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Zucchini S, Tumini S, Scaramuzza AE, Bonfanti R, Delvecchio M, Franceschi R, Iafusco D, Lenzi L, Mozzillo E, Passanisi S, Piona C, Rabbone I, Rapini N, Rigamonti A, Ripoli C, Salzano G, Savastio S, Schiaffini R, Zanfardino A, Cherubini V. Recommendations for recognizing, risk stratifying, treating, and managing children and adolescents with hypoglycemia. Front Endocrinol (Lausanne) 2024; 15:1387537. [PMID: 38894740 PMCID: PMC11183505 DOI: 10.3389/fendo.2024.1387537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 05/17/2024] [Indexed: 06/21/2024] Open
Abstract
There has been continuous progress in diabetes management over the last few decades, not least due to the widespread dissemination of continuous glucose monitoring (CGM) and automated insulin delivery systems. These technological advances have radically changed the daily lives of people living with diabetes, improving the quality of life of both children and their families. Despite this, hypoglycemia remains the primary side-effect of insulin therapy. Based on a systematic review of the available scientific evidence, this paper aims to provide evidence-based recommendations for recognizing, risk stratifying, treating, and managing patients with hypoglycemia. The objective of these recommendations is to unify the behavior of pediatric diabetologists with respect to the timely recognition and prevention of hypoglycemic episodes and the correct treatment of hypoglycemia, especially in patients using CGM or advanced hybrid closed-loop systems. All authors have long experience in the specialty and are members of the Italian Society of Pediatric Endocrinology and Diabetology. The goal of treating hypoglycemia is to raise blood glucose above 70 mg/dL (3.9 mmol/L) and to prevent further decreases. Oral glucose at a dose of 0.3 g/kg (0.1 g/kg for children using "smart pumps" or hybrid closed loop systems in automated mode) is the preferred treatment for the conscious individual with blood glucose <70 mg/dL (3.9 mmol/L), although any form of carbohydrate (e.g., sucrose, which consists of glucose and fructose, or honey, sugary soft drinks, or fruit juice) containing glucose may be used. Using automatic insulin delivery systems, the oral glucose dose can be decreased to 0.1 g/kg. Practical flow charts are included to aid clinical decision-making. Although representing the official position of the Italian Society of Pediatric Endocrinology and Diabetology (ISPED), these guidelines are applicable to the global audience and are especially pertinent in the era of CGM and other advanced technologies.
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Affiliation(s)
- Stefano Zucchini
- Study Group of Diabetology of the Italian Society for Pediatric Endocrinology and Diabetes (I.S.P.E.D.,) University Hospital of Ferrara, Ferrara, Italy
| | - Stefano Tumini
- Department of Maternal and Child Health, UOSD Regional Center of Pediatric Diabetology, Annunziata Hospital, Chieti, Italy
| | - Andrea Enzo Scaramuzza
- Division of Pediatrics, Pediatric Diabetes, Endocrinology and Nutrition, Azienda Socio Sanitaria Territoriale (ASST) Cremona, Cremona, Italy
| | - Riccardo Bonfanti
- UO Pediatric Diabetes Research Institute, Ospedale San Raffaele, Milan, Italy
| | - Maurizio Delvecchio
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Roberto Franceschi
- Department of Pediatrics, S. Chiara Hospital of Trento, APSS, Trento, Italy
| | - Dario Iafusco
- Department of Woman, Child and General and Specialistic Surgery, Regional Center of Pediatric Diabetes, University of Campania ‘L. Vanvitelli’, Naples, Italy
| | - Lorenzo Lenzi
- Diabetology Unit, Pediatric Department, Anna Meyer Children’s Hospital, Florence, Italy
| | - Enza Mozzillo
- Section of Pediatrics, Regional Center of Pediatric Diabetes, University Federico II, Naples, Italy
| | - Stefano Passanisi
- Department of Human Pathology of Adulthood and Childhood G. Barresi, University of Messina, Messina, Italy
| | - Claudia Piona
- Pediatric Diabetes and Metabolic Disorders Unit, Regional Center for Pediatric Diabetes, Department of Surgery, Dentistry, Pediatrics, and Gynecology, University of Verona, Verona, Italy
| | - Ivana Rabbone
- Division of Pediatrics, Department of Health Sciences, University of Piemonte Orientale, Novara, Italy
| | - Novella Rapini
- Diabetes Unit, Bambino Gesú Childrens’ Hospital, Rome, Italy
| | - Andrea Rigamonti
- UO Pediatric Diabetes Research Institute, Ospedale San Raffaele, Milan, Italy
| | - Carlo Ripoli
- Pediatric Diabetology Unit, Department of Pediatrics, ASL 8 Cagliari, Cagliari, Italy
| | - Giuseppina Salzano
- Department of Human Pathology of Adulthood and Childhood G. Barresi, University of Messina, Messina, Italy
| | - Silvia Savastio
- Division of Pediatrics, Department of Health Sciences, University of Piemonte Orientale, Novara, Italy
| | | | - Angela Zanfardino
- Department of Woman, Child and General and Specialistic Surgery, Regional Center of Pediatric Diabetes, University of Campania ‘L. Vanvitelli’, Naples, Italy
| | - Valentino Cherubini
- Department of Women’s and Children’s Health, Azienda Ospedaliero-Universitaria, Ospedali Riuniti di Ancona, ‘Salesi Hospital’, Ancona, Italy
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Frontino G, Di Tonno R, Castorani V, Rigamonti A, Morotti E, Sandullo F, Scialabba F, Arrigoni F, Foglino R, Dionisi B, Ferri CIC, Zirpoli S, Barera G, Meschi F, Bonfanti R. Non-Occlusive Mesenteric Ischemia in Children With Diabetic Ketoacidosis: Case Report and Review of Literature. Front Endocrinol (Lausanne) 2022; 13:900325. [PMID: 35928892 PMCID: PMC9345499 DOI: 10.3389/fendo.2022.900325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 06/13/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Despite the use of technology, recurrent diabetic ketoacidosis (DKA) prevention remains an unmet need in children and adolescents with T1D and may be accompanied by life-threatening acute complications. We present a rare case of non-occlusive mesenteric ischemia (NOMI) with overt manifestation after DKA resolution and a discussion of recent literature addressing DKA-associated NOMI epidemiology and pathogenesis in children and adolescents. CASE PRESENTATION A 13-year-old female with previously diagnosed T1D, was admitted at our emergency department with hypovolemic shock, DKA, hyperosmolar state and acute kidney injury (AKI). Mildly progressive abdominal pain persisted after DKA correction and after repeated ultrasound evaluations ultimately suspect for intestinal perforation, an intraoperative diagnosis of NOMI was made. CONCLUSION The diagnosis of DKA-associated NOMI must be suspected in pediatric patients with DKA, persistent abdominal pain, and severe dehydration even after DKA resolution.
