepted: 11/14/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND/OBJECTIVE Poor early glycemic control in childhood onset type 1 diabetes (T1D) is associated with future risk of acute and chronic complications. Our aim was to identify the predictors of higher glycated hemoglobin (HbA1c) within 24 months of T1D diagnosis in children and adolescents. METHODS Mixed effects models with fractional polynomials were used to analyze longitudinal data of patients <19 years of age, followed from T1D diagnosis for up to 2 years, at three diabetes clinics in East London, United Kingdom. RESULTS A total of 2209 HbA1c observations were available for 356 patients (52.5% female; 64.4% non-white), followed from within 3 months of diagnosis during years 2005 to 2015, with a mean ± SD of 6.2 ± 2.5 HbA1c observations/participant. The mean age and HbA1c at diagnosis were 8.9 ± 4.3 years and 10.7% ±4.3% (or expressed as mmol/mol HbA1c mean ± SD 92.9 ± 23.10 mmol/mol) respectively. Over the 2 years following T1D diagnosis, HbA1c levels were mostly above the National Institute for Health, Care and Excellence (NICE), UK recommendations of 7.5% (<58 mmol/mol). Significant (P < .05) predictors of poorer glycemic control were: Age at diagnosis (12-18 years), higher HbA1c at baseline (>9.5%, ie, >80 mmol/mol), clinic site, non-white ethnicity, and period (pre-year 2011) of diagnosis. Additionally in univariable analyses, frequency of clinic visits, HbA1c at diagnosis, and type of insulin treatment regimen showed association with poor glycemic control (P < .05). CONCLUSIONS Major risk factors of poorer glycemic control during 3-24 months following childhood onset T1D are: diagnosis prior to 2011, higher HbA1c levels at baseline, age at diagnosis, non-white ethnicity, and clinic site.
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Affiliation(s)
- Veena Mazarello Paes
- Population, Policy and Practice Research and Teaching DepartmentUCL Great Ormond Street Institute of Child Health, University College LondonLondonUK,Department of PaediatricsUniversity of CambridgeCambridgeUK
| | | | - David B. Dunger
- Department of PaediatricsUniversity of CambridgeCambridgeUK,Wellcome Trust—MRC Institute of Metabolic SciencesUniversity of CambridgeCambridgeUK
| | - Evelien F. Gevers
- Centre for Endocrinology, William Harvey Research InstituteQueen Mary UniversityLondonUK,Department of Paediatric EndocrinologyBarts Health NHS Trust, Royal London Children's HospitalLondonUK
| | | | - Russell M. Viner
- Population, Policy and Practice Research and Teaching DepartmentUCL Great Ormond Street Institute of Child Health, University College LondonLondonUK,The Royal College of Paediatrics and Child HealthLondonUK
| | - Terence J. Stephenson
- Population, Policy and Practice Research and Teaching DepartmentUCL Great Ormond Street Institute of Child Health, University College LondonLondonUK
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21
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Troullinaki M, Chen LS, Witt A, Pyrina I, Phieler J, Kourtzelis I, Chmelar J, Sprott D, Gercken B, Koutsilieris M, Chavakis T, Chatzigeorgiou A. Robo4-mediated pancreatic endothelial integrity decreases inflammation and islet destruction in autoimmune diabetes. FASEB J 2020; 34:3336-3346. [PMID: 31916652 DOI: 10.1096/fj.201900125rr] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 12/23/2019] [Accepted: 12/24/2019] [Indexed: 12/18/2022]
Abstract
In Type 1 Diabetes Mellitus (T1DM), leukocyte infiltration of the pancreatic islets and the resulting immune-mediated destruction of beta cells precede hyperglycemia and clinical disease symptoms. In this context, the role of the pancreatic endothelium as a barrier for autoimmunity- and inflammation-related destruction of the islets is not well studied. Here, we identified Robo4, expressed on endothelial cells, as a regulator of pancreatic vascular endothelial permeability during autoimmune diabetes. Circulating levels of Robo4 were upregulated in mice subjected to the Multiple Low-Dose Streptozotocin (MLDS) model of diabetes. Upon MLDS induction, Robo4-deficiency resulted in increased pancreatic vascular permeability, leukocyte infiltration to the islets and islet apoptosis, associated with reduced insulin levels and faster diabetes development. On the contrary, in vivo administration of Slit2 in mice modestly delayed the emergence of hyperglycaemia and ameliorated islet inflammation in MLDS-induced diabetes. Thus, Robo4-mediated endothelial barrier integrity reduces insulitis and islet destruction in autoimmune diabetes. Our findings highlight the importance of the endothelium as gatekeeper of pancreatic inflammation during T1DM development and may pave the way for novel Robo4-related therapeutic approaches for autoimmune diabetes.
