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ElSayed NA, Aleppo G, Bannuru RR, Bruemmer D, Collins BS, Ekhlaspour L, Hilliard ME, Johnson EL, Khunti K, Lingvay I, Matfin G, McCoy RG, Perry ML, Pilla SJ, Polsky S, Prahalad P, Pratley RE, Segal AR, Seley JJ, Stanton RC, Gabbay RA. 14. Children and Adolescents: Standards of Care in Diabetes-2024. Diabetes Care 2024; 47:S258-S281. [PMID: 38078582 PMCID: PMC10725814 DOI: 10.2337/dc24-s014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Harvengt A, Beckers M, Boutsen L, Costenoble E, Brunelle C, Lysy P. Deep Analysis of Clinical Parameters and Temporal Evolution of Glycemic Parameters Based on CGM Data for the Characterization of Severe Hypoglycemia in a Cohort of Children and Adolescents with Type 1 Diabetes. Nutrients 2023; 15:2957. [PMID: 37447282 DOI: 10.3390/nu15132957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 06/21/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023] Open
Abstract
This study aims to evaluate the determinants and clinical markers of patients at risk for severe hypoglycemia (SH) in children and adolescents with type 1 diabetes. In the EPI-GLUREDIA study, clinical parameters and continuous glucose monitoring metrics from children and adolescents with type 1 diabetes were retrospectively analyzed between July 2017 and June 2022. Their clinical parameters were collected during traditional and quarterly medical consultations according to whether they experienced severe hypoglycemia or not. Then, continuous glucose monitoring metrics were analyzed on days surrounding SH during specific periods. According to the glycemic parameters, glycemic hemoglobin and glycemic mean were significantly lower in the three months preceding a SH compared with during three normal months (p < 0.05). Moreover, the time spent in hypoglycemia(time below the range, TBR<3.3) and its strong correlation (R = 0.9, p < 0.001) with the frequency of SH represent a sensitive and specific clinical parameter to predict SH (cut-off: 9%, sensitivity: 71%, specificity: 63%). The second finding of the GLUREDIA study is that SH is not an isolated event in the glycemic follow-up of our T1DM patients. Indeed, most of the glycemic parameters (i.e., glycemic mean, glycemic variability, frequency of hypoglycemia, and glycemic targets) vary considerably in the month preceding an SH (all p < 0.05), whereas most of these studied glycemic parameters remain stable in the absence of a severe acute complication (all p > 0.05). Furthermore, the use of ROC curves allowed us to determine for each glycemic parameter a sensitive or specific threshold capable of more accurately predicting SH. For example, a 10% increase in the frequency of hypoglycemia predicts a risk of near SH with good combination of sensitivity and specificity (sensitivity: 80%, specificity: 60%). The GLUREDIA study aimed to target clinical and glycemic parameters to predict patients at risk for SH. First, we identified TBR<3.3 < 9% as a sensitive and specific tool to reduce the frequency of SH. In addition, SH was not an isolated event but rather it was accompanied by glycemic disturbances in the 30 days before SH.
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Affiliation(s)
- Antoine Harvengt
- Pôle PEDI, Institut de Recherche Expérimentale et Clinique, UCLouvain, 1200 Brussels, Belgium
| | - Maude Beckers
- Specialized Pediatrics Service, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Laure Boutsen
- Specialized Pediatrics Service, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Elise Costenoble
- Specialized Pediatrics Service, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Chloé Brunelle
- Specialized Pediatrics Service, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Philippe Lysy
- Pôle PEDI, Institut de Recherche Expérimentale et Clinique, UCLouvain, 1200 Brussels, Belgium
- Specialized Pediatrics Service, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
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3
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The Advanced Diabetes Technologies for Reduction of the Frequency of Hypoglycemia and Minimizing the Occurrence of Severe Hypoglycemia in Children and Adolescents with Type 1 Diabetes. J Clin Med 2023; 12:jcm12030781. [PMID: 36769430 PMCID: PMC9917934 DOI: 10.3390/jcm12030781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 01/09/2023] [Accepted: 01/17/2023] [Indexed: 01/20/2023] Open
Abstract
Hypoglycemia is an often-observed acute complication in the management of children and adolescents with type 1 diabetes. It causes inappropriate glycemic outcomes and may impair the quality of life in the patients. Severe hypoglycemia with cognitive impairment, such as a convulsion and coma, is a lethal condition and is associated with later-onset cognitive impairment and brain-structural abnormalities, especially in young children. Therefore, reducing the frequency of hypoglycemia and minimizing the occurrence of severe hypoglycemia are critical issues in the management of children and adolescents with type 1 diabetes. Advanced diabetes technologies, including continuous glucose monitoring and sensor-augmented insulin pumps with low-glucose suspension systems, can reduce the frequency of hypoglycemia and the occurrence of severe hypoglycemia without aggravating glycemic control. The hybrid closed-loop system, an automated insulin delivery system, must be the most promising means to achieve appropriate glycemic control with preventing severe hypoglycemia. The use of these advanced diabetes technologies could improve glycemic outcomes and the quality of life in children and adolescents with type 1 diabetes.
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4
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ElSayed NA, Aleppo G, Aroda VR, Bannuru RR, Brown FM, Bruemmer D, Collins BS, Hilliard ME, Isaacs D, Johnson EL, Kahan S, Khunti K, Leon J, Lyons SK, Perry ML, Prahalad P, Pratley RE, Seley JJ, Stanton RC, Gabbay RA, on behalf of the American Diabetes Association. 14. Children and Adolescents: Standards of Care in Diabetes-2023. Diabetes Care 2023; 46:S230-S253. [PMID: 36507640 PMCID: PMC9810473 DOI: 10.2337/dc23-s014] [Citation(s) in RCA: 80] [Impact Index Per Article: 80.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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5
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Demirbilek H, Vuralli D, Haris B, Hussain K. Managing Severe Hypoglycaemia in Patients with Diabetes: Current Challenges and Emerging Therapies. Diabetes Metab Syndr Obes 2023; 16:259-273. [PMID: 36760580 PMCID: PMC9888015 DOI: 10.2147/dmso.s313837] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 01/14/2023] [Indexed: 01/28/2023] Open
Abstract
Hypoglycaemia is common in patients with diabetes mellitus and is a limiting factor for achieving adequate glycaemic control. In the vast majority of cases, hypoglycaemia develops due to the imbalance between food intake and insulin injections. As recurrent hypoglycaemia leads to significant morbidity and mortality, the recognition and immediate treatment of hypoglycaemia in diabetic patients is thus important. In the last 20 years, the introduction of improved insulin analogues, insulin pump therapy, continuous glucose monitoring (CGM), and sensor-augmented pump therapy have all made significant improvements in helping to reduce and prevent hypoglycaemia. In terms of treatment, the American Diabetes Association recommends oral glucose as the first-line treatment option for all conscious patients with hypoglycaemia. The second line of treatment (or first line in unconscious patients) is the use of glucagon. Novel formulations of glucagon include the nasal form, the Gvoke HypoPen which is a ready-to-deliver auto-injector packaged formulation and finally a glucagon analogue, Dasiglucagon. The Dasiglucagon formulation has recently been approved for the treatment of severe hypoglycaemia. It is a ready-to-use, similar to endogenous glucagon and its potency is also the same as native glucagon. It does not require reconstitution before injection and therefore ensures better compliance. Thus, significant improvements including development of newer insulin analogues, insulin pump therapy, continuous glucose monitoring (CGM), sensor-augmented pump therapy and novel formulations of glucagon have all contributed to reducing and preventing hypoglycaemia in diabetic individuals. However, considerable challenges remain as not all patients have access to diabetes technologies and to the newer glucagon formulations to help reduce and prevent hypoglycaemia.
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Affiliation(s)
- Huseyin Demirbilek
- Department of Pediatric Endocrinology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Dogus Vuralli
- Department of Pediatric Endocrinology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Basma Haris
- Department of Pediatric Endocrinology, Sidra Medicine, Doha, Qatar
| | - Khalid Hussain
- Department of Pediatric Endocrinology, Sidra Medicine, Doha, Qatar
- Correspondence: Khalid Hussain, Sidra Medicine, OPC, C6-340, PO Box 26999, Al Luqta Street, Education City North Campus, Doha, Qatar, Tel +974-4003-7608, Email
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Abraham MB, Karges B, Dovc K, Naranjo D, Arbelaez AM, Mbogo J, Javelikar G, Jones TW, Mahmud FH. ISPAD Clinical Practice Consensus Guidelines 2022: Assessment and management of hypoglycemia in children and adolescents with diabetes. Pediatr Diabetes 2022; 23:1322-1340. [PMID: 36537534 PMCID: PMC10107518 DOI: 10.1111/pedi.13443] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 10/27/2022] [Indexed: 12/24/2022] Open
Affiliation(s)
- Mary B Abraham
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia.,Children's Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, Australia.,Discipline of Pediatrics, Medical School, The University of Western Australia, Perth, Australia
| | - Beate Karges
- Division of Endocrinology and Diabetes, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Klemen Dovc
- Department of Pediatric Endocrinology, Diabetes and Metabolic Diseases, UMC - University Children's Hospital, Ljubljana, Slovenia, and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Diana Naranjo
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Ana Maria Arbelaez
- Division of Endocrinology and Diabetes, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Joyce Mbogo
- Department of Pediatric and Child Health, Aga Khan University Hospital, Nairobi, Kenya
| | - Ganesh Javelikar
- Department of Endocrinology and Diabetes, Max Super Speciality Hospital, New Delhi, India
| | - Timothy W Jones
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia.,Children's Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, Australia.,Discipline of Pediatrics, Medical School, The University of Western Australia, Perth, Australia
| | - Farid H Mahmud
- Division of Endocrinology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Canada
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Keyu G, Jiaqi L, Liyin Z, Jianan Y, Li F, Zhiyi D, Qin Z, Xia L, Lin Y, Zhiguang Z. Comparing the effectiveness of continuous subcutaneous insulin infusion with multiple daily insulin injection for patients with type 1 diabetes mellitus evaluated by retrospective continuous glucose monitoring: A real-world data analysis. Front Public Health 2022; 10:990281. [PMID: 36091534 PMCID: PMC9454013 DOI: 10.3389/fpubh.2022.990281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 08/11/2022] [Indexed: 01/26/2023] Open
Abstract
Objective Regarding the effects and practical application of insulin pumps on patients with type 1 diabetes mellitus (T1DM), the real-world evidence is limited especially concerning the incidence of hypoglycemia. This study aimed to compare the efficacy of continuous subcutaneous insulin infusion (CSII) therapy with multiple daily injection (MDI) therapy on glycemic metrics evaluated by retrospective continuous glucose monitoring (CGM) in Chinese patients with T1DM. Methods In total, 362 T1DM Chinese patients from the outpatient department of the Second Xiangya Hospital, Central South University, who underwent intensive insulin therapy and used a retrospective CGM system were included in this retrospective cross-sectional study. Comprehensive analysis of clinical and biological features and retrospective CGM derived-metrics was performed on the 362 enrolled T1DM patients who underwent CSII (n = 61) or MDI (n = 301) therapy (defined as 4 or more insulin injections per day). Results Our findings demonstrated that patients who underwent CSII therapy, compared with those who received MDI therapy, had lower levels of hemoglobin A1c (HbA1c) and fasting blood glucose; moreover, CSII therapy was associated with better glycemic outcomes in terms of increasing time in range (TIR), decreasing time above range (TAR), and achieving CGM-associated targets of TIR ≥70% and TAR <25%. However, patients who underwent CSII therapy did not experience decreasing time below range (TBR), achieving CGM-associated targets of TBR <4%, and reduction of the risk of hypoglycemia as evidenced by comparing TBR and low blood glucose index (LBGI) between the two treatment regimens. The parameters of glycemic variability, such as standard deviation of glucose (SD), mean amplitude glycemic excursion (MAGE), and large amplitude glycemic excursion (LAGE) in T1DM patients who underwent CSII therapy outperformed. Conclusion Our results provided further evidence that CSII therapy is safe and effective for management of Chinese T1DM patients, which was confirmed by a lower HbA1c level and better CGM-derived metrics but no demonstration of improvment in the risk of hypoglycemia. To achieve more satisfactory glycemic outcomes through the utilization of CSII therapy for Chinese T1DM patients, a strong physician-patient relationship is essential.