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Affiliation(s)
- Giulio Frontino
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
| | - Raffaella Di Tonno
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
| | - Valeria Castorani
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
- *Correspondence: Valeria Castorani,
| | - Andrea Rigamonti
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
| | - Elisa Morotti
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
| | - Federica Sandullo
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
| | - Francesco Scialabba
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
| | - Francesca Arrigoni
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
| | - Riccardo Foglino
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
| | - Benedetta Dionisi
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
| | | | - Salvatore Zirpoli
- Pediatric Radiology and Neuroradiology, Children’s Hospital “V. Buzzi”, Milan, Italy
| | - Graziano Barera
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
| | - Franco Meschi
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
| | - Riccardo Bonfanti
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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Piemonti L. Felix dies natalis, insulin… ceterum autem censeo "beta is better". Acta Diabetol 2021; 58:1287-1306. [PMID: 34027619 DOI: 10.1007/s00592-021-01737-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 05/06/2021] [Indexed: 12/12/2022]
Abstract
One hundred years after its discovery, insulin remains the life-saving therapy for many patients with diabetes. It has been a 100-years-old success story thanks to the fact that insulin therapy has continuously integrated the knowledge developed over a century. In 1982, insulin becomes the first therapeutic protein to be produced using recombinant DNA technology. The first "mini" insulin pump and the first insulin pen become available in 1983 and 1985, respectively. In 1996, the first generation of insulin analogues were produced. In 1999, the first continuous glucose-monitoring device for reading interstitial glucose was approved by the FDA. In 2010s, the ultra-long action insulins were introduced. An equally exciting story developed in parallel. In 1966. Kelly et al. performed the first clinical pancreas transplant at the University of Minnesota, and now it is a well-established clinical option. First successful islet transplantations in humans were obtained in the late 1980s and 1990s. Their ability to consistently re-establish the endogenous insulin secretion was obtained in 2000s. More recently, the possibility to generate large numbers of functional human β cells from pluripotent stem cells was demonstrated, and the first clinical trial using stem cell-derived insulin producing cell was started in 2014. This year, the discovery of this life-saving hormone turns 100 years. This provides a unique opportunity not only to celebrate this extraordinary success story, but also to reflect on the limits of insulin therapy and renew the commitment of the scientific community to an insulin free world for our patients.
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Affiliation(s)
- Lorenzo Piemonti
- San Raffaele Diabetes Research Institute, San Raffaele Scientific Institute, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132, Milan, Italy.
- Università Vita-Salute San Raffaele, Milan, Italy.
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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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Ferrito L, Predieri B, Pjetraj D, Alessandrelli MC, Pagnini M, Iannilli A, Marino M, Tombolini S, Pintaudi B, Lucisano G, Zani F, Iughetti L, Nicolucci A, Cherubini V. Weekend-Based Parent-Group Intervention to Reduce Stress in Parents of Children and Adolescents with Type 1 Diabetes: A Pilot Study. J Diabetes Res 2019; 2019:7935945. [PMID: 31871949 PMCID: PMC6906866 DOI: 10.1155/2019/7935945] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 08/28/2019] [Accepted: 09/12/2019] [Indexed: 02/07/2023] Open
Abstract
Diagnosis of type 1 diabetes (T1D) in a child is often associated with anger, denial, fear, and depression from the parents. The aim of the study was to improve parents' adaptation to the diagnosis of diabetes of their child. Sixty-two parents (29 mothers, 33 fathers) of 36 children with type 1 diabetes (mean age = 11.3-3.3 years; diabetes duration > 1 year; HbA1c = 57 ± 11 mmol/mol) participated in a three-day educational working group pilot intervention study. Intervention was based on the reexamination of the traumatic event of diagnosis of T1D through spatial and time-line anchorage, retracing of the future, emotional awareness, and interactive discussion. Relaxing technique, diaphragmatic breathing, and guided visualization were used by 2 psychologists and 1 pediatric endocrinologist. The study was approved by EC and participants filled a consent form. At baseline and after intervention, parents filled in a questionnaire including Diabetes-Related Distress (DRD), Parent Health Locus of Control Scale (PHLOC), Parent Stress Index Short Form (PSI-SF), Hypoglycemia Fear Survey-Parents (HFS-P) and Hypoglycemia Fear Survey-Parents of Young Children (HFS-P-YC), and Health Survey Short Form-36 (SF-36). Three months after the intervention, both parents reported a reduction in the "difficult child" subscale of the PSI-SF (p < 0.05) and increased scores of social functioning of the SF-36 (p < 0.05). DRD score was significantly reduced in mothers (p = 0.03), while the "parental distress" subscale of the PSI-SF was significantly improved in fathers (p = 0.03). This weekend-based parent group intervention seems to reduce stress and improve social functioning of parents of children and adolescents with type 1 diabetes.