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Affiliation(s)
- Maria Troullinaki
- Institute for Clinical Chemistry and Laboratory Medicine, University Clinic Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Lan-Sun Chen
- Institute for Clinical Chemistry and Laboratory Medicine, University Clinic Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Anke Witt
- Institute for Clinical Chemistry and Laboratory Medicine, University Clinic Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Iryna Pyrina
- Institute for Clinical Chemistry and Laboratory Medicine, University Clinic Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Julia Phieler
- Institute for Clinical Chemistry and Laboratory Medicine, University Clinic Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Ioannis Kourtzelis
- Institute for Clinical Chemistry and Laboratory Medicine, University Clinic Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jindrich Chmelar
- Faculty of Science, University of South Bohemia, České Budějovice, Czech Republic
| | - David Sprott
- Institute for Clinical Chemistry and Laboratory Medicine, University Clinic Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Bettina Gercken
- Institute for Clinical Chemistry and Laboratory Medicine, University Clinic Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Michael Koutsilieris
- Department of Physiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Triantafyllos Chavakis
- Institute for Clinical Chemistry and Laboratory Medicine, University Clinic Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Paul Langerhans Institute Dresden of the Helmholtz Center Munich, University Hospital and Faculty of Medicine, TU Dresden, Dresden, Germany.,German Center for Diabetes Research (DZD), Neuherberg, Germany
| | - Antonios Chatzigeorgiou
- Institute for Clinical Chemistry and Laboratory Medicine, University Clinic Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Department of Physiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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22
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Prahalad P, Zaharieva DP, Addala A, New C, Scheinker D, Desai M, Hood KK, Maahs DM. Improving Clinical Outcomes in Newly Diagnosed Pediatric Type 1 Diabetes: Teamwork, Targets, Technology, and Tight Control-The 4T Study. Front Endocrinol (Lausanne) 2020; 11:360. [PMID: 32733375 PMCID: PMC7363838 DOI: 10.3389/fendo.2020.00360] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 05/07/2020] [Indexed: 12/12/2022] Open
Abstract
Many youth with type 1 diabetes (T1D) do not achieve hemoglobin A1c (HbA1c) targets. The mean HbA1c of youth in the USA is higher than much of the developed world. Mean HbA1c in other nations has been successfully modified following benchmarking and quality improvement methods. In this review, we describe the novel 4T approach-teamwork, targets, technology, and tight control-to diabetes management in youth with new-onset T1D. In this program, the diabetes care team (physicians, nurse practitioners, certified diabetes educators, dieticians, social workers, psychologists, and exercise physiologists) work closely to deliver diabetes education from diagnosis. Part of the education curriculum involves early integration of technology, specifically continuous glucose monitoring (CGM), and developing a curriculum around using the CGM to maintain tight control and optimize quality of life.