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Affiliation(s)
- Guo Keyu
- National Clinical Research Center for Metabolic Diseases, Key Laboratory of Diabetes Immunology, Ministry of Education, and Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Li Jiaqi
- National Clinical Research Center for Metabolic Diseases, Key Laboratory of Diabetes Immunology, Ministry of Education, and Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Zhang Liyin
- National Clinical Research Center for Metabolic Diseases, Key Laboratory of Diabetes Immunology, Ministry of Education, and Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Ye Jianan
- National Clinical Research Center for Metabolic Diseases, Key Laboratory of Diabetes Immunology, Ministry of Education, and Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Fan Li
- National Clinical Research Center for Metabolic Diseases, Key Laboratory of Diabetes Immunology, Ministry of Education, and Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Ding Zhiyi
- National Clinical Research Center for Metabolic Diseases, Key Laboratory of Diabetes Immunology, Ministry of Education, and Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Zhou Qin
- National Clinical Research Center for Metabolic Diseases, Key Laboratory of Diabetes Immunology, Ministry of Education, and Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Li Xia
- National Clinical Research Center for Metabolic Diseases, Key Laboratory of Diabetes Immunology, Ministry of Education, and Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Yang Lin
- National Clinical Research Center for Metabolic Diseases, Key Laboratory of Diabetes Immunology, Ministry of Education, and Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Zhou Zhiguang
- National Clinical Research Center for Metabolic Diseases, Key Laboratory of Diabetes Immunology, Ministry of Education, and Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, China
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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9
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Coolen M, Aalders J, Broadley M, Aanstoot HJ, Hartman E, Hendrieckx C, Nefs G, Pouwer F. Hypoglycaemia and diabetes-specific quality of life in adolescents with type 1 diabetes. Diabet Med 2021; 38:e14565. [PMID: 33774871 DOI: 10.1111/dme.14565] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/15/2021] [Accepted: 03/24/2021] [Indexed: 12/14/2022]
Abstract
AIMS To examine whether frequency, perceived severity and fear of hypoglycaemia are independently associated with diabetes-specific quality of life in adolescents with type 1 diabetes. METHODS Cross-sectional self-reported data on demographics, frequency and perceived severity of both self-treated and severe hypoglycaemia, fear of hypoglycaemia (Hypoglycaemia Fear Survey-Child version) and diabetes-specific quality of life (Pediatric Quality of Life Diabetes Module; PedsQL-DM) were obtained from the project 'Whose diabetes is it anyway?'. Hierarchical regression analyses were performed for the total scale and recommended summary scores of the PedsQL-DM as dependent variables; independent variables were entered in the following steps: (1) age, gender and HbA1c , (2) frequency of hypoglycaemia, (3) perceived severity of hypoglycaemia and (4) fear of hypoglycaemia. RESULTS Adolescents (12-18 years; n = 96) completed questionnaires. In the first three steps, female gender (p < 0.05), higher HbA1c (p < 0.05), higher frequency of severe hypoglycaemia (p < 0.05) and higher perceived severity of severe (p < 0.05) and self-treated hypoglycaemia (p < 0.001) were significantly associated with lower diabetes-specific quality of life (β ranging from 0.20 to 0.35). However, in the final model only fear of hypoglycaemia was significantly associated with QoL (p < 0.001). Adolescents with greater fear reported lower diabetes-specific quality of life, with 52% explained variance. This pattern was observed across subdomains of diabetes-specific quality of life. CONCLUSIONS Fear of hypoglycaemia was the only factor independently associated with diabetes-specific quality of life, whereas frequency and perceived severity of hypoglycaemia were not. These findings highlight the importance of awareness and assessment of fear of hypoglycaemia in clinical practice.
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Affiliation(s)
- Manon Coolen
- Department of Psychology, University of Southern Denmark, Odense, Denmark
| | - Jori Aalders
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- Center of Research on Psychological and Somatic disorders (CoRPS), Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands
- Steno Diabetes Center Odense, Odense, Denmark
| | - Melanie Broadley
- Department of Psychology, University of Southern Denmark, Odense, Denmark
| | - Henk-Jan Aanstoot
- Diabeter, Center for Pediatric and Adolescent Diabetes Care and Research, Rotterdam, The Netherlands
| | - Esther Hartman
- Center of Research on Psychological and Somatic disorders (CoRPS), Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands
| | - Christel Hendrieckx
- School of Psychology, Deakin University, Geelong, Vic., Australia
- The Australian Centre for Behavioural Research in Diabetes (ACBRD, Melbourne, Vic., Australia
| | - Giesje Nefs
- Center of Research on Psychological and Somatic disorders (CoRPS), Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands
- Diabeter, Center for Pediatric and Adolescent Diabetes Care and Research, Rotterdam, The Netherlands
- Radboud University Medical Centre, Radboud Institute for Health Sciences, Department of Medical Psychology, Nijmegen, The Netherlands
| | - Frans Pouwer
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- Steno Diabetes Center Odense, Odense, Denmark
- School of Psychology, Deakin University, Geelong, Vic., Australia
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10
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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11
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Svensson J, Sildorf SM, Bøjstrup J, Kreiner S, Skrivarhaug T, Hanberger L, Petersson C, Åkesson K, Frøisland DH, Chaplin J. The DISABKIDS generic and diabetes-specific modules are valid but not directly comparable between Denmark, Sweden, and Norway. Pediatr Diabetes 2020; 21:900-908. [PMID: 32333631 DOI: 10.1111/pedi.13036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 03/31/2020] [Accepted: 04/06/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND/OBJECTIVES Government guidance promote benchmarking comparing quality of care including both clinical values and patient reported outcome measures in young persons with type 1 diabetes. The aim was to test if the Nordic DISABKIDS health-related quality of life (HrQoL) modules were construct valid and measurement comparable within the three Nordic countries. METHODS Data from three DISABKIDS validation studies in Sweden, Denmark, and Norway were compared using Rasch and the graphical log-linear Rasch modeling. Monte Carlo methods were used to estimate reliability coefficient and target was defined as the point with the lowest SE of the mean. Self-report data were available from 99 Danish (8-18 years), 103 Norwegian (7-19 years), and 131 Swedish (8-18 years) young people. RESULTS For the DISABKIDS higher scores on most subscales were noted in the Norwegian population. The Swedish sample had a significantly higher score on the "Diabetes treatment" subscale and scores closer to optimal target than the other countries. For each country, construct validity and sensitivity were acceptable when accounting for differential item function (DIF) and local dependency (LD). Less LD and DIF were found if only Denmark and Norway were included. The combined model was reliable; however, some differences were noted in the scale translations relating to the stem and response alternatives, which could explain the discrepancies. CONCLUSION The Nordic versions of the DISABKIDS questionnaires measures valid and reliable HrQoL both within and between countries when adjusted for DIF and LD. Adjusting the Likert scales to the same respond categories may improve comparability.
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Affiliation(s)
- Jannet Svensson
- Pediatric Department, Herlev University Hospital, Herlev, Denmark
| | | | - Julie Bøjstrup
- Pediatric Department, Herlev University Hospital, Herlev, Denmark
| | - Svend Kreiner
- Section of Biostatistics, Department of Public Health, Faculty of Health and Medical Sciences , University of Copenhagen, Copenhagen, Denmark
| | - Torild Skrivarhaug
- Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, The Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Lena Hanberger
- Division of Nursing Science, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Christina Petersson
- Department of Nursing Sciences, School of Health and Welfare, Jönköping University, Jönköping, Sweden
| | - Karin Åkesson
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Department of Pediatrics, Ryhov County Hospital, Jønkøping, Sweden
| | | | - John Chaplin
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
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12
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Pilgaard KA, Breinegaard N, Johannesen J, Pörksen S, Fredheim S, Madsen M, Kristensen K, Svensson J, Birkebaek NH. Episodes of severe hypoglycemia is associated with a progressive increase in hemoglobin A1c in children and adolescents with type 1 diabetes. Pediatr Diabetes 2020; 21:808-813. [PMID: 32304129 DOI: 10.1111/pedi.13020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 03/01/2020] [Accepted: 04/02/2020] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To investigate the trajectory in glycemic control following episodes of severe hypoglycemia (SH) among children and adolescents with type 1 diabetes (T1D). METHODS A Danish national population-based study comprising data from 2008-17. SH was defined according to the 2014 ISPAD guidelines. A mixed model was applied with HbA1c as outcome and SH episodes and time since first episode as explanatory variables. Data were adjusted for age, gender and diabetes duration. RESULTS A total of 4244 children (51.6% boys) with 18 793 annual outpatient visits were included. Mean (SD) age at diabetes onset was 9.0 (4.1) years. Median diabetes duration at inclusion in the study was 1.2 (Q1 = 0.9, Q3 = 3.0) years, and median diabetes duration at last visit was 5.0 (Q1 = 2.7, Q3 = 8.1) years. A total of 506 children experienced at least one episode of SH during the nine-year follow-up; 294 children experienced one episode, 115 two episodes and 97 three or more episodes of SH. HbA1c increased with episodes of SH and in the years following the first episode. The glycemic trajectory peaked 2 to 3 years after an SH episode. The accumulated deterioration in glycemic control was in the range of 5% in patients with two or more episodes equivalent to an increase in HbA1c of 4 mmol/mol (HbA1c ~0.4%). CONCLUSION SH was followed by a progressive and lasting increase in HbA1c among Danish children and adolescents with T1D. Thus, in addition to the known risk of new episodes of hypoglycemia and cognitive impairment, SH contributes to long-term diabetes complications.