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MESH Headings
- Adaptation, Psychological
- Adolescent
- Adolescent Behavior
- Adult
- Age Factors
- Breathing Exercises
- Child
- Child Behavior
- Child, Preschool
- Cost of Illness
- Diabetes Mellitus, Type 1/diagnosis
- Diabetes Mellitus, Type 1/psychology
- Diabetes Mellitus, Type 1/therapy
- Emotions
- Feasibility Studies
- Female
- Health Knowledge, Attitudes, Practice
- Humans
- Imagery, Psychotherapy
- Male
- Middle Aged
- Parents/education
- Parents/psychology
- Pilot Projects
- Psychotherapy, Group
- Relaxation Therapy
- Social Behavior
- Stress, Psychological/diagnosis
- Stress, Psychological/prevention & control
- Stress, Psychological/psychology
- Time Factors
- Treatment Outcome
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Affiliation(s)
- Lucia Ferrito
- SOD Pediatric Diabetology, Department of Women's and Children's, “G. Salesi” Children's Hospital, AOU Ospedali Riuniti Ancona, Italy
| | - Barbara Predieri
- Department of Medical and Surgical Sciences of the Mother, Children, and Adults, University of Modena and Reggio Emilia, Modena, Italy
| | - Dorina Pjetraj
- SOD Pediatric Diabetology, Department of Women's and Children's, “G. Salesi” Children's Hospital, AOU Ospedali Riuniti Ancona, Italy
| | | | - Manuela Pagnini
- SOD Pediatric Diabetology, Department of Women's and Children's, “G. Salesi” Children's Hospital, AOU Ospedali Riuniti Ancona, Italy
| | - Antonio Iannilli
- SOD Pediatric Diabetology, Department of Women's and Children's, “G. Salesi” Children's Hospital, AOU Ospedali Riuniti Ancona, Italy
| | - Monica Marino
- SOD Pediatric Diabetology, Department of Women's and Children's, “G. Salesi” Children's Hospital, AOU Ospedali Riuniti Ancona, Italy
| | - Stefano Tombolini
- SOD Pediatric Diabetology, Department of Women's and Children's, “G. Salesi” Children's Hospital, AOU Ospedali Riuniti Ancona, Italy
| | | | - Giuseppe Lucisano
- CORESEARCH SRL-Center for Outcomes Research and Clinical Epidemiology, Pescara, Italy
| | - Fabiana Zani
- Department of Medical and Surgical Sciences of the Mother, Children, and Adults, University of Modena and Reggio Emilia, Modena, Italy
| | - Lorenzo Iughetti
- Department of Medical and Surgical Sciences of the Mother, Children, and Adults, University of Modena and Reggio Emilia, Modena, Italy
| | - Antonio Nicolucci
- CORESEARCH SRL-Center for Outcomes Research and Clinical Epidemiology, Pescara, Italy
| | - Valentino Cherubini
- SOD Pediatric Diabetology, Department of Women's and Children's, “G. Salesi” Children's Hospital, AOU Ospedali Riuniti Ancona, Italy
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Gloaguen E, Bendelac N, Nicolino M, Julier C, Mathieu F. A systematic review of non-genetic predictors and genetic factors of glycated haemoglobin in type 1 diabetes one year after diagnosis. Diabetes Metab Res Rev 2018; 34:e3051. [PMID: 30063815 DOI: 10.1002/dmrr.3051] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 07/20/2018] [Accepted: 07/23/2018] [Indexed: 12/13/2022]
Abstract
Type 1 diabetes (T1D) results from autoimmune destruction of the pancreatic βcells. Although all T1D patients require daily administration of exogenous insulin, their insulin requirement to achieve good glycaemic control may vary significantly. Glycated haemoglobin (HbA1c) level represents a stable indicator of glycaemic control and is a reliable predictor of long-term complications of T1D. The purpose of this article is to systematically review the role of non-genetic predictors and genetic factors of HbA1c level in T1D patients after the first year of T1D, to exclude the honeymoon period. A total of 1974 articles published since January 2011 were identified and 78 were finally included in the analysis of non-genetic predictors. For genetic factors, a total of 277 articles were identified and 14 were included. The most significantly associated factors with HbA1c level are demographic (age, ethnicity, and socioeconomic status), personal (family characteristics, parental care, psychological traits...) and features related to T1D (duration of T1D, adherence to treatment …). Only a few studies have searched for genetic factors influencing HbA1c level, most of which focused on candidate genes using classical genetic statistical methods, with generally limited power and incomplete adjustment for confounding factors and multiple testing. Our review shows the complexity of explaining HbA1c level variations, which involves numerous correlated predictors. Overall, our review underlines the lack of studies investigating jointly genetic and non-genetic factors and their interactions to better understand factors influencing glycaemic control for T1D patients.