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Affiliation(s)
- Priya Prahalad
- Division of Endocrinology, Department of Pediatrics, Stanford University, Stanford, CA, United States
- *Correspondence: Priya Prahalad
| | - Dessi P. Zaharieva
- Division of Endocrinology, Department of Pediatrics, Stanford University, Stanford, CA, United States
| | - Ananta Addala
- Division of Endocrinology, Department of Pediatrics, Stanford University, Stanford, CA, United States
| | - Christin New
- Division of Endocrinology, Department of Pediatrics, Stanford University, Stanford, CA, United States
| | - David Scheinker
- Division of Endocrinology, Department of Pediatrics, Stanford University, Stanford, CA, United States
- Department of Management Science and Engineering, Stanford University, Stanford, CA, United States
| | - Manisha Desai
- Quantitative Sciences Unit, Division of Biomedical Informatics Research, Stanford University, Stanford, CA, United States
- Stanford Diabetes Research Center, Stanford, CA, United States
| | - Korey K. Hood
- Division of Endocrinology, Department of Pediatrics, Stanford University, Stanford, CA, United States
- Stanford Diabetes Research Center, Stanford, CA, United States
| | - David M. Maahs
- Division of Endocrinology, Department of Pediatrics, Stanford University, Stanford, CA, United States
- Stanford Diabetes Research Center, Stanford, CA, United States
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23
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Prahalad P, Addala A, Scheinker D, Hood KK, Maahs DM. CGM Initiation Soon After Type 1 Diabetes Diagnosis Results in Sustained CGM Use and Wear Time. Diabetes Care 2020; 43:e3-e4. [PMID: 31558548 PMCID: PMC7011198 DOI: 10.2337/dc19-1205] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 07/03/2019] [Indexed: 02/03/2023]
Affiliation(s)
- Priya Prahalad
- Division of Endocrinology, Department of Pediatrics, Stanford University, Stanford, CA
| | - Ananta Addala
- Division of Endocrinology, Department of Pediatrics, Stanford University, Stanford, CA
| | - David Scheinker
- Division of Endocrinology, Department of Pediatrics, Stanford University, Stanford, CA.,Department of Management Science and Engineering, Stanford University, Stanford, CA
| | - Korey K Hood
- Division of Endocrinology, Department of Pediatrics, Stanford University, Stanford, CA
| | - David M Maahs
- Division of Endocrinology, Department of Pediatrics, Stanford University, Stanford, CA.,Stanford Diabetes Research Center, Stanford, CA
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Enhancement of the Soluble Form of OX40 and OX40L Costimulatory Molecules but Reduction of the Membrane Form in Type 1 Diabetes (T1D). J Immunol Res 2019; 2019:1780567. [PMID: 31467932 PMCID: PMC6701347 DOI: 10.1155/2019/1780567] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 05/15/2019] [Accepted: 06/28/2019] [Indexed: 01/10/2023] Open
Abstract
This study analyzed the expression of membrane OX40 and OX40L (mOX40 and mOX40L) and levels of soluble OX40 and OX40L (sOX40 and sOX40L) in T1D patients to determine their clinical significance. Peripheral blood (PB) was collected from patients with T1D and healthy control participants. Expression of mOX40 and mOX40L on immune cells was detected by flow cytometry. Levels of sOX40 and sOX40L in sera were measured by ELISA. We demonstrated for the first time enhanced sOX40 and sOX40L expression and reduced mOX40 and mOX40L levels in T1D patients which correlated with the clinical characteristics and inflammatory factors. These results suggest that OX40/OX40L signal may be promising biomarkers and associated with the pathogenesis of T1D.
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Mazarello Paes V, Barrett JK, Taylor‐Robinson DC, Chesters H, Charalampopoulos D, Dunger DB, Viner RM, Stephenson TJ. Effect of early glycemic control on HbA1c tracking and development of vascular complications after 5 years of childhood onset type 1 diabetes: Systematic review and meta-analysis. Pediatr Diabetes 2019; 20:494-509. [PMID: 30932298 PMCID: PMC6701989 DOI: 10.1111/pedi.12850] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 03/25/2019] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE A systematic review and meta-analysis was conducted to investigate if glycemic control measured by glycated hemoglobin (HbA1c) levels near diagnosis are predictive of future glycemic outcomes and vascular complications in childhood onset type 1 diabetes (T1D). METHODS Evidence was gathered using electronic databases (MEDLINE, EMBASE, Web of Science, CINAHL, Scopus, and Cochrane Library up to February 2017) and snowballing techniques. Studies investigating the association between the exposure "early glycemic control" and main outcome: "tracking of early control" and secondary outcome: risk of future complications; in children and young people aged 0 to 19 years at baseline; were systematically double-reviewed, quality assessed, and outcome data extracted for synthesis and meta-analysis. FINDINGS Five studies (N = 4227 participants) were eligible. HbA1c levels were sub-optimal throughout the study period but tended to stabilize in a "track" by 6 months after T1D diagnosis. The group with low HbA1c <53 mmol/mol (<7%) at baseline had lower long-term HbA1c levels than the higher HbA1c group. The estimated standardized mean difference between the sub groups showed a reduction of HbA1c levels on average by 1.6% (range -0.95% to -2.28%) from baseline. Only one study investigated the association between early glycemic control and development of vascular complications in childhood onset T1D. INTERPRETATIONS Glycemic control after the first few months of childhood onset T1D, remains stable but sub-optimal for a decade. The low and high HbA1c levels at baseline seem to "track" in their respective tracks during the 10-year follow-up, however, the initial difference between groups narrows over time. PROSPERO CRD42015024546 http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42015024546.