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Affiliation(s)
- Kasper A Pilgaard
- Department of Paediatrics, Nordsjaellands Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Nina Breinegaard
- Department of Biostatistics, University of Copenhagen, Kobenhavn, Denmark
| | - Jesper Johannesen
- Department of Paediatrics, Herlev University Hospital, Herlev, Denmark
| | - Sven Pörksen
- Department of Paediatrics, Roskilde University Hospital, Roskilde, Denmark.,Steno Diabetes Center Region of Zealand, Roskilde, Denmark
| | - Siri Fredheim
- Steno Diabetes Center Region of Zealand, Roskilde, Denmark.,Department of Paediatrics, Sjaellands University Hospital, Roskilde, Denmark
| | - Mette Madsen
- Department of Paediatrics, Aalborg University Hospital, Aalborg, Denmark
| | - Kurt Kristensen
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark
| | - Jannet Svensson
- Department of Paediatrics, Herlev University Hospital, Herlev, Denmark
| | - Niels H Birkebaek
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark.,Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark
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13
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Kochar I, Sethi A, Ramachandran S. Real-World Efficacy and Safety of Continuous Subcutaneous Insulin Infusion (CSII) Therapy and Comparison of Treatment Satisfaction between CSII and Multiple Daily Injection Therapy. DUBAI DIABETES AND ENDOCRINOLOGY JOURNAL 2020. [DOI: 10.1159/000507391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
<b><i>Objectives:</i></b> Type 1 diabetes mellitus (T1DM) is one of the most common pediatric endocrine diseases. India alone is home to around 97,700 children with T1DM. This paper evaluates the efficacy, safety, and quality of life with continuous subcutaneous insulin infusion (CSII) in patients treated for a protracted time period of 1 year in a retrospective study versus multiple-dose insulin (MDI). <b><i>Methods:</i></b> CSII was offered to patients with poor metabolic control (HbA1c >8.5%) on MDI, patients needing flexible timing of meals, or patients with hypoglycemia unawareness/nocturnal hypoglycemia/high blood sugar fluctuations. Continuous blood glucose monitoring (CGM) was done using the Medtronic CGM system gold/iPro 2 in all patients. Data were collected through a questionnaire completed by patients with the help of a pediatric endocrinologist. <b><i>Results:</i></b> A total of 45 patients completed the study evaluation period. The results demonstrated better glycemic control, reduced hypoglycemia on CGM, and no events of diabetic ketoacidosis noted on CSII. The hypoglycemic events were few and nonsevere. The patients in the CSII group reported better quality of life on the Pediatric Quality of Life Inventory 3.2 Diabetic Module diabetes score than the MDI group. <b><i>Conclusions:</i></b> This study is the first of this kind in India in the field of pediatric endocrinology. The clinical outcomes validate the use of CSII as the desirable intensive insulin therapy.
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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15
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Urakami T. Severe Hypoglycemia: Is It Still a Threat for Children and Adolescents With Type 1 Diabetes? Front Endocrinol (Lausanne) 2020; 11:609. [PMID: 33042005 PMCID: PMC7523511 DOI: 10.3389/fendo.2020.00609] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 07/27/2020] [Indexed: 12/13/2022] Open
Abstract
Severe hypoglycemia is defined as a condition with serious cognitive dysfunction, such as a convulsion and coma, requiring external help from other persons. This condition is still lethal and is reported to be the cause of death in 4-10% in children and adolescents with type 1 diabetes. The incidence of severe hypoglycemia in the pediatric population was previously reported as high as more than 50-100 patient-years; however, there was a decline in the frequency of severe hypoglycemia during the past decades, and relationship with glycemic control became weaker than previously reported. A lot of studies have shown the neurological sequelae with severe hypoglycemia as cognitive dysfunction and abnormalities in brain structure. This serious condition also provides negative psychosocial outcomes and undesirable compensatory behaviors. Various possible factors, such as younger age, recurrent hypoglycemia, nocturnal hypoglycemia, and impaired awareness of hypoglycemia, are possible risk factors for developing severe hypoglycemia. A low HbA1c level is not a predictable value for severe hypoglycemia. Prevention of severe hypoglycemia remains one of the most critical issues in the management of pediatric patients with type 1 diabetes. Advanced technologies, such as continuous glucose monitoring (CGM), intermittently scanned CGM, and sensor-augmented pump therapy with low-glucose suspend system, potentially minimize the occurrence of severe hypoglycemia without worsening overall glycemic control. Hybrid closed-loop system must be the most promising tool for achieving optimal glycemic control with preventing the occurrence of severe hypoglycemia in pediatric patients with type 1 diabetes.
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16
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Haynes A, Hermann JM, Clapin H, Hofer SE, Karges B, Jones TW, Davis EA, Holl RW. Decreasing Trends in Mean HbA 1c Are Not Associated With Increasing Rates of Severe Hypoglycemia in Children: A Longitudinal Analysis of Two Contemporary Population-Based Pediatric Type 1 Diabetes Registries From Australia and Germany/Austria Between 1995 and 2016. Diabetes Care 2019; 42:1630-1636. [PMID: 31213467 DOI: 10.2337/dc18-2448] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 05/28/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To investigate temporal trends in glycemic control and severe hypoglycemia rates for pediatric patients with type 1 diabetes from 1995 to 2016 by analyzing data from the longitudinal, prospective, population-based German/Austrian (Diabetes Patient History Documentation [DPV]) and Western Australian (Western Australian Children's Diabetes Database [WACDD]) diabetes registries. RESEARCH DESIGN AND METHODS Patients diagnosed with type 1 diabetes aged <15 years were identified from the DPV (N = 59,883) and WACDD (N = 2,595) registries and data extracted for all clinic visits occurring between 1995 and 2016, inclusive. Mean HbA1c and severe hypoglycemia (self-reported loss of consciousness/convulsion) rates were calculated per 100 patient-years. RESULTS Between 1995 and 2016, the annual mean HbA1c decreased from 8.3 to 7.8% in the DPV cohort and from 9.2 to 8.3% in the WACDD cohort. Over the same period, the severe hypoglycemia rate decreased by an annual average of 2% (relative risk 0.983 [95% CI 0.981, 0.986]) in the DPV cohort and 6% (relative risk 0.935 [95% CI 0.934, 0.937]) in the WACDD cohort. Concomitant decreasing trends in both HbA1c and severe hypoglycemia rates were observed in boys and girls, all age-groups, and injection therapy/pump regimen groups. CONCLUSIONS Over the past two decades, there have been concurrent improvements in HbA1c and decreasing severe hypoglycemia rates in two contemporary, longitudinal, population-based pediatric cohorts of type 1 diabetes. Translation of these data into clinical practice and patient education may reduce fear of hypoglycemia and enable better glycemic control.
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Affiliation(s)
- Aveni Haynes
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | - Julia M Hermann
- Central Institution for Biomedical Engineering, Institute of Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany.,German Center for Diabetes Research, München-Neuherberg, Germany
| | - Helen Clapin
- Department of Diabetes and Endocrinology, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Sabine E Hofer
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | - Beate Karges
- Division of Endocrinology and Diabetes, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Timothy W Jones
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia.,Department of Diabetes and Endocrinology, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Elizabeth A Davis
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia.,Department of Diabetes and Endocrinology, Perth Children's Hospital, Perth, Western Australia, Australia
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17
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Henriksen MM, Andersen HU, Thorsteinsson B, Pedersen-Bjergaard U. Asymptomatic hypoglycaemia in Type 1 diabetes: incidence and risk factors. Diabet Med 2019; 36:62-69. [PMID: 30368899 DOI: 10.1111/dme.13848] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/25/2018] [Indexed: 01/24/2023]
Abstract
AIM The epidemiology of asymptomatic (silent) hypoglycaemia is not well-described. We investigated incidence and risk factors for asymptomatic hypoglycaemia in Type 1 diabetes. METHODS A cohort of 153 people with Type 1 diabetes participated in 6 days of blinded continuous glucose monitoring (CGM) and recording of hypoglycaemia symptoms. At entry, hypoglycaemia awareness was classified (by three different methods) and HbA1c and C-peptide were measured. Hypoglycaemic episodes were defined as interstitial glucose ≤ 3.9 mmol/l (IG3.9 ) or ≤ 3.0 mmol/l (IG3.0 ) for ≥ 15 min, and were considered asymptomatic if no hypoglycaemic symptoms were reported. RESULTS At thresholds IG3.9 and IG3.0 , the incidence rates of hypoglycaemic episodes were 5.0 (7.9) [median (IQR)] and 1.3 (3.4) episodes/person-week, respectively. Three-quarters of episodes were asymptomatic. In total, 77% and 52% of participants experienced one or more episode of asymptomatic hypoglycaemia at IG3.9 and IG3.0 [3.0 (6.2) and 1.0 (2.3) asymptomatic episodes/person-week]. At multivariate analysis, reduced awareness was positively associated with asymptomatic hypoglycaemia, particularly nocturnal events, and negatively with symptomatic hypoglycaemia. High insulin dose was associated with increased risk of both asymptomatic and symptomatic hypoglycaemia, whereas low HbA1c and long diabetes duration were risk factors only for symptomatic hypoglycaemia. CONCLUSIONS Asymptomatic hypoglycaemia constitutes the majority of hypoglycaemic events in Type 1 diabetes. Reduced hypoglycaemia awareness and high insulin dose are risk factors for asymptomatic hypoglycaemia but other conventional risk factors for severe hypoglycaemia do not correlate with risk of asymptomatic episodes.
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Affiliation(s)
- M M Henriksen
- Department of Endocrinology and Nephrology, Nordsjaellands Hospital, Hillerød
| | | | - B Thorsteinsson
- Department of Endocrinology and Nephrology, Nordsjaellands Hospital, Hillerød
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - U Pedersen-Bjergaard
- Department of Endocrinology and Nephrology, Nordsjaellands Hospital, Hillerød
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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18
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Fredheim S, Foli-Andersen P, Laerkholm G, Svensson J, Juhl CB, Olsen B, Pilgaard K, Johannesen J. Adrenaline and cortisol levels are lower during nighttime than daytime hypoglycaemia in children with type 1 diabetes. Acta Paediatr 2018. [PMID: 29520851 DOI: 10.1111/apa.14310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
AIM We investigated children's counter regulatory hormone profiles during a hyperinsulinaemic hypoglycaemic clamp procedure at day and night. METHODS In 2013, we assessed the counter regulatory response to hypoglycaemia in eight outpatients with type 1 diabetes, recruited from the Herlev Hospital, Denmark, at a mean age of 9.6 ± 2.3 years. Hyperinsulinaemic 80 mU/m2 /min clamps were performed with a stepwise reduction in plasma glucose from euglycaemia (7-9 mmol/L) to hypoglycaemia (<3.5 mmol/L) and the glucose nadir (≤2.2 mmol/L) during the day and night. Adrenaline, cortisol, glucagon and growth hormone levels were assessed. RESULTS Adrenaline and growth hormone levels were higher during the day versus the night (p = 0.04 and p = 0.01, respectively). However, at the glucose nadir, the level of adrenaline was lower during the night than the day (0.6 ± 0.2 versus 1.9 ± 0.5 nmol/L, p = 0.016) and cortisol was lower during the day than the night (42 ± 15 versus 319 ± 81 nmol/L, p = 0.016). No differences were demonstrated for glucagon and growth hormone levels based on the same criteria. CONCLUSION The adrenaline response was blunted during nocturnal iatrogenic hypoglycaemia in our study cohort, and no increase in cortisol levels was demonstrated.