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Affiliation(s)
- Emilie Gloaguen
- Inserm UMRS-958, Paris, France
- Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | | | - Marc Nicolino
- Hôpital Femme-Mère-Enfant, Hospices Civils de Lyon, Bron, France
| | - Cécile Julier
- Inserm UMRS-958, Paris, France
- Université Paris Diderot, Sorbonne Paris Cité, Paris, France
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Nicolucci A, Rossi MC, D'Ostilio D, Delbaere A, de Portu S, Roze S. Cost-effectiveness of sensor-augmented pump therapy in two different patient populations with type 1 diabetes in Italy. Nutr Metab Cardiovasc Dis 2018; 28:707-715. [PMID: 29753586 DOI: 10.1016/j.numecd.2018.03.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 03/06/2018] [Accepted: 03/23/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND AIMS Sensor-augmented pump therapy (SAP) combines real time continuous glucose monitoring (CGM) with Continuous Subcutaneous Insulin Infusion (CSII) and provides additional benefits beyond those provided by CSII alone. SAP with automated insulin suspension provides early warning of the onset of hyperglycemia and hypoglycemia and has the functionality to suspend insulin delivery if sensor glucose levels are predicted to fall below a predefined threshold. Aim of this study was to assess the cost-effectiveness of SAP with automated insulin suspension versus CSII alone in type 1 diabetes. METHODS AND RESULTS Cost-effectiveness analysis was performed using the CORE Diabetes Model. The analysis was performed in two different cohorts: one with high baseline HbA1c and one at elevated risk for hypoglycemic events. Clinical input data were sourced from published data. The analysis was conducted from a societal perspective over a lifetime time horizon; costs and clinical outcomes were discounted at 3% per year. In patients with poor glycemic control, SAP with automated insulin suspension resulted in improved discounted quality-adjusted life expectancy (QALY) versus CSII (12.44 QALYs vs. 10.99 QALYs) but higher mean total lifetime costs (€324,991 vs. €259,852), resulting in an incremental cost effectiveness ratio (ICER) of €44,982 per QALY gained. In patients at elevated risk for hypoglycemia, the ICER was €33,692 per QALY gained for SAP versus CSII. CONCLUSION In Italy, the use of SAP with automated insulin suspension is associated with projected improvements in outcomes as compared to CSII. These benefits translate into an ICER usually considered as good value for money, particularly in patients at elevated risk of hypoglycemia.
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Affiliation(s)
- A Nicolucci
- Center for Outcomes Research and Clinical Epidemiology, CORESEARCH, Pescara, Italy.
| | - M C Rossi
- Center for Outcomes Research and Clinical Epidemiology, CORESEARCH, Pescara, Italy
| | | | - A Delbaere
- Medtronic International Trading Sarl, Tolochenaz, Switzerland
| | - S de Portu
- Medtronic International Trading Sarl, Tolochenaz, Switzerland
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Lindner LME, Gontscharuk V, Bächle C, Castillo K, Stahl-Pehe A, Tönnies T, Yossa R, Holl RW, Rosenbauer J. Severe hypoglycemia and diabetic ketoacidosis in young persons with preschool onset of type 1 diabetes mellitus: An analysis of three nationwide population-based surveys. Pediatr Diabetes 2018; 19:713-720. [PMID: 29498171 DOI: 10.1111/pedi.12628] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 11/14/2017] [Accepted: 11/27/2017] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES To describe incidence rates and temporal trends of severe hypoglycemia (SH) and of hospitalizations for SH or diabetic ketoacidosis (DKA) in persons with early-onset, long-term type 1 diabetes (T1D) and associations of these short-term complications with potential risk factors. METHODS This study includes data of 1,875 persons 11.2 to 21.9 years of age with early-onset (<5 years) and long-term (>10 years) T1D from 3 cross-sectional nationwide, population-based surveys conducted in 2009/2010, 2012/2013 and 2015/2016 using standardized questionnaires. Negative binomial regression was used to estimate incidence rates per 100 person-years (py), temporal trends and associations between potential risk factors and outcomes. RESULTS The crude incidence rate of SH showed a decreasing trend over time (P for trend = .004), disappearing after adjustment for confounders (P for trend = .341). In contrast, adjusted rates of SH- and DKA-associated hospitalizations did not change significantly between 2009 and 2016 (P for trend = .306 and .774, respectively). Associations between sex, diabetes duration, insulin treatment regimen, hypoglycemia awareness as well as physical activity and SH were found, while family structure was associated with hospitalizations for SH. Family structure, socioeconomic status (SES), diabetes duration, and hemoglobin A1c values showed associations with DKA-related hospitalizations. CONCLUSIONS After adjustment, rates of SH and SH- or DKA-associated hospitalization showed no significant changes in recent years. Structured education programs focusing on high-risk groups as, for example, persons with T1D living with 1 biological parent and the parents' partner or those with a low SES, should be implemented to reduce incidence rates of hospitalizations.