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Affiliation(s)
- Veena Mazarello Paes
- Great Ormond Street Institute of Child HealthUniversity College LondonLondonUK,Department of PaediatricsUniversity of CambridgeCambridgeUK
| | | | | | - Heather Chesters
- Great Ormond Street Institute of Child HealthUniversity College LondonLondonUK
| | | | - David B. Dunger
- Department of PaediatricsUniversity of CambridgeCambridgeUK,Wellcome Trust/MRC Institute of Metabolic Sciences, University of CambridgeCambridgeUK
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26
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Thayakaran R, Perrins M, Gokhale KM, Kumaran S, Narendran P, Price MJ, Nirantharakumar K, Toulis KA. Impact of glycaemic control on fracture risk in 5368 people with newly diagnosed Type 1 diabetes: a time-dependent analysis. Diabet Med 2019; 36:1013-1019. [PMID: 30848519 DOI: 10.1111/dme.13945] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/05/2019] [Indexed: 12/30/2022]
Abstract
AIMS To assess whether glycaemic control is associated with a lifelong increased risk of fracture in people with newly diagnosed Type 1 diabetes. METHODS People with newly diagnosed Type 1 diabetes between 1 January 1995 and 10 May 2016 were identified in The Health Improvement Network database. Longitudinal HbA1c measurements from diagnosis to fracture or study end or loss to follow-up were collected. A Cox proportional hazards model with HbA1c included as a time-dependent variable was fitted to these data. RESULTS Some 5368 people with newly diagnosed Type 1 diabetes were included. The estimated adjusted hazard ratio (aHR) for HbA1c was statistically significant [aHR 1.007; 95% confidence interval (CI) 1.002-1.011 (mmol/mol) and aHR 1.07; 95% CI 1.03-1.12 (%)]. An incremental higher risk of fracture was observed with increasing levels of HbA1c . CONCLUSIONS In people with newly diagnosed Type 1 diabetes, higher HbA1c is associated with an increased risk for fractures.