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Affiliation(s)
- S Fredheim
- Department of Paediatrics; CPH-Direct; Copenhagen University Hospital, Herlev and Gentofte; Herlev Denmark
| | - P Foli-Andersen
- Department of Paediatrics; CPH-Direct; Copenhagen University Hospital, Herlev and Gentofte; Herlev Denmark
| | - G Laerkholm
- Department of Paediatrics; CPH-Direct; Copenhagen University Hospital, Herlev and Gentofte; Herlev Denmark
| | - J Svensson
- Department of Paediatrics; CPH-Direct; Copenhagen University Hospital, Herlev and Gentofte; Herlev Denmark
- Faculty of Health and Medical Sciences; University of Copenhagen; Copenhagen Denmark
| | - CB Juhl
- HypoSafe A/S; Lyngby Denmark
| | - B Olsen
- Department of Paediatrics; CPH-Direct; Copenhagen University Hospital, Herlev and Gentofte; Herlev Denmark
| | - K Pilgaard
- Department of Paediatrics; CPH-Direct; Copenhagen University Hospital, Herlev and Gentofte; Herlev Denmark
| | - J Johannesen
- Department of Paediatrics; CPH-Direct; Copenhagen University Hospital, Herlev and Gentofte; Herlev Denmark
- Faculty of Health and Medical Sciences; University of Copenhagen; Copenhagen Denmark
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19
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Abraham MB, Jones TW, Naranjo D, Karges B, Oduwole A, Tauschmann M, Maahs DM. ISPAD Clinical Practice Consensus Guidelines 2018: Assessment and management of hypoglycemia in children and adolescents with diabetes. Pediatr Diabetes 2018; 19 Suppl 27:178-192. [PMID: 29869358 DOI: 10.1111/pedi.12698] [Citation(s) in RCA: 141] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 05/28/2018] [Indexed: 12/23/2022] Open
Affiliation(s)
- Mary B Abraham
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia.,Children's Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, Australia.,Division of Paediatrics, Medical School, The University of Western Australia, Perth, Australia
| | - Timothy W Jones
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia.,Children's Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, Australia.,Division of Paediatrics, Medical School, The University of Western Australia, Perth, Australia
| | - Diana Naranjo
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Beate Karges
- Division of Endocrinology and Diabetes, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | | | - Martin Tauschmann
- Wellcome Trust-MRC Institute of Metabolic Science, Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - David M Maahs
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
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20
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Bratina N, Forsander G, Annan F, Wysocki T, Pierce J, Calliari LE, Pacaud D, Adolfsson P, Dovč K, Middlehurst A, Goss P, Goss J, Janson S, Acerini CL. ISPAD Clinical Practice Consensus Guidelines 2018: Management and support of children and adolescents with type 1 diabetes in school. Pediatr Diabetes 2018; 19 Suppl 27:287-301. [PMID: 30084519 DOI: 10.1111/pedi.12743] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 07/27/2018] [Indexed: 12/13/2022] Open
Affiliation(s)
- Natasa Bratina
- Department of Endocrinology, Diabetes & Metabolism, University Children's Hospital, Ljubljana, Slovenia
| | - Gun Forsander
- The Queen Silvia Children's Hospital and Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Tim Wysocki
- Center for Healthcare Delivery Science, Nemours Children Health System, Orlando, Florida
| | - Jessica Pierce
- Center for Healthcare Delivery Science, Nemours Children Health System, Orlando, Florida
| | - Luis E Calliari
- Department of Pediatrics, Santa Casa de Sao Paulo School of Medical Sciences, Brazil
| | - Danièle Pacaud
- Division of Diabetes and Endocrinology, Alberta Children's Hospital, Department of Paediatrics, University of Calgary, Calgary, Canada
| | - Peter Adolfsson
- Department of Pediatrics, The Hospital of Halland, Kungsbacka and Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Klemen Dovč
- Department of Endocrinology, Diabetes & Metabolism, University Children's Hospital, Ljubljana, Slovenia
| | - Angie Middlehurst
- International Diabetes Federation Life for a Child Program, Sydney, Australia
| | - Peter Goss
- Team Diabetes, Geelong, Victoria, Australia
| | | | - Staffan Janson
- Department of Women´s and Children´s Health, Uppsala University, Uppsala, Sweden
| | - Carlo L Acerini
- Department of Paediatrics, University of Cambridge, Cambridge, UK
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21
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Berg AK, Olsen BS, Thyssen JP, Zachariae C, Simonsen AB, Pilgaard K, Svensson J. High frequencies of dermatological complications in children using insulin pumps or sensors. Pediatr Diabetes 2018; 19:733-740. [PMID: 29484783 DOI: 10.1111/pedi.12652] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 01/08/2018] [Accepted: 01/22/2018] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Dermatological complications in children and adolescents that are related to continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring (CGM) have not been well-characterized. This study examined the prevalence and characteristics of different types of dermatological complications. METHODS Online questionnaires regarding dermatological complications related to CSII and/or CGM were returned from a total of 144 children and adolescents, aged 2 to 20 years. Both previous and current skin problems were reported along with their clinical characteristics. Descriptive statistics, χ2 tests, and multivariate analyses were used to evaluate the data. RESULTS Of 143 patients using CSII, 90% had previous and 63% reported current dermatological complications. Non-specific eczema was most frequently reported and was currently present in 25.7% of the patients. These results were independent of age and current CGM use. Among the 76 patients using CGM, 46% reported current dermatological complications. A history of atopy was associated with dermatological complications in individuals using CSII, but not CGM. The patients rated CGM-related dermal issues as significantly worse than those associated with CSII (P < .05). CONCLUSIONS Dermatological complications can be a serious problem in treating pediatric and adolescent patients of all ages with CSII and/or CGM. Only a few clinical characteristics associated with these complications were identified in this study, highlighting the need for prospective studies that might lead to improvements in the prevention and treatment of dermatological problems.
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Affiliation(s)
- Anna Korsgaard Berg
- Department of Pediatrics, Copenhagen Diabetes Research Center (CPH-DIRECT), Copenhagen University Hospital, Copenhagen, Denmark.,Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark
| | - Birthe Susanne Olsen
- Department of Pediatrics, Copenhagen Diabetes Research Center (CPH-DIRECT), Copenhagen University Hospital, Copenhagen, Denmark
| | - Jacob P Thyssen
- Department of Dermatology and Allergy, Copenhagen University Hospital, Copenhagen, Denmark
| | - Claus Zachariae
- Department of Dermatology and Allergy, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anne Birgitte Simonsen
- Department of Dermatology and Allergy, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kasper Pilgaard
- Pediatric and Adolescent Department, Nordsjaellands Hospital, Hillerød, Denmark
| | - Jannet Svensson
- Department of Pediatrics, Copenhagen Diabetes Research Center (CPH-DIRECT), Copenhagen University Hospital, Copenhagen, Denmark.,Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark
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22
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Agesen RM, Kristensen PL, Beck-Nielsen H, Nørgaard K, Perrild H, Jensen T, Parving HH, Thorsteinsson B, Tarnow L, Pedersen-Bjergaard U. Effect of Insulin Analogs on Frequency of Non-Severe Hypoglycemia in Patients with Type 1 Diabetes Prone to Severe Hypoglycemia: Much Higher Rates Detected by Continuous Glucose Monitoring than by Self-Monitoring of Blood Glucose-The HypoAna Trial. Diabetes Technol Ther 2018; 20:247-256. [PMID: 29565719 DOI: 10.1089/dia.2017.0372] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Hypoglycemia is an increasingly important endpoint in clinical diabetes trials. The assessment of hypoglycemia should therefore be as complete as possible. Blinded continuous glucose monitoring (CGM) provides an improved opportunity to capture asymptomatic and nocturnal events. Here we report results from the HypoAna trial comparing all-analog-insulin therapy (aspart/detemir) with all-human-insulin therapy (neutral protamine Hagedorn/regular) on non-severe hypoglycemia (symptomatic and asymptomatic hypoglycemia) as assessed by blinded CGM and compared with data obtained by self-monitoring of blood glucose (SMBG) in patients with type 1 diabetes and recurrent severe hypoglycemia. METHODS Fifty-three patients completed a substudy of 4 × 3 days of blinded CGM. CGM traces were reviewed for hypoglycemic events lasting 15 min or longer. RESULTS At the threshold ≤3.9 mmol/L, the per-protocol analysis demonstrated a 40% rate reduction (95% confidence interval [CI] 20%-60%; P = 0.002) in nocturnal non-severe hypoglycemia during analog treatment, mainly due to a 40% rate reduction (95% CI 0%-70%; P = 0.03) of nocturnal asymptomatic hypoglycemia. Similar nonsignificant trends were seen at the glucose threshold ≤3.0 mmol/L. Overall CGM-detected that nocturnal asymptomatic hypoglycemia ≤3.9 mmol/L was ∼17 times more frequent than SMBG-detected episodes (52 vs. 3 events/patient-year). This translates into a time needed to treat one patient with insulin analogs to prevent one episode that is 34 times shorter using CGM data than SMBG data (1.4 vs. 47 weeks). CONCLUSIONS Capturing hypoglycemic events by the conventional method of SMBG in patients with impaired awareness reveals only a limited number of events. Blinded CGM can provide more complete data, particularly in terms of asymptomatic and nocturnal events.