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Affiliation(s)
- Lena M E Lindner
- German Diabetes Center (DDZ), Institute for Biometrics and Epidemiology, Leibniz Center for Diabetes Research at the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.,German Diabetes Center (DZD), München-Neuherberg, Germany
| | - Veronika Gontscharuk
- Department of Statistics in Medicine, Faculty of Medicine, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.,Center for Health and Society, Faculty of Medicine, Institute for Health Services Research and Health Economics, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.,German Diabetes Center (DDZ), Institute for Health Services Research and Health Economics, Leibniz Center for Diabetes Research at the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Christina Bächle
- German Diabetes Center (DDZ), Institute for Biometrics and Epidemiology, Leibniz Center for Diabetes Research at the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.,German Diabetes Center (DZD), München-Neuherberg, Germany
| | - Katty Castillo
- German Diabetes Center (DDZ), Institute for Biometrics and Epidemiology, Leibniz Center for Diabetes Research at the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.,German Diabetes Center (DZD), München-Neuherberg, Germany
| | - Anna Stahl-Pehe
- German Diabetes Center (DDZ), Institute for Biometrics and Epidemiology, Leibniz Center for Diabetes Research at the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.,German Diabetes Center (DZD), München-Neuherberg, Germany
| | - Thaddäus Tönnies
- German Diabetes Center (DDZ), Institute for Biometrics and Epidemiology, Leibniz Center for Diabetes Research at the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.,German Diabetes Center (DZD), München-Neuherberg, Germany
| | - Rhuphine Yossa
- German Diabetes Center (DDZ), Institute for Biometrics and Epidemiology, Leibniz Center for Diabetes Research at the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.,German Diabetes Center (DZD), München-Neuherberg, Germany
| | - Reinhard W Holl
- German Diabetes Center (DZD), München-Neuherberg, Germany.,Institute of Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany
| | - Joachim Rosenbauer
- German Diabetes Center (DDZ), Institute for Biometrics and Epidemiology, Leibniz Center for Diabetes Research at the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.,German Diabetes Center (DZD), München-Neuherberg, Germany
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9
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Pacaud D, Hermann JM, Karges B, Rosenbauer J, Danne T, Dürr R, Herbst A, Lindauer S, Müther S, Pötzsch S, Raile K, Witsch M, Holl RW. Risk of recurrent severe hypoglycemia remains associated with a past history of severe hypoglycemia up to 4 years: Results from a large prospective contemporary pediatric cohort of the DPV initiative. Pediatr Diabetes 2018; 19:493-500. [PMID: 29218766 DOI: 10.1111/pedi.12610] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 08/17/2017] [Accepted: 10/18/2017] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES In a contemporary cohort of youth with type 1 diabetes, we examined the interval between episodes of severe hypoglycemia (SH) as a risk factor for recurrent SH or hypoglycemic coma (HC). METHODS This was a large longitudinal observational study. Using the DPV Diabetes Prospective follow-up data, we analyzed frequency and timing of recurrent SH (defined as requiring assistance from another person) and HC (loss of consciousness or seizures) in 14 177 youths with type 1 diabetes aged <20 years and at least 5 years of follow-up. RESULTS Among 14 177 patients with type 1 diabetes, 72% (90%) had no, 14% (6.8%) had 1 and 14% (3.2%) >1 SH (HC). SH or HC in the last year of observation was highest with SH in the previous year (odds ratio [OR] 4.7 [CI 4.0-5.5]/4.6 [CI 3.6-6.0]), but remained elevated even 4 years after an episode (OR 2.0 [CI 1.6-2.7]/2.2 [CI 1.5-3.1]). The proportion of patients who experienced SH or HC during the last year of observation was highest with SH/HC recorded during the previous year (23% for SH and 13% for HC) and lowest in those with no event (4.6% for SH and 2% for HC) in the initial 4 years of observation. CONCLUSIONS Even 4 years after an episode of SH/HC, risk for SH/HC remains higher compared to children who never experienced SH/HC. Clinicians should continue to regularly track hypoglycemia history at every visit, adjust diabetes education and therapy in order to avoid recurrences.
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Affiliation(s)
- D Pacaud
- Department of Pediatrics, University of Calgary, Calgary, Canada.,Department of Pediatric Diabetes and Endocrinology, Alberta Children's Hospital, Calgary, Canada.,Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany
| | - J M Hermann
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany.,German Center for Diabetes Research (DZD), Munich, Germany
| | - B Karges
- Division of Endocrinology and Diabetes, Medical Faculty, German Center for Diabetes Research (DZD), RWTH Aachen University, Aachen, Germany
| | - J Rosenbauer
- German Center for Diabetes Research (DZD), Munich, Germany.,German Diabetes Center, Institute for Biometrics and Epidemiology, Leibniz Center for Diabetes Research at Heinrich Heine University, Düsseldorf, Germany
| | - T Danne
- Diabetes Centre for Children and Adolescents, Children's and Youth Hospital "AUF DER BULT", Hannover, Germany
| | - R Dürr
- Department of Children and Adolescent Medicine, Rems-Murr-Clinics, Winnenden, Germany
| | - A Herbst
- Center for Paediatrics, Medical Clinic Leverkusen, Leverkusen, Germany