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Affiliation(s)
- R Thayakaran
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - M Perrins
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - K M Gokhale
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - S Kumaran
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - P Narendran
- Department of Diabetes, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Immunology and Immunotherapy, Birmingham, UK
| | - M J Price
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - K Nirantharakumar
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Department of Diabetes, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, Birmingham, UK
- Health Data Research UK Midlands, Birmingham, UK
| | - K A Toulis
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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27
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Cavalcante R, Matheus ASM, Zanette A, Braga B, Duarte B, Würdig B, Maieron D, Sorio JS, Bagatini L, Cherit M, Gomes MB. The influence of demographic, social-educational determinants and diabetes management on agreement between glucometer and logbook and its impact on glycemic control in patients with type 1 diabetes: a follow-up study. Diabetol Metab Syndr 2019; 11:46. [PMID: 31236141 PMCID: PMC6580586 DOI: 10.1186/s13098-019-0443-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 06/11/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The primary objective of this study was to evaluate the demographic, clinical, social-educational determinants and diabetes management factors that have influenced the agreement between glycaemia obtained from a glucometer and logbook; the second objective was to evaluate the influence of the above-mentioned factors on glycemic control and its trajectories in Type 1 diabetes (T1D) over 1 year follow-up period during routine clinical practice. METHODS This was a prospective observational cohort study conducted at the Diabetes Unit at Rio de Janeiro's State University, between May 2017 and May 2018. All consecutive patients with clinical diagnosis of T1D that attended the Diabetes Unit between April and June 2017 were enrolled in this study. RESULTS Data were obtained from 158 patients. Overall, for 112 (73.2%) of the patients, we found no agreement between glycaemia obtained from a glucometer and the logbook (group 2). In 41 (26.8%) of the patients there was an agreement (group 1). Patients from group 1 presented a lower mean glycated hemoglobin (HbA1c) (p = 0.03) and a tendency to have a lower baseline HbA1c (p = 0.08), they received more frequently strips for glucose monitoring from the Sistema Único de Saúde (SUS) (p = 0.047) and were more adherent to the prescribed diet (p = 0.01) than patients from group 2. Multivariate analysis of this agreement (as a dependent variable) showed that adherence to diet was the only significant independent variable. Significant difference was noted between baseline and final HbA1c [(9.4 ± 2.2%) vs (9.03 ± 1.8%), p = 0.017], respectively. CONCLUSIONS Our study revealed that the majority of T1D patients that were followed at a tertiary center did not have significant agreement between glycaemia obtained from a glucometer and a logbook. Adherence to diet was the main factor related to the agreement, but the supply of strips by SUS should also be considered in clinical practice.
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Affiliation(s)
- Rebeca Cavalcante
- Department of Internal Medicine, Diabetes Unit, State University Hospital of Rio de Janeiro, Rio de Janeiro, RJ Brazil
- Manaus, Brazil
| | - Alessandra S. M. Matheus
- Department of Internal Medicine, Diabetes Unit, State University Hospital of Rio de Janeiro, Rio de Janeiro, RJ Brazil
| | - Aneliza Zanette
- Department of Internal Medicine, Diabetes Unit, State University Hospital of Rio de Janeiro, Rio de Janeiro, RJ Brazil
| | - Bruna Braga
- Department of Internal Medicine, Diabetes Unit, State University Hospital of Rio de Janeiro, Rio de Janeiro, RJ Brazil
| | - Bruna Duarte
- Department of Internal Medicine, Diabetes Unit, State University Hospital of Rio de Janeiro, Rio de Janeiro, RJ Brazil
| | - Bruna Würdig
- Department of Internal Medicine, Diabetes Unit, State University Hospital of Rio de Janeiro, Rio de Janeiro, RJ Brazil
| | - Daniele Maieron
- Department of Internal Medicine, Diabetes Unit, State University Hospital of Rio de Janeiro, Rio de Janeiro, RJ Brazil
| | - João Scarparo Sorio
- Department of Internal Medicine, Diabetes Unit, State University Hospital of Rio de Janeiro, Rio de Janeiro, RJ Brazil
| | - Luciana Bagatini
- Department of Internal Medicine, Diabetes Unit, State University Hospital of Rio de Janeiro, Rio de Janeiro, RJ Brazil
| | - Michelle Cherit
- Department of Internal Medicine, Diabetes Unit, State University Hospital of Rio de Janeiro, Rio de Janeiro, RJ Brazil