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Affiliation(s)
- Rikke Mette Agesen
- 1 Department of Cardiology, Nephrology and Endocrinology, Nordsjællands Hospital-Hillerød , Hillerød, Denmark
- 2 Faculty of Health and Medical Sciences, University of Copenhagen , Copenhagen, Denmark
| | - Peter Lommer Kristensen
- 1 Department of Cardiology, Nephrology and Endocrinology, Nordsjællands Hospital-Hillerød , Hillerød, Denmark
- 3 Clinical Research Unit, Steno Diabetes Center , Gentofte, Denmark
| | - Henning Beck-Nielsen
- 4 Department of Endocrinology M, Odense University Hospital , Odense, Denmark
- 5 Faculty of Health Sciences, University of Southern Denmark , Odense, Denmark
| | - Kirsten Nørgaard
- 6 Department of Endocrinology, Hvidovre Hospital , Hvidovre, Denmark
| | - Hans Perrild
- 7 Department of Internal Medicine, Bispebjerg Hospital , Copenhagen, Denmark
| | - Tonny Jensen
- 8 Department of Medical Endocrinology, Copenhagen University Hospital (Rigshospitalet) , Copenhagen, Denmark
| | - Hans-Henrik Parving
- 8 Department of Medical Endocrinology, Copenhagen University Hospital (Rigshospitalet) , Copenhagen, Denmark
- 9 Health, University of Aarhus , Aarhus, Denmark
| | - Birger Thorsteinsson
- 1 Department of Cardiology, Nephrology and Endocrinology, Nordsjællands Hospital-Hillerød , Hillerød, Denmark
- 2 Faculty of Health and Medical Sciences, University of Copenhagen , Copenhagen, Denmark
| | - Lise Tarnow
- 3 Clinical Research Unit, Steno Diabetes Center , Gentofte, Denmark
- 9 Health, University of Aarhus , Aarhus, Denmark
- 10 Department of Clinical Research, Nordsjællands Hospital-Hillerød , Hillerød, Denmark
| | - Ulrik Pedersen-Bjergaard
- 1 Department of Cardiology, Nephrology and Endocrinology, Nordsjællands Hospital-Hillerød , Hillerød, Denmark
- 2 Faculty of Health and Medical Sciences, University of Copenhagen , Copenhagen, Denmark
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23
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Thorsen SU, Pipper CB, Mortensen HB, Skogstrand K, Pociot F, Johannesen J, Svensson J. Levels of soluble TREM-1 in children with newly diagnosed type 1 diabetes and their siblings without type 1 diabetes: a Danish case-control study. Pediatr Diabetes 2017; 18:749-754. [PMID: 27862781 DOI: 10.1111/pedi.12464] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 09/22/2016] [Accepted: 09/23/2016] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Type 1 diabetes (T1D) is an organ-specific autoimmune disease with an increase in incidence worldwide including Denmark. The triggering receptor expressed on myeloid cells-1 (TREM-1) is a potent amplifier of pro-inflammatory responses and has been linked to autoimmunity, severe psychiatric disorders, sepsis, and cancer. HYPOTHESIS Our primary hypothesis was that levels of soluble TREM-1 (sTREM-1) differed between newly diagnosed children with T1D and their siblings without T1D. METHODS Since 1996, the Danish Childhood Diabetes Register has collected data on all patients who have developed T1D before the age of 18 years. Four hundred and eighty-one patients and 478 siblings with measurements of sTREM-1-blood samples were taken within 3 months after onset-were available for statistical analyses. Sample period was from 1997 through 2005. A robust log-normal regression model was used, which takes into account that measurements are left censored and accounts for correlation within siblings from the same family. RESULTS In the multiple regression model (case status, gender, age, HLA-risk, season, and period of sampling), levels of sTREM-1 were found to be significantly higher in patients (relative change [95%CI], 1.5 [1.1; 2.2],P = 0.02), but after adjustment for multiple testing our result was no longer statistically significant (P adjust = 0.1). We observed a statistical significant temporal increase in levels of sTREM-1. CONCLUSION Our results need to be replicated by independent studies, but our study suggests that the TREM-1 pathway may have a role in T1D pathogenesis.
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Affiliation(s)
- Steffen U Thorsen
- Copenhagen Diabetes Research Center (CPH-DIRECT), Department of Paediatrics, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Christian B Pipper
- Department of Public Health, Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Henrik B Mortensen
- Copenhagen Diabetes Research Center (CPH-DIRECT), Department of Paediatrics, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kristin Skogstrand
- Department of Congenital Disorders, Center for Neonatal Screening, Statens Serum Institute, Copenhagen, Denmark
| | - Flemming Pociot
- Copenhagen Diabetes Research Center (CPH-DIRECT), Department of Paediatrics, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jesper Johannesen
- Copenhagen Diabetes Research Center (CPH-DIRECT), Department of Paediatrics, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jannet Svensson
- Copenhagen Diabetes Research Center (CPH-DIRECT), Department of Paediatrics, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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24
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Haynes A, Hermann JM, Miller KM, Hofer SE, Jones TW, Beck RW, Maahs DM, Davis EA, Holl RW. Severe hypoglycemia rates are not associated with HbA1c: a cross-sectional analysis of 3 contemporary pediatric diabetes registry databases. Pediatr Diabetes 2017; 18:643-650. [PMID: 27878914 PMCID: PMC7162500 DOI: 10.1111/pedi.12477] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 09/07/2016] [Accepted: 10/15/2016] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To examine the association between glycated hemoglobin (HbA1c) and severe hypoglycemia rates in patients with type 1 diabetes receiving usual care, by analysing data from the US Type 1 Diabetes Exchange (T1DX), German/Austrian Diabetes Patienten Verlaufsdokumenation (DPV), and Western Australian Children Diabetes Database (WACDD) diabetes registries. METHODS Data for patients with type 1 diabetes, aged <18 years with a minimum duration of diabetes of 2 years, were extracted from each registry for a 12-month observation period between 2011 and 2012 (7,102 T1DX, 18,887 DPV, and 865 WACDD). Rates of severe hypoglycemia (self-reported loss of consciousness/convulsion) were estimated per 100 patient-years and analyzed by HbA1c, source registry, treatment regimen, and age group. RESULTS Overall, the severe hypoglycemia rate per 100 patient years was 7.1, 3.3, and 6.7 in T1DX, DPV, and WACDD patients, respectively. Lower HbA1c was not associated with an increased rate of severe hypoglycemia when examined by source registry, treatment regimen, or age group. CONCLUSION An inverse relationship between mean HbA1c and risk of severe hypoglycemia was not observed in this study of 3, independent cohorts of children and adolescents with type 1 diabetes. Investigation in other large, longitudinal cohorts is recommended to further characterize the contemporary relationship between glycemic control and risk of severe hypoglycemia rates in pediatric patients with type 1 diabetes.
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Affiliation(s)
- Aveni Haynes
- Telethon Kids Institute, The University of Western Australia, Perth, Australia
| | - Julia M. Hermann
- University of Ulm, ZIBMT, Institute of Epidemiology and Medical Biometry, Ulm, Germany,German Center for Diabetes Research (DZD), München-Neuherberg, Germany
| | | | - Sabine E. Hofer
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | - Timothy W. Jones
- Telethon Kids Institute, The University of Western Australia, Perth, Australia,Department of Diabetes & Endocrinology, Princess Margaret Hospital, Perth, Australia
| | - Roy W. Beck
- Jaeb Center for Health Research, Tampa, Florida
| | - David M. Maahs
- Department of Pediatrics, Stanford University, Stanford, California
| | - Elizabeth A. Davis
- Telethon Kids Institute, The University of Western Australia, Perth, Australia,Department of Diabetes & Endocrinology, Princess Margaret Hospital, Perth, Australia
| | - Reinhard W. Holl
- University of Ulm, ZIBMT, Institute of Epidemiology and Medical Biometry, Ulm, Germany,German Center for Diabetes Research (DZD), München-Neuherberg, Germany
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25
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Karges B, Schwandt A, Heidtmann B, Kordonouri O, Binder E, Schierloh U, Boettcher C, Kapellen T, Rosenbauer J, Holl RW. Association of Insulin Pump Therapy vs Insulin Injection Therapy With Severe Hypoglycemia, Ketoacidosis, and Glycemic Control Among Children, Adolescents, and Young Adults With Type 1 Diabetes. JAMA 2017; 318:1358-1366. [PMID: 29049584 PMCID: PMC5818842 DOI: 10.1001/jama.2017.13994] [Citation(s) in RCA: 262] [Impact Index Per Article: 37.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
IMPORTANCE Insulin pump therapy may improve metabolic control in young patients with type 1 diabetes, but the association with short-term diabetes complications is unclear. OBJECTIVE To determine whether rates of severe hypoglycemia and diabetic ketoacidosis are lower with insulin pump therapy compared with insulin injection therapy in children, adolescents, and young adults with type 1 diabetes. DESIGN, SETTING, AND PARTICIPANTS Population-based cohort study conducted between January 2011 and December 2015 in 446 diabetes centers participating in the Diabetes Prospective Follow-up Initiative in Germany, Austria, and Luxembourg. Patients with type 1 diabetes younger than 20 years and diabetes duration of more than 1 year were identified. Propensity score matching and inverse probability of treatment weighting analyses with age, sex, diabetes duration, migration background (defined as place of birth outside of Germany or Austria), body mass index, and glycated hemoglobin as covariates were used to account for relevant confounders. EXPOSURES Type 1 diabetes treated with insulin pump therapy or with multiple (≥4) daily insulin injections. MAIN OUTCOMES AND MEASURES Primary outcomes were rates of severe hypoglycemia and diabetic ketoacidosis during the most recent treatment year. Secondary outcomes included glycated hemoglobin levels, insulin dose, and body mass index. RESULTS Of 30 579 patients (mean age, 14.1 years [SD, 4.0]; 53% male), 14 119 used pump therapy (median duration, 3.7 years) and 16 460 used insulin injections (median duration, 3.6 years). Patients using pump therapy (n = 9814) were matched with 9814 patients using injection therapy. Pump therapy, compared with injection therapy, was associated with lower rates of severe hypoglycemia (9.55 vs 13.97 per 100 patient-years; difference, -4.42 [95% CI, -6.15 to -2.69]; P < .001) and diabetic ketoacidosis (3.64 vs 4.26 per 100 patient-years; difference, -0.63 [95% CI, -1.24 to -0.02]; P = .04). Glycated hemoglobin levels were lower with pump therapy than with injection therapy (8.04% vs 8.22%; difference, -0.18 [95% CI, -0.22 to -0.13], P < .001). Total daily insulin doses were lower for pump therapy compared with injection therapy (0.84 U/kg vs 0.98 U/kg; difference, -0.14 [-0.15 to -0.13], P < .001). There was no significant difference in body mass index between both treatment regimens. Similar results were obtained after propensity score inverse probability of treatment weighting analyses in the entire cohort. CONCLUSIONS AND RELEVANCE Among young patients with type 1 diabetes, insulin pump therapy, compared with insulin injection therapy, was associated with lower risks of severe hypoglycemia and diabetic ketoacidosis and with better glycemic control during the most recent year of therapy. These findings provide evidence for improved clinical outcomes associated with insulin pump therapy compared with injection therapy in children, adolescents, and young adults with type 1 diabetes.