| | - S Lindauer
- Department for Children and Adolescent Medicine, Hospital Barmherzige Schwestern Linz, Linz, Austria
| | - S Müther
- Diabetes Center for Children and Adolescent, DRK Clinics Berlin Westend, Berlin, Germany
| | - S Pötzsch
- Department for Children and Adolescent Medicine, Helios Vogtland Clinic Plauen, Plauen, Germany
| | - K Raile
- Department of Pediatric Endocrinology and Diabetes, Charité Berlin, Berlin, Germany
| | - M Witsch
- Centre Hospitalier de Luxembourg, Clinique Pediatrie, Luxembourg, Luxembourg
| | - R W Holl
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany.,German Center for Diabetes Research (DZD), Munich, Germany
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10
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Lepore G, Bonfanti R, Bozzetto L, Di Blasi V, Girelli A, Grassi G, Iafusco D, Laviola L, Rabbone I, Schiaffini R, Bruttomesso D, Mammì F, Bruzzese M, Schettino M, Nuzzo M, Di Blasi V, Fresa R, Lambiase C, Iafusco D, Zanfardino A, Confetto S, Bozzetto L, Annuzzi G, Alderisio A, Riccardi G, Gentile S, Marino G, Guarino G, Zucchini S, Maltoni G, Suprani T, Graziani V, Nizzoli M, Acquati S, Cavani R, Romano S, Michelini M, Manicardi E, Bonadonna R, Dei Cas A, Dall'aglio E, Papi M, Riboni S, Manicardi V, Manicardi E, Manicardi E, Pugni V, Lasagni A, Street M, Pagliani U, Rossi C, Assaloni R, Brunato B, Tortul C, Zanette G, Li Volsi P, Zanatta M, Tonutti L, Agus S, Pellegrini M, Ceccano P, Pozzilli G, Anguissola B, Buzzetti R, Moretti C C, Leto G, Pozzilli P, Manfrini S, Maurizi A, Leotta S, Altomare M, Abbruzzese S, Carletti S, Suraci C, Filetti S, Manca Bitti M, Arcano S, Cavallo M, De Bernardinis M, Pitocco D, Caputo S, Rizzi A, Manto A, Schiaffini R, Cappa M, Benevento D, Frontoni S, Malandrucco I, Morano S, Filardi T, Lauro D, Marini M, Castaldo E, Sabato D, Tuccinardi F, Forte E, Viterbori P, Arnaldi C, Minuto N, d'Annunzio G, Corsi A, Rota R, Scaranna C, Trevisan R, Valentini U, Girelli A, Bonfadini S, Zarra E, Plebani A, Prandi E, Felappi B, Rocca A, Meneghini E, Galli P, Ruggeri P, Carrai E, Fugazza L, Baggi V, Conti D, Bosi E, Laurenzi A, Caretto A, Molinari C, Orsi E, Grancini V, Resi V, Bonfanti R, Favalli V, Bonura C, Rigamonti A, Bonomo M, Bertuzzi F, Pintaudi B, Disoteo O, Perseghin G, Perra S, Chiovato L, De Cata P, Zerbini F, Lovati E, Laneri M, Guerraggio L, Bossi A, De Mori V, Galetta M, Meloncelli I, Aiello A A, Di Vincenzo S, Nuzzi A, Fraticelli E, Ansaldi E, Battezzati M, Lombardi M, Balbo M, Lera R, Secco A, De Donno V, Cadario F, Savastio S, Ponzani C, Aimaretti G, Rabbone I, Ignaccolo G, Tinti D, Cerutti F, Bari F, Giorgino F, Piccinno E, Zecchino O, Cignarelli M, Lamacchia O, Picca G, De Cosmo S, Rauseo A, Tomaselli L, Tumminia A, Egiziano C, Scarpitta A, Maggio F, Cardella F, Roppolo R, Provenzano V, Fleres M, Scorsone A, Scatena A, Gregori G, Lucchesi S, Gadducci F, Di Cianni S, Pancani S, Del Prato S, Aragona M, Crisci I, Calianno A, Fattor B, Crazzolara D, Reinstadler P, Longhi S, Incelli G, Rauch S, Romanelli T, Orrasch M, Cauvin V, Franceschi R, Lalli C, Pianta A, Marangoni A, Aricò C, Marin N, Nogara N, Simioni N, Filippi A, Gidoni Guarneri G, Contin M.L M, Decata A, Bondesan L, Confortin L, Coracina A, Lombardi S, Costa Padova S, Cipponeri E, Scotton R, Galasso S, Boscari F, Zanon M, Vinci C, Lisato G, Gottardo L, Bonora E, Trombetta M, Negri C, Brangani C, Maffeis C, Sabbion A, Marigliano M. Metabolic control and complications in Italian people with diabetes treated with continuous subcutaneous insulin infusion. Nutr Metab Cardiovasc Dis 2018; 28:335-342. [PMID: 29428572 DOI: 10.1016/j.numecd.2017.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 10/31/2017] [Accepted: 12/02/2017] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND AIM The objective of this cross-sectional study was to evaluate the degree of glycaemic control and the frequency of diabetic complications in Italian people with diabetes who were treated with continuous subcutaneous insulin infusion (CSII). METHODS AND RESULTS Questionnaires investigating the organisation of diabetes care centres, individuals' clinical and metabolic features and pump technology and its management were sent to adult and paediatric diabetes centres that use CSII for treatment in Italy. Information on standard clinical variables, demographic data and acute and chronic diabetic complications was derived from local clinical management systems. The sample consisted of 6623 people with diabetes, which was obtained from 93 centres. Of them, 98.8% had type 1 diabetes mellitus, 57.2% were female, 64% used a conventional insulin pump and 36% used a sensor-augmented insulin pump. The median glycated haemoglobin (HbA1c) level was 60 mmol/mol (7.6%). The HbA1c target (i.e. <58 mmol/mol for age <18 years and <53 mmol/mol for age >18 years) was achieved in 43.4% of paediatric and 23% of adult participants. Factors such as advanced pump functions, higher rate of sensor use, pregnancy in the year before the study and longer duration of diabetes were associated with lower HbA1c levels. The most common chronic complications occurring in diabetes were retinopathy, microalbuminuria and hypertension. In the year before the study, 5% of participants reported ≥1 episode of severe hypoglycaemic (SH) episodes (SH) and 2.6% reported ≥1 episode of ketoacidosis. CONCLUSIONS Advanced personal skills and use of sensor-based pump are associated with better metabolic control outcomes in Italian people with diabetes who were treated with CSII. The reduction in SH episodes confirms the positive effect of CSII on hypoglycaemia. CLINICAL TRIAL REGISTRATION NUMBER NCT 02620917 (ClinicalTrials.gov).