| | - Marilia Brito Gomes
- Department of Internal Medicine, Diabetes Unit, State University Hospital of Rio de Janeiro, Rio de Janeiro, RJ Brazil
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28
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Mulinacci G, Alonso GT, Snell-Bergeon JK, Shah VN. Glycemic Outcomes with Early Initiation of Continuous Glucose Monitoring System in Recently Diagnosed Patients with Type 1 Diabetes. Diabetes Technol Ther 2019; 21:6-10. [PMID: 30575413 DOI: 10.1089/dia.2018.0257] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND We investigated the efficacy and safety of continuous glucose monitoring (CGM) initiation within 1 year of type 1 diabetes (T1D) diagnosis among children, adolescents, and adults. METHODS Differences in mean A1c (primary outcome) and diabetes-related emergency visits (secondary outcome) for 2.5 years between early CGM users and non-CGM users were studied among 396 newly diagnosed patients with T1D (94% children [age <18 years], 5% adults, 46% females) between January 2013 and December 2015 at Barbara Davis Center for Diabetes. The primary outcome was adjusted by age at diagnosis and gender. P < 0.05 was considered significant. RESULTS Gender, ethnicity, body mass index, and A1c at diagnosis were similar between the groups. Irrespective of insulin delivery methods, CGM users had a significantly greater improvement in glycemic control than non-CGM users at 1, 1.5, 2, and 2.5 years. For 2.5 years of follow-up, the multiple daily injection (MDI)+CGM group (n = 19) had 1.5% ± 0.2% lower A1c than the MDI only group (n = 225) (7.7% ± 0.2% vs. 9.2% ± 0.04%, P < 0.0001), and the insulin pump (continuous subcutaneous insulin infusion [CSII])+CGM group (n = 62) had 0.7% ± 0.1% lower A1c than the CSII only group (n = 90) (8.0% ± 0.08% vs. 8.7% ± 0.07%, P < 0.0001). The MDI+CGM group had significantly lower A1c than the CSII only group (7.7% ± 0.2% vs. 8.7% ± 0.07%, P < 0.0001). The number of diabetes-related (severe hypoglycemia or hyperglycemia) emergency department visits was significantly lower among early CGM users compared with non-CGM users (P = 0.003). CONCLUSION Irrespective of insulin delivery system, early initiation of CGM within 1 year from T1D diagnosis was associated with better glucose control and fewer diabetes-related emergency visits.
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Affiliation(s)
| | - G Todd Alonso
- 2 Barbara Davis Center for Diabetes, University of Colorado Anschutz Campus, Aurora, Colorado
| | - Janet K Snell-Bergeon
- 2 Barbara Davis Center for Diabetes, University of Colorado Anschutz Campus, Aurora, Colorado
| | - Viral N Shah
- 2 Barbara Davis Center for Diabetes, University of Colorado Anschutz Campus, Aurora, Colorado
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29
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Affiliation(s)
- Parth Narendran
- Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.
- Department of Diabetes, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
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30
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Chib A, Lin SH. Theoretical Advancements in mHealth: A Systematic Review of Mobile Apps. JOURNAL OF HEALTH COMMUNICATION 2018; 23:909-955. [PMID: 30449261 DOI: 10.1080/10810730.2018.1544676] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
There are now few hundred thousand healthcare apps, yet there is a gap in our understanding of the theoretical mechanisms for which, and how, technological features translate into improved healthcare outcomes. In particular, the technological convergence, within mobile health (mHealth) apps, of the processes of mass and interpersonal communication, and human-computer interaction requires greater parsing in the literature. This paper analyzed 85 empirical studies on mHealth apps using the Input-Mechanism-Output model. We found in the literature that, firstly, there is a greater emphasis on technological inputs (87%) of accessibility, usability, usage, and data quality, than health outputs (52%) such as system process efficiencies and individual level behavioral or health outcomes. Secondly, there is little evidence of explanatory mechanisms (19%) of how the effects of mHealth apps are achieved. While we believe that successful apps would require research that incorporates technological inputs, theoretical mechanisms and health outputs, such studies are a rarity (n = 3). There is a minor increase in rigor with randomized control trials (n = 5), and a preponderance of discussion around social influence (n = 8) and gamification (n = 7), albeit in a scattered manner. We discuss the implications of the trend towards socialization and gamification findings in terms of future research, particularly in terms of study design guided by theoretical mechanisms.