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Affiliation(s)
- Beate Karges
- Division of Endocrinology and Diabetes, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Anke Schwandt
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany
- German Center for Diabetes Research (DZD), Neuherberg
| | | | - Olga Kordonouri
- Diabetes Center for Children and Adolescents, Children's Hospital Auf Der Bult, Hannover, Germany
| | - Elisabeth Binder
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | - Ulrike Schierloh
- Department of Pediatrics, Centre Hospitalier de Luxembourg, Luxembourg City, Luxembourg
| | - Claudia Boettcher
- Division of Paediatric Endocrinology and Diabetology, Center of Child and Adolescent Medicine, Justus Liebig University Giessen, Giessen, Germany
| | - Thomas Kapellen
- Hospital for Children and Adolescents, University of Leipzig, Leipzig, Germany
| | - Joachim Rosenbauer
- German Center for Diabetes Research (DZD), Neuherberg
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center at the University of Düsseldorf, Düsseldorf, Germany
| | - Reinhard W Holl
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany
- German Center for Diabetes Research (DZD), Neuherberg
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26
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Jendle J, Smith-Palmer J, Delbaere A, de Portu S, Papo N, Valentine W, Roze S. Cost-Effectiveness Analysis of Sensor-Augmented Insulin Pump Therapy with Automated Insulin Suspension Versus Standard Insulin Pump Therapy in Patients with Type 1 Diabetes in Sweden. Diabetes Ther 2017; 8:1015-1030. [PMID: 28871565 PMCID: PMC5630551 DOI: 10.1007/s13300-017-0294-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION In Sweden an estimated 10,000 people with type 1 diabetes use continuous subcutaneous insulin infusion (CSII). Sensor-augmented pump therapy (SAP) is associated with higher acquisition costs but provides additional clinical benefits (e.g. reduced rate of hypoglycemic events) over and above that of CSII alone. The aim of the analysis was to assess the cost-effectiveness of SAP with automated insulin suspension relative to CSII alone in two different groups of patients with type 1 diabetes in Sweden. METHODS Cost-effectiveness analyses were performed using the QuintilesIMS CORE Diabetes Model, with clinical and economic input data derived from published literature. Separate analyses were performed for patients at increased risk of hypoglycemia and for patients with uncontrolled glycated hemoglobin (HbA1c) at baseline. Analyses were performed from a societal perspective over a lifetime time horizon. Future costs and clinical outcomes were discounted at 3% per annum. RESULTS SAP with automated insulin suspension was associated with an incremental gain in quality-adjusted life expectancy versus the CSII of 1.88 quality-adjusted life years (QALYs) in patients at high risk of hypoglycemia and of 1.07 QALYs in patients with uncontrolled HbA1c at baseline. Higher lifetime costs for SAP with automated insulin suspension resulted in projected incremental cost-effectiveness ratios for the SAP with automated insulin suspension versus CSII of Swedish Krona (SEK) 139,795 [euros (EUR) 14,648] per QALY gained for patients at increased risk for hypoglycemia and SEK 251,896 (EUR 26,395) per QALY gained for patients with uncontrolled HbA1c. In both groups, SAP with automated insulin suspension also reduced the incidence of diabetes-related complications relative to CSII. CONCLUSIONS In Sweden, SAP with automated insulin suspension likely represents a cost-effective treatment option relative to CSII for the management of patients with type 1 diabetes with a history of severe hypoglycemic events or patients who struggle to achieve good glycemic control despite the use of CSII. FUNDING Medtronic International Trading Sàrl.
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Affiliation(s)
| | | | - Alexis Delbaere
- Medtronic International Trading Sarl, Tolochenaz, Switzerland
| | - Simona de Portu
- Medtronic International Trading Sarl, Tolochenaz, Switzerland
| | - Natalie Papo
- Medtronic International Trading Sarl, Tolochenaz, Switzerland
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27
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Sandahl K, Nielsen LB, Svensson J, Johannesen J, Pociot F, Mortensen HB, Hougaard P, Broe R, Rasmussen ML, Grauslund J, Peto T, Olsen BS. Increased mortality in a Danish cohort of young people with Type 1 diabetes mellitus followed for 24 years. Diabet Med 2017; 34:380-386. [PMID: 27027777 DOI: 10.1111/dme.13124] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/29/2016] [Indexed: 11/28/2022]
Abstract
AIM To determine the mortality rate in a Danish cohort of children and adolescents diagnosed with Type 1 diabetes mellitus compared with the general population. METHODS In 1987 and 1989 we included 884 children and 1020 adolescents aged 20 years and under, corresponding to 75% of all Danish children and adolescents with Type 1 diabetes, in two nationwide studies in Denmark. Those who had participated in both investigations (n = 720) were followed until 1 January 2014, using the Danish Civil Registration System on death certificates and emigration. We derived the expected number of deaths in the cohort, using population data values from Statistics Denmark to calculate the standardized mortality ratio. Survival analysis was performed using Cox proportional hazards model. RESULTS During the 24 years of follow-up, 49 (6.8%) patients died, resulting in a standardized mortality ratio of 4.8 (95% confidence interval 3.5, 6.2) compared with the age-standardized general population. A 1% increase in baseline HbA1c (1989), available in 718 of 720 patients, was associated with all-cause mortality (hazard ratio = 1.38; 95% confidence interval 1.2, 1.6; P < 0.0001). Type 1 diabetes with multiple complications was the most common reported cause of death (36.7%). CONCLUSION We found an increased mortality rate in this cohort of children and adolescents with Type 1 diabetes compared with the general population. The only predictor for increased risk of death up to 24 years after inclusion was the HbA1c level in 1989. This emphasizes the importance of achieving optimal metabolic control in young people with Type 1 diabetes.
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Affiliation(s)
- K Sandahl
- Department of Paediatrics, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - L B Nielsen
- Department of Paediatrics, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - J Svensson
- Department of Paediatrics, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - J Johannesen
- Department of Paediatrics, Herlev Hospital, University of Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - F Pociot
- Department of Paediatrics, Herlev Hospital, University of Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - H B Mortensen
- Department of Paediatrics, Herlev Hospital, University of Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - P Hougaard
- Department of Epidemiology, Biostatistics and Biodemography, Odense University Hospital, Odense, Denmark
| | - R Broe
- Department of Ophthalmology, Odense University Hospital, Odense, Denmark
- The Clinical Research Institute, University of Southern Denmark, Odense, Denmark
- OPEN Odense Patient data Explorative Network, Odense University Hospital, Odense, Denmark
| | - M L Rasmussen
- Department of Ophthalmology, Odense University Hospital, Odense, Denmark
- The Clinical Research Institute, University of Southern Denmark, Odense, Denmark
- OPEN Odense Patient data Explorative Network, Odense University Hospital, Odense, Denmark
| | - J Grauslund
- Department of Ophthalmology, Odense University Hospital, Odense, Denmark
- The Clinical Research Institute, University of Southern Denmark, Odense, Denmark
- OPEN Odense Patient data Explorative Network, Odense University Hospital, Odense, Denmark
| | - T Peto
- Department of Ophthalmology, Odense University Hospital, Odense, Denmark
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - B S Olsen
- Department of Paediatrics, Herlev Hospital, University of Copenhagen, Herlev, Denmark
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28
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Karges B, Kapellen T, Wagner VM, Steigleder-Schweiger C, Karges W, Holl RW, Rosenbauer J. Glycated hemoglobin A1c as a risk factor for severe hypoglycemia in pediatric type 1 diabetes. Pediatr Diabetes 2017; 18:51-58. [PMID: 26712064 DOI: 10.1111/pedi.12348] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 11/12/2015] [Accepted: 11/23/2015] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To assess the risk of severe hypoglycemia related to glycated hemoglobin A1c (HbA1c) levels in a population-based cohort of pediatric type 1 diabetes patients during two time periods since 1995. METHODS The association between HbA1c levels and severe hypoglycemia (defined as requiring assistance from another person) or hypoglycemic coma (loss of consciousness or seizures) was analyzed by multivariable regression analysis in children and adolescents with type 1 diabetes from the DPV Diabetes Prospective Follow-up in Germany and Austria in 1995-2003 (n = 15 221 patients) and 2004-2012 (n = 22 318 patients). RESULTS Mean adjusted rates of severe hypoglycemia and hypoglycemic coma decreased from 19.18 [95% confidence interval (CI), 17.95-20.48] and 4.36 (3.93-4.83) per 100 patient-years in 1995-2003 to 15.01 (14.18-15.88) and 2.15 (1.94-2.39) in 2004-2012, respectively (p < 0.001). From the first to the second period, the relative risk (RR) for severe hypoglycemia and hypoglycemic coma per 1% lower HbA1c decreased from 1.22 (1.15-1.30) to 1.06 (1.01-1.12) and from 1.27 (1.15-1.40) to 1.04 (0.94-1.16), respectively. Risk of severe hypoglycemia and coma declined most in patients with HbA1c levels of 6-6.9% (RR 0.70 and 0.43, respectively) and with HbA1c of 7-7.9% (RR 0.63 and 0.38, respectively). Mean HbA1c levels fell from 8.4% in 1995-2003 to 8.2% in 2004-2012, while the use of insulin pumps, short- and long-acting insulin analogs, and glucose monitoring increased (p < 0.001). CONCLUSIONS In contrast to 1995-2003, low HbA1c has become a minor risk factor for severe hypoglycemia and coma in pediatric patients with type 1 diabetes in the 2004-2012 period.
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Affiliation(s)
- Beate Karges
- Division of Endocrinology and Diabetes, Medical Faculty, RWTH Aachen University, German Center for Diabetes Research (DZD), Aachen, Germany.,Department of Gynecological Endocrinology and Reproductive Medicine, Medical Faculty, RWTH Aachen University, German Center for Diabetes Research (DZD), Aachen, Germany.,Department of Pediatrics, Bethlehem Hospital, Stolberg, Germany
| | - Thomas Kapellen
- Hospital for Children and Adolescents, University of Leipzig, Leipzig, Germany
| | - Verena M Wagner
- Department of Pediatrics, University of Lübeck, Lübeck, Germany
| | | | - Wolfram Karges
- Division of Endocrinology and Diabetes, Medical Faculty, RWTH Aachen University, German Center for Diabetes Research (DZD), Aachen, Germany
| | - Reinhard W Holl
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, German Center for Diabetes Research (DZD), Ulm, Germany
| | - Joachim Rosenbauer
- Institute for Biometrics and Epidemiology, Leibniz Center at University of Düsseldorf, German Center for Diabetes Research (DZD), Düsseldorf, Germany
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29
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Ishtiak-Ahmed K, Carstensen B, Pedersen-Bjergaard U, Jørgensen ME. Incidence Trends and Predictors of Hospitalization for Hypoglycemia in 17,230 Adult Patients With Type 1 Diabetes: A Danish Register Linkage Cohort Study. Diabetes Care 2017; 40:226-232. [PMID: 27899494 DOI: 10.2337/dc16-0862] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 11/02/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVE This study aimed to examine nationwide incidence trends and predictors of hospitalization for hypoglycemia (HH) in the adult population with type 1 diabetes in Denmark. RESEARCH DESIGN AND METHODS All 17,230 patients with type 1 diabetes aged 16 years and above registered in the Danish Adult Diabetes Database (DADD) from 2006 were followed to 2012 by linkage of registers. Incidence rates of HH were modeled by Poisson regression by calendar time, taking sex, age, diabetes duration, clinical variables, and previous HH into account. RESULTS A total of 2,369 events of HH occurred among 1,735 patients with type 1 diabetes of HH during 70,002 patient-years (mean follow-up 3.7 years). A decrease in incidence rate was observed with calendar time with an 8.4% (4.9-11.7%) annual decrease. Predictors of HH included previous HH, age, diabetes duration, albuminuria, and HbA1c. CONCLUSIONS This study revealed a decreasing trend in incidence of HH in patients with type 1 diabetes. Previous HH, longer diabetes duration, macroalbuminuria, and HbA1c were associated with increased risk of HH in type 1 diabetes, and attention to those factors is warranted in both clinical and public health aspects.