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11
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Guo C, Wang Q, Yang L, Wang H, Wang D, Tang X. Selective naked eye and turn-on fluorescence for detection of D-3-HB based on an erbium complex. J Photochem Photobiol A Chem 2018. [DOI: 10.1016/j.jphotochem.2017.07.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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12
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Di Bartolo P, Nicolucci A, Cherubini V, Iafusco D, Scardapane M, Rossi MC. Young patients with type 1 diabetes poorly controlled and poorly compliant with self-monitoring of blood glucose: can technology help? Results of the i-NewTrend randomized clinical trial. Acta Diabetol 2017; 54:393-402. [PMID: 28138788 DOI: 10.1007/s00592-017-0963-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 01/05/2017] [Indexed: 01/31/2023]
Abstract
AIMS To compare iBGStar™ + DMApp (experimental meter + telemedicine system) (iBGStar) with a traditional glucose meter (Control) in type 1 diabetes adolescents/young adults. METHODS i-NewTrend was a multicenter, open-label, randomized trial involving subjects aged 14-24 years, on basal-bolus insulin, HbA1c ≥ 8.0%, and poorly compliant with SMBG (i.e., <30% of the recommended frequency). Primary end points were change in HbA1c and achievement of compliance with SMBG (≥30% of the recommended frequency) after 6 months. Quality of life was also evaluated. A post-trial observational phase was conducted, where both groups used the experimental device. RESULTS Of 182 randomized patients (51.1% male; age 17.7 ± 3.0 years; diabetes duration 8.8 ± 4.7 years; HbA1c levels 10.0% ± 1.4), 92 were allocated to iBGStar and 90 to Control; 6.5% in iBGStar and 8.9% in Control dropped-out. After 6 months, HbA1c changes (±SE) were -0.44% ± 0.13 in iBGStar and -0.32% ± 0.13 in Control (p = 0.51). In the post-trial phase, HbA1c changes from 6 months (±SE) were -0.07% ± 0.14 in iBGStar and -0.31% ± 0.14 in Control (p = 0.24). Compliance end point was reached by 53.6% in iBGStar and 55.0% in Control (p = 0.86). Mean daily SMBG measurements increased from 1.1 to 2.3 in both groups without worsening quality of life. Compliant subjects showed a greater reduction in HbA1c levels (-0.60% ± 0.23 in iBGStar; -0.41% ± 0.21 in Control; p = 0.31). Within iBGStar group, telemedicine users (38.0%) reduced HbA1c by -0.58 ± 0.18. CONCLUSIONS iBGStar was not superior to the traditional meter. Irrespective of the strategy, increasing from 1 to 2 SMBG tests/day was associated with HbA1c reduction in both groups, without pharmacologic interventions. Identifying new technologies effective and acceptable to patients is an option to improve adherence to diabetes care. TRIAL REGISTRATION The trial was registered at ClinicalTrials.gov (registration number NCT02073188).
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Affiliation(s)
| | - Antonio Nicolucci
- CORESEARCH - Center for Outcomes Research and Clinical Epidemiology, Via Tiziano Vecellio, 2, 65124, Pescara, Italy
| | | | - Diario Iafusco
- Department of Pediatrics, Second University of Naples, Naples, Italy
| | - Marco Scardapane
- CORESEARCH - Center for Outcomes Research and Clinical Epidemiology, Via Tiziano Vecellio, 2, 65124, Pescara, Italy
| | - Maria Chiara Rossi
- CORESEARCH - Center for Outcomes Research and Clinical Epidemiology, Via Tiziano Vecellio, 2, 65124, Pescara, Italy.
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13
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Bruno G, Pagano E, Rossi E, Cataudella S, De Rosa M, Marchesini G, Miccoli R, Vaccaro O, Bonora E. Incidence, prevalence, costs and quality of care of type 1 diabetes in Italy, age 0-29 years: The population-based CINECA-SID ARNO Observatory, 2002-2012. Nutr Metab Cardiovasc Dis 2016; 26:1104-1111. [PMID: 27817991 DOI: 10.1016/j.numecd.2016.09.002] [Citation(s) in RCA: 9] [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: 04/27/2016] [Revised: 08/04/2016] [Accepted: 09/02/2016] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND AIMS To assess temporal trend in incidence (2003-12) and prevalence (2002-12) of type 1 diabetes in children and young adults, direct costs and selected indicators of quality of care under the coverage of the universalistic Italian National Health System (NHS). METHODS AND RESULTS The ARNO Observatory, a healthcare monitoring system based on administrative data, identified a population-based multiregional cohort of subjects aged 0-29 years. Type 1 diabetes was defined by at least two prescriptions of insulin over 12 months and continuous insulin-treatment in the following year. Indicators of quality of care and directs costs were assessed in persons with diabetes and in people without diabetes, individually matched for age, gender and health unit (1:4 ratio). We identified 2357 incident cases of type 1 diabetes aged 0-29 years (completeness of ascertainment, 99%). Incidence rates were similar in ages 0-14 (15.8, 95% CI 14.9-16.8) and 15-29 years (16.3, 15.4-17.2), with no significant trend. Prevalence increased from 137 to 166.9/100,000, particularly in the age 15-29 years. Direct costs accounted for € 2117 in persons with diabetes and € 292 in control individuals. A statistically significant decreasing trend in hospitalization for acute complications was evident (p < 0.001), which was almost completely due to ketoacidosis. People with at least one HbA1c measurement over the year were 48.5%. CONCLUSION We showed high incidence and increasing prevalence of type 1 diabetes in young adults in Italy, which impact on direct costs under the universalistic coverage of the NHS.
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Affiliation(s)
- G Bruno
- Dept. of Medical Sciences, University of Torino, Italy.