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Affiliation(s)
- Arul Chib
- a Wee Kim Wee School of Communication and Information , Nanyang Technological University , Singapore
| | - Sapphire H Lin
- a Wee Kim Wee School of Communication and Information , Nanyang Technological University , Singapore
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31
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Rigalleau V, Benoit J, Charret L, Bertrand C, Foussard N, Blanco L, Alexandre L, Monlun M, Mohammedi K. Longitudinal trends in HbA1c in diabetes: Stable means can hide meaningful long-term changes. Diabetes Metab Res Rev 2018; 34:e3065. [PMID: 30123984 DOI: 10.1002/dmrr.3065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 07/02/2018] [Accepted: 07/29/2018] [Indexed: 12/13/2022]
Affiliation(s)
- Vincent Rigalleau
- Endocrinology-Nutrition Department, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Julie Benoit
- Endocrinology-Nutrition Department, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Léa Charret
- Endocrinology-Nutrition Department, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Capucine Bertrand
- Endocrinology-Nutrition Department, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Ninon Foussard
- Endocrinology-Nutrition Department, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Laurence Blanco
- Endocrinology-Nutrition Department, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Laure Alexandre
- Endocrinology-Nutrition Department, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Marie Monlun
- Endocrinology-Nutrition Department, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Kamel Mohammedi
- Endocrinology-Nutrition Department, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Bordeaux, France
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Shields BM, McDonald TJ, Oram R, Hill A, Hudson M, Leete P, Pearson ER, Richardson SJ, Morgan NG, Hattersley AT, Roep BO, Tree TI, Hammersley S, Bolt R, Hill AV. C-Peptide Decline in Type 1 Diabetes Has Two Phases: An Initial Exponential Fall and a Subsequent Stable Phase. Diabetes Care 2018; 41:1486-1492. [PMID: 29880650 PMCID: PMC6027962 DOI: 10.2337/dc18-0465] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 04/16/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The decline in C-peptide in the 5 years after diagnosis of type 1 diabetes has been well studied, but little is known about the longer-term trajectory. We aimed to examine the association between log-transformed C-peptide levels and the duration of diabetes up to 40 years after diagnosis. RESEARCH DESIGN AND METHODS We assessed the pattern of association between urinary C-peptide/creatinine ratio (UCPCR) and duration of diabetes in cross-sectional data from 1,549 individuals with type 1 diabetes using nonlinear regression approaches. Findings were replicated in longitudinal follow-up data for both UCPCR (n = 161 individuals, 326 observations) and plasma C-peptide (n = 93 individuals, 473 observations). RESULTS We identified two clear phases of C-peptide decline: an initial exponential fall over 7 years (47% decrease/year [95% CI -51, -43]) followed by a stable period thereafter (+0.07%/year [-1.3, +1.5]). The two phases had similar durations and slopes in patients above and below the median age at diagnosis (10.8 years), although levels were lower in the younger patients irrespective of duration. Patterns were consistent in both longitudinal UCPCR (n = 162; ≤7 years duration: -48%/year [-55, -38]; >7 years duration -0.1% [-4.1, +3.9]) and plasma C-peptide (n = 93; >7 years duration only: -2.6% [-6.7, +1.5]). CONCLUSIONS These data support two clear phases of C-peptide decline: an initial exponential fall over a 7-year period, followed by a prolonged stabilization where C-peptide levels no longer decline. Understanding the pathophysiological and immunological differences between these two phases will give crucial insights into understanding β-cell survival.
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Affiliation(s)
- Beverley M. Shields
- National Institute for Health Research Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, U.K
| | | | - Richard Oram
- National Institute for Health Research Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, U.K
| | - Anita Hill
- National Institute for Health Research Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, U.K
| | - Michelle Hudson
- National Institute for Health Research Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, U.K
| | - Pia Leete
- Islet Biology Exeter (IBEx), Institute of Biomedical and Clinical Sciences, University of Exeter Medical School, Exeter, U.K
| | - Ewan R. Pearson
- Division of Molecular & Clinical Medicine, School of Medicine, University of Dundee, Dundee, U.K
| | - Sarah J. Richardson
- Islet Biology Exeter (IBEx), Institute of Biomedical and Clinical Sciences, University of Exeter Medical School, Exeter, U.K
| | - Noel G. Morgan
- Islet Biology Exeter (IBEx), Institute of Biomedical and Clinical Sciences, University of Exeter Medical School, Exeter, U.K
| | - Andrew T. Hattersley
- National Institute for Health Research Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, U.K
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