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Affiliation(s)
- Kazi Ishtiak-Ahmed
- Steno Diabetes Centre, Gentofte, Denmark.,Section of Social Medicine, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | | | - Ulrik Pedersen-Bjergaard
- Department of Cardiology, Nephrology and Endocrinology, Nordsjællands Hospital Hillerød, Hillerød, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Marit E Jørgensen
- Steno Diabetes Centre, Gentofte, Denmark .,National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
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30
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Birkebaek NH, Drivvoll AK, Aakeson K, Bjarnason R, Johansen A, Samuelsson U, Skrivarhaug T, Thorsson AV, Svensson J. Incidence of severe hypoglycemia in children with type 1 diabetes in the Nordic countries in the period 2008-2012: association with hemoglobin A 1c and treatment modality. BMJ Open Diabetes Res Care 2017; 5:e000377. [PMID: 28761652 PMCID: PMC5530237 DOI: 10.1136/bmjdrc-2016-000377] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 04/11/2017] [Accepted: 04/17/2017] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE Treatment of type 1 diabetes has been intensified aiming at normalizing blood glucose, which may increase the risk of severe hypoglycemia (SH). We aimed to compare the incidence of SH events in the four Nordic countries Denmark, Iceland, Norway and Sweden, and to assess the influence of hemoglobin A1c (HbA1c) and treatment modalities on the frequency of SH; particularly, to explore if a HbA1c target ≤6.7% (50 mmol/mol) is feasible. RESEARCH DESIGN AND METHODS Data on children below 15 years with a diabetes duration more than 1 year, registered in the national childhood diabetes databases in the four Nordic countries from 2008 to 2012, were compiled. Data completeness was more than 95%. RESULTS Totally 8806 (48% females) patients with 29 715 person years were included, mean age and diabetes duration were 11 years and 5.1 years, respectively. The overall rate of SH was 6.0 per 100 patient-years, and did not change during the study period. The Swedish population constantly had the lowest SH incidence while it decreased significantly in the Danish population. HbA1c decreased significantly over time (p<0.01), while the number of pump users increased (p<0.01). Stratifying for HbA1c levels showed the lowest risk of SH in patients with HbA1c ≤6.7% (≤50 mmol/mol), but in the statistical models adjusting for possible confounders the difference between the HbA1c groups disappeared. Pump users had the lowest SH risk, also after adjusting for possible confounders. CONCLUSIONS Risk of SH differs between the Nordic countries with the lowest risk in Sweden. Pump therapy was associated with decreased risk of SH. The low HbA1c group had the same or a lower risk of SH compared with the highest HbA1c groups. A target HbA1c ≤6.7% (≤50 mmol/mol) seems achievable without increasing the risk of SH.
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Affiliation(s)
- NH Birkebaek
- Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark
| | - AK Drivvoll
- Norwegian Childhood Diabetes Registry, Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - K Aakeson
- Department of Pediatrics, County Hospital Ryhov, Jönköping, Sweden
| | - R Bjarnason
- Medical Center, Landspitali University Hospital, Reykjavik, Iceland
- Department of Pediatrics, University of Iceland, Reykjavik, Iceland
| | - A Johansen
- Department of Growth and Reproduction, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - U Samuelsson
- Department of Pediatrics, Linköping University Hospital, Linköping, Sweden
| | - T Skrivarhaug
- Norwegian Childhood Diabetes Registry, Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - AV Thorsson
- Medical Center, Landspitali University Hospital, Reykjavik, Iceland
- Department of Pediatrics, University of Iceland, Reykjavik, Iceland
| | - J Svensson
- Copenhagen Diabetes Research Center (CPH-DIRECT), Department of Children and Adolescents, Copenhagen University Hospital, Herlev, Denmark
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31
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Hansen GL, Foli-Andersen P, Fredheim S, Juhl C, Remvig LS, Rose MH, Rosenzweig I, Beniczky S, Olsen B, Pilgaard K, Johannesen J. Hypoglycemia-Associated EEG Changes in Prepubertal Children With Type 1 Diabetes. J Diabetes Sci Technol 2016; 10:1222-1229. [PMID: 26920641 PMCID: PMC5094317 DOI: 10.1177/1932296816634357] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The purpose of this study was to explore the possible difference in the electroencephalogram (EEG) pattern between euglycemia and hypoglycemia in children with type 1 diabetes (T1D) during daytime and during sleep. The aim is to develop a hypoglycemia alarm based on continuous EEG measurement and real-time signal processing. METHOD Eight T1D patients aged 6-12 years were included. A hyperinsulinemic hypoglycemic clamp was performed to induce hypoglycemia both during daytime and during sleep. Continuous EEG monitoring was performed. For each patient, quantitative EEG (qEEG) measures were calculated. A within-patient analysis was conducted comparing hypoglycemia versus euglycemia changes in the qEEG. The nonparametric Wilcoxon signed rank test was performed. A real-time analyzing algorithm developed for adults was applied. RESULTS The qEEG showed significant differences in specific bands comparing hypoglycemia to euglycemia both during daytime and during sleep. In daytime the EEG-based algorithm identified hypoglycemia in all children on average at a blood glucose (BG) level of 2.5 ± 0.5 mmol/l and 18.4 (ranging from 0 to 55) minutes prior to blood glucose nadir. During sleep the nighttime algorithm did not perform. CONCLUSIONS We found significant differences in the qEEG in euglycemia and hypoglycemia both during daytime and during sleep. The algorithm developed for adults detected hypoglycemia in all children during daytime. The algorithm had too many false alarms during the night because it was more sensitive to deep sleep EEG patterns than hypoglycemia-related EEG changes. An algorithm for nighttime EEG is needed for accurate detection of nocturnal hypoglycemic episodes in children. This study indicates that a hypoglycemia alarm may be developed using real-time continuous EEG monitoring.
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Affiliation(s)
| | - Pia Foli-Andersen
- Pediatric Department, Copenhagen University Hospital Herlev, Denmark
| | - Siri Fredheim
- Pediatric Department, Copenhagen University Hospital Herlev, Denmark
| | - Claus Juhl
- Hypo-Safe A/S, Lyngby, Denmark
- Department of Medicine, Hospital of South West Denmark, Esbjerg, Denmark
| | | | | | - Ivana Rosenzweig
- Sleep and Brain Plasticity Centre, Department of Neuroimaging, King's College London, London, UK
- Sleep Disorders Centre, Guy's and St Thomas's Hospitals NHS Trust, London, UK
| | - Sándor Beniczky
- Department of Clinical Neurophysiology, Danish Epilepsy Center, Dianalund, Denmark
- Aarhus University, Århus, Denmark
| | - Birthe Olsen
- Pediatric Department, Copenhagen University Hospital Herlev, Denmark
| | - Kasper Pilgaard
- Pediatric Department, Copenhagen University Hospital, Hillerød, Denmark
| | - Jesper Johannesen
- Pediatric Department, Copenhagen University Hospital Herlev, Denmark
- Faculty of Health and Medical Sciences, Copenhagen University, Denmark
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Svensson J, Cerqueira C, Kjærsgaard P, Lyngsøe L, Hertel NT, Madsen M, Mortensen HB, Johannesen J. Danish Registry of Childhood and Adolescent Diabetes. Clin Epidemiol 2016; 8:679-683. [PMID: 27822115 PMCID: PMC5094642 DOI: 10.2147/clep.s99469] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
AIM The aims of the Danish Registry of Childhood and Adolescent Diabetes (DanDiabKids) are to monitor and improve the quality of care for children and adolescents with diabetes in Denmark and to follow the incidence and prevalence of diabetes. STUDY POPULATION The study population consists of all children diagnosed with diabetes before the age of 15 years since 1996. Since 2015, every child followed up at a pediatric center (<18 years of age) will be included. MAIN VARIABLES The variables in the registry are the quality indicators, demographic variables, associated conditions, diabetes classification, family history of diabetes, growth parameters, self-care, and treatment variables. The quality indicators are selected based on international consensus of measures of good clinical practice. The indicators are metabolic control as assessed by HbA1c, blood pressure, albuminuria, retinopathy, neuropathy, number of severe hypoglycemic events, and hospitalization with ketoacidosis. DESCRIPTIVE DATA The number of children diagnosed with diabetes is increasing with ∼3% per year mainly for type 1 diabetes (ie, 296 new patients <15 years of age were diagnosed in 2014). The disease management has changed dramatically with more children treated intensively with multiple daily injections, insulin pumps, and increased number of self-monitored blood glucose values per day. These initiatives have resulted in a significant improvement in HbA1c over the years and a decrease in the number of children experiencing severe hypoglycemia, diabetic nephropathy, and retinopathy. CONCLUSION The systematic collection of data in DanDiabKids documents improved quality of care over the last 12 years, despite a substantial increase in the number of patients cared for by pediatric departments in Denmark, fulfilling the purpose of the registry.
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Affiliation(s)
- Jannet Svensson
- Pediatric and Adolescent Department, Copenhagen University Hospital, Herlev and Gentofte, Herlev
| | - Charlotte Cerqueira
- Registry Support Centre (East) - Epidemiology and Biostatistics, Research Centre for Prevention and Health, Capital Region of Denmark, Glostrup
| | | | - Lene Lyngsøe
- Pediatric and Adolescent Department, Nordsjællands Hospital, Hillerød
| | | | - Mette Madsen
- Pediatric Department, Aalborg University Hospital, Aalborg, Denmark
| | - Henrik B Mortensen
- Pediatric and Adolescent Department, Copenhagen University Hospital, Herlev and Gentofte, Herlev
| | - Jesper Johannesen
- Pediatric and Adolescent Department, Copenhagen University Hospital, Herlev and Gentofte, Herlev
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33
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Franchini S, Comegna L, Prezioso G, Blasetti A. Hypoglycemia in children with type 1 diabetes: unawareness is a concrete risk. Curr Med Res Opin 2016; 32:1487-91. [PMID: 27142345 DOI: 10.1080/03007995.2016.1185400] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- S Franchini
- a Department of Pediatrics , University of Chieti , Chieti , Italy
| | - L Comegna
- a Department of Pediatrics , University of Chieti , Chieti , Italy
| | - G Prezioso
- a Department of Pediatrics , University of Chieti , Chieti , Italy
| | - A Blasetti
- a Department of Pediatrics , University of Chieti , Chieti , Italy
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34
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Hanazaki K, Munekage M, Kitagawa H, Yatabe T, Munekage E, Shiga M, Maeda H, Namikawa T. Current topics in glycemic control by wearable artificial pancreas or bedside artificial pancreas with closed-loop system. J Artif Organs 2016; 19:209-18. [PMID: 27142278 DOI: 10.1007/s10047-016-0904-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 04/17/2016] [Indexed: 02/05/2023]
Affiliation(s)
- Kazuhiro Hanazaki
- Department of Surgery, Kochi Medical School, Kochi University, Kohasu, Okocho, Nankoku, Kochi, 783-8505, Japan
| | - Masaya Munekage
- Department of Surgery, Kochi Medical School, Kochi University, Kohasu, Okocho, Nankoku, Kochi, 783-8505, Japan
| | - Hiroyuki Kitagawa
- Department of Surgery, Kochi Medical School, Kochi University, Kohasu, Okocho, Nankoku, Kochi, 783-8505, Japan
| | - Tomoaki Yatabe
- Department of Anesthesiology, Kochi Medical School, Kochi University, Kohasu, Okocho, Nankoku, Kochi, Japan
| | - Eri Munekage
- Department of Surgery, Kochi Medical School, Kochi University, Kohasu, Okocho, Nankoku, Kochi, 783-8505, Japan
| | - Mai Shiga
- Department of Surgery, Kochi Medical School, Kochi University, Kohasu, Okocho, Nankoku, Kochi, 783-8505, Japan
| | - Hiromichi Maeda
- Department of Surgery, Kochi Medical School, Kochi University, Kohasu, Okocho, Nankoku, Kochi, 783-8505, Japan
| | - Tsutomu Namikawa
- Department of Surgery, Kochi Medical School, Kochi University, Kohasu, Okocho, Nankoku, Kochi, 783-8505, Japan.