| | - E Pagano
- Unit of Cancer Epidemiology, "Città della Salute e della Scienza" Hospital-University of Turin and CPO Piemonte, Turin, Italy
| | - E Rossi
- CINECA Interuniversity Consortium, Health Department, Bologna, Italy
| | - S Cataudella
- CINECA Interuniversity Consortium, Health Department, Bologna, Italy
| | - M De Rosa
- CINECA Interuniversity Consortium, Health Department, Bologna, Italy
| | - G Marchesini
- Unit of Metabolic Diseases and Clinical Dietetics, Alma Mater Studiorum University, Bologna, Italy
| | - R Miccoli
- Dept. of Endocrinology and Metabolism, Section of Metabolic Diseases and Diabetes, University of Pisa, Italy
| | - O Vaccaro
- Dept. of Clinical Medicine and Surgery, University of Napoli Federico II, Napoli, Italy
| | - E Bonora
- Endocrinology, Diabetes and Metabolism, Dept. of Medicine, University and University Hospital of Verona, Italy
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14
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Salardi S, Porta M, Maltoni G, Cerutti F, Rovere S, Iafusco D, Tumini S, Cauvin V, Zucchini S, Cadario F, dʾAnnunzio G, Toni S, Salvatoni A, Zedda MA, Schiaffini R. Ketoacidosis at diagnosis in childhood-onset diabetes and the risk of retinopathy 20years later. J Diabetes Complications 2016; 30:55-60. [PMID: 26598223 DOI: 10.1016/j.jdiacomp.2015.10.009] [Citation(s) in RCA: 9] [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: 07/16/2015] [Revised: 10/14/2015] [Accepted: 10/16/2015] [Indexed: 01/06/2023]
Abstract
AIMS To investigate on the relationship between severity of ketoacidosis, an important risk factor for C-peptide preservation, and long-term microvascular complications in childhood-onset type 1 diabetes mellitus (T1DM). METHODS 230 childhood-onset diabetic patients (177 pre-pubertal), aged 7.0±3.8years followed for at least 15years after their diagnosis, were enrolled. Clinical and laboratory data at diagnosis, and C-peptide levels in a subset of patients, were compared with the severity of retinopathy and nephropathy, after a mean of 19.6±3.8years of disease. Digital retinal photographs were taken in all patients, and centrally graded. Repeated measurements of HbA1c and microalbuminuria for the whole duration of diabetes were collected in over half of the cases. RESULTS Out of 230 patients, those with the lowest age at diagnosis had the most severe DKA and clinical conditions (p<0.05), and lower C-peptide levels (p<0.0001) at diagnosis. There was a significant relationship between pH and clinical severity (r=-0.783, p<0.0001), and between pH and C-peptide levels (r=0.278, p<0.05). The severity of ketoacidosis had no relationship with subsequent lifetime HbA1c values and long-term microvascular complications. In logistic regression analysis, the only variables that independently influenced severity of retinopathy were lifetime HbA1c (B=0.838, p<0.001), duration of disease (B=0.208, p<0.005) and age at diagnosis (B=0.116, p<0.05). CONCLUSIONS The degree of metabolic derangement at diagnosis is not associated with retinopathy and nephropathy in childhood-onset T1DM. Age at diagnosis seems to be an important variable to be considered when evaluating the long-term effects of residual beta-cell function.
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Affiliation(s)
- Silvana Salardi
- Department of Pediatrics, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
| | - Massimo Porta
- Diabetic Retinopathy Centre of the Department of Medical Sciences, University of Turin, Turin, Italy
| | - Giulio Maltoni
- Department of Pediatrics, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Franco Cerutti
- Department of Pediatrics, University of Turin, Turin, Italy
| | - Silvia Rovere
- Diabetic Retinopathy Centre of the Department of Medical Sciences, University of Turin, Turin, Italy
| | - Dario Iafusco
- Department of Pediatrics, Second University of Naples, Naples, Italy
| | - Stefano Tumini
- Department of Pediatrics, University of Chieti, Chieti, Italy
| | | | - Stefano Zucchini
- Department of Pediatrics, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Francesco Cadario
- Department of Pediatrics, "Maggiore della Carità" Hospital Novara, University of Piemonte Orientale, Vercelli, Italy
| | - Giuseppe dʾAnnunzio
- Department of Pediatrics, IRCCS Gaslini Children's Hospital, University of Genoa, Genoa, Italy
| | - Sonia Toni
- Meyer Pediatric Institute, University of Firenze, Firenze, Italy
| | | | | | - Riccardo Schiaffini
- Endocrinology and Diabetes Palidoro Unit, University Department of Pediatric Medicine, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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15
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Giorda CB, Ozzello A, Gentile S, Aglialoro A, Chiambretti A, Baccetti F, Gentile FM, Lucisano G, Nicolucci A, Rossi MC. Incidence and risk factors for severe and symptomatic hypoglycemia in type 1 diabetes. Results of the HYPOS-1 study. Acta Diabetol 2015; 52:845-53. [PMID: 25670242 DOI: 10.1007/s00592-015-0713-4] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Accepted: 01/13/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Hypoglycemia is common in type 1 diabetes mellitus (T1DM). We aimed to update the incidence of severe and symptomatic hypoglycemia and investigate several correlated factors. METHODS In this multicenter, observational retrospective study, the data of 206 T1DM patients from a sample of 2,229 consecutive patients seen at 18 diabetes clinics were analyzed. Sociodemographic and clinical characteristics, severe hypoglycemia in the past 12 months, and symptomatic hypoglycemia in the past 4 weeks were recorded with a self-report questionnaire and a clinical form during a routine visit. Poisson multivariate models were applied. RESULTS A minority of patients accounted for the majority of both severe and symptomatic episodes. The incidence rate (IR) of severe hypoglycemia was 0.49 (0.40-0.60) events/person-years. The incidence rate ratio (IRR) was higher in patients with previous severe hypoglycemia (3.71; 2.28-6.04), neuropathy (4.16; 2.14-8.05), long duration (>20 years, 2.96; 1.60-5.45), and on polypharmacy (1.24; 1.13-1.36), but it was lower when a complication was present. The IR of symptomatic hypoglycemia was 53.3 events/person-years, with an IRR significantly higher among women or patients with better education, or shorter duration or on pumps. The IRR was lower in patients with higher BMI or neuropathy or aged more than 50 years. CONCLUSIONS Fewer than 20 % of T1DM patients are free from hypoglycemia, with one in six having experienced at least one severe episode in the last year. The distribution is uneven, with a tendency of episodes to cluster in some patients. Severe and symptomatic episodes have different correlates and reflect different conditions.
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Affiliation(s)
- Carlo B