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Sildorf SM, Hertel NT, Thomsen J, Fredheim S, Hastrup H, Pipper C, Hertz B, Svensson J. Treatment intensification without improved HbA1c levels in children and adolescents with Type 1 diabetes mellitus. Diabet Med 2016; 33:515-22. [PMID: 26333180 DOI: 10.1111/dme.12900] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/25/2015] [Indexed: 01/15/2023]
Abstract
AIMS To examine trends in diabetes treatment in Danish children and adolescents with Type 1 diabetes mellitus, comparing treatment intensity with metabolic outcomes in the population, and to describe the challenges of population-based registries in a clinical setting with rapidly changing treatment methods. METHODS This observational study is based on the Danish national population registry of childhood diabetes, which includes 99% of children diagnosed with Type 1 diabetes before the age of 15 years. We included 4527 people diagnosed between 2000 and 2012. Self-monitored blood glucose measurements, insulin injections/boluses, treatment method and metabolic control quantifications were analysed and adjusted for the effects of gender and ethnicity, the combined effect of age, visit year and duration, and for the random effects of individual and hospital settings. RESULTS Treatment was intensified via an increasing number of self-monitored blood glucose measurements and injections/boluses. More than six injections/boluses and an increased number of self-monitored blood glucose measurements were significantly associated with lower metabolic control. No reduction, however, in the overall mean HbA1c concentration was observed between 2005 [66 mmol/mol (8.2%)] and 2012 [65 mmol/mol (8.1%)]. Changed registration practices in 2009 introduced artificial jumps in data. CONCLUSIONS Intensifying treatment alone does not lead to improved metabolic control in the overall population despite the appearance of lower HbA1c in individuals with a greater number of self-monitored blood glucose measurements and injections/boluses. The contradictory results reflect difficulties in using observational studies to predict results of intervention in the individual. Data collected from population-based registries need to be adjusted continuously to reflect changes in care.
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Affiliation(s)
- S M Sildorf
- Paediatric Department, Herlev Hospital, Herlev, Denmark
| | - N T Hertel
- H.C. Andersen Children's Hospital, Odense University Hospital, Odense C, Denmark
| | - J Thomsen
- Paediatric Department, Kolding Hospital, Kolding, Denmark
| | - S Fredheim
- Paediatric Department, Herlev Hospital, Herlev, Denmark
| | - H Hastrup
- Paediatric Department, Aalborg University Hospital, Aalborg, Denmark
| | - C Pipper
- Section of Biostatistics, Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - B Hertz
- Paediatric Department, Regionshospitalet Viborg, Viborg, Denmark
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Kurien M, Mollazadegan K, Sanders DS, Ludvigsson JF. A nationwide population-based study on the risk of coma, ketoacidosis and hypoglycemia in patients with celiac disease and type 1 diabetes. Acta Diabetol 2015; 52:1167-74. [PMID: 26403595 DOI: 10.1007/s00592-015-0808-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 08/31/2015] [Indexed: 02/06/2023]
Abstract
AIMS Celiac disease (CD) may influence metabolic control in type 1 diabetes (T1D). This work examines whether CD in T1D influences hospital admissions due to coma, ketoacidosis and hypoglycemia. METHODS In population-based cohort study, individuals with CD were identified using biopsy data (1969-2008) from Sweden's 28 pathology departments. T1D was defined as a recorded diagnosis of T1D at age ≤30 years in the Swedish National Patient Register between 1964 and 2009. In total, 906 individuals had both T1D and CD and were matched for sex, age and calendar period with 4303 reference individuals. Through stratified Cox regression analysis, we modeled CD as a time-dependent covariate and estimated the risk of future coma, ketoacidosis and hypoglycemia, defined by relevant international classification of disease codes among T1D patients with and without CD. RESULTS During follow-up, patients with both T1D and CD had 49 hospital admissions with diabetic coma, 91 episodes of ketoacidosis and 25 hypoglycemic events. Among patients with T1D, CD did not influence the risk of coma (adjusted HR 0.97; 95 % CI 0.72-1.32), ketoacidosis (adjusted HR 1.08; 95 % CI 0.86-1.34), or hypoglycemia (adjusted HR 1.34; 95 % CI 0.87-2.05). The absolute risk of coma was 621/100,000 person-years in T1D and CD (637 in controls). Corresponding figures for ketoacidosis were 1175/100,000 person-years in T1D and CD (1092 in controls) and for hypoglycemia 316/100,000 person-years (236 in controls). HRs for metabolic emergencies in T1D were similar in the first 5 years after T1D diagnosis as thereafter. CONCLUSIONS Having a diagnosis of CD is unlikely to influence the risk of coma, ketoacidosis and hypoglycemia in T1D patients.
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Affiliation(s)
- Matthew Kurien
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK.
- Academic Unit of Gastroenterology, University of Sheffield, Sheffield, S10 2RX, UK.
| | - Kaziwe Mollazadegan
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, 17177, Stockholm, Sweden
| | - David S Sanders
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK
- Academic Unit of Gastroenterology, University of Sheffield, Sheffield, S10 2RX, UK
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, 17177, Stockholm, Sweden.
- Department of Pediatrics, Örebro University Hospital, Örebro University, Örebro, Sweden.
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Steineck I, Cederholm J, Eliasson B, Rawshani A, Eeg-Olofsson K, Svensson AM, Zethelius B, Avdic T, Landin-Olsson M, Jendle J, Gudbjörnsdóttir S. Insulin pump therapy, multiple daily injections, and cardiovascular mortality in 18,168 people with type 1 diabetes: observational study. BMJ 2015; 350:h3234. [PMID: 26100640 PMCID: PMC4476263 DOI: 10.1136/bmj.h3234] [Citation(s) in RCA: 154] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To investigate the long term effects of continuous subcutaneous insulin infusion (insulin pump therapy) on cardiovascular diseases and mortality in people with type 1 diabetes. DESIGN Observational study. SETTING Swedish National Diabetes Register, Sweden 2005-12. PARTICIPANTS 18,168 people with type 1 diabetes, 2441 using insulin pump therapy and 15,727 using multiple daily insulin injections. MAIN OUTCOME MEASURES Cox regression analysis was used to estimate hazard ratios for the outcomes, with stratification of propensity scores including clinical characteristics, risk factors for cardiovascular disease, treatments, and previous diseases. RESULTS Follow-up was for a mean of 6.8 years until December 2012, with 114,135 person years. With multiple daily injections as reference, the adjusted hazard ratios for insulin pump treatment were significantly lower: 0.55 (95% confidence interval 0.36 to 0.83) for fatal coronary heart disease, 0.58 (0.40 to 0.85) for fatal cardiovascular disease (coronary heart disease or stroke), and 0.73 (0.58 to 0.92) for all cause mortality. Hazard ratios were lower, but not significantly so, for fatal or non-fatal coronary heart disease and fatal or non-fatal cardiovascular disease. Unadjusted absolute differences were 3.0 events of fatal coronary heart disease per 1000 person years; corresponding figures were 3.3 for fatal cardiovascular disease and 5.7 for all cause mortality. When lower body mass index and previous cardiovascular diseases were excluded, results of subgroup analyses were similar to the results from complete data. A sensitivity analysis of unmeasured confounders in all individuals showed that an unmeasured confounders with hazard ratio of 1.3 would have to be present in >80% of the individuals treated with multiple daily injections versus not presence in those treated with pump therapy to invalidate the significantly lower hazard ratios for fatal cardiovascular disease. Data on patient education and frequency of blood glucose monitoring were missing, which might have influenced the observed association. CONCLUSION Among people with type 1 diabetes use of insulin pump therapy is associated with lower cardiovascular mortality than treatment with multiple daily insulin injections.
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Affiliation(s)
- Isabelle Steineck
- Department of Endocrinology, Aarhus University Hospital, Aarhus Denmark
| | - Jan Cederholm
- Department of Public Health and Caring Sciences/Family and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Björn Eliasson
- Institute of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Araz Rawshani
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | - Katarina Eeg-Olofsson
- Institute of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | | | - Björn Zethelius
- Department of Public Health and Caring Sciences/Geriatrics, Uppsala University, Uppsala, Sweden Medical Products Agency, Uppsala, Sweden
| | - Tarik Avdic
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | | | - Johan Jendle
- Faculty of Health Sciences and Medicine, Örebro University, Örebro, Sweden
| | - Soffia Gudbjörnsdóttir
- Institute of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden National Diabetes Register, Centre of Registers, Gothenburg, Sweden
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Heinemann L, Deiss D, Hermanns N, Graham C, Kaltheuner M, Liebl A, Price D. HypoDE: Research Design and Methods of a Randomized Controlled Study Evaluating the Impact of Real-Time CGM Usage on the Frequency of CGM Glucose Values <55 mg/dl in Patients With Type 1 Diabetes and Problematic Hypoglycemia Treated With Multiple Daily Injections. J Diabetes Sci Technol 2015; 9:651-62. [PMID: 25759183 PMCID: PMC4604551 DOI: 10.1177/1932296815575999] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Systems for continuous glucose monitoring (CGM) have been available for a number of years, and numerous clinical studies have been performed with them. Interestingly, in many of these studies patients with an increased risk of hypoglycemic events were excluded. In addition, in most studies subjects were using a pump for insulin delivery. Therefore our knowledge about the benefit of CGM in patients employing multiple daily injections (MDI) of insulin is limited, especially when it comes to a reduction in the risk of low glucose events in high-risk individuals. We are planning to run a 26-week randomized controlled study in Germany (HypoDE, Hypoglycemia in Deutschland) that is focused on evaluating if such a reduction can be observed in patients on MDI with an increased risk of low glucose events. In all, 160 patients will participate in the study, randomized into the intervention group and control group. Ideally one would study if the frequency of severe hypoglycemic events is different between both groups. However, this would require such a large sample size and study duration, so for pragmatic reasons we will use low glucose levels <55 mg/dl (measured by CGM) for at least 20 minutes as a risk marker for severe hypoglycemic events. The results from the HypoDE study shall help determine the advantage of using CGM in subjects with type 1 diabetes with an increased risk of low glucose events treated with MDI.
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Affiliation(s)
| | | | - Norbert Hermanns
- Forschungsinstitut Diabetes Akademie Bad Mergentheim (FIDAM), Bad Mergentheim, Germany
| | | | | | | | - David Price
- Forschungsinstitut Diabetes Akademie Bad Mergentheim (FIDAM), Bad Mergentheim, Germany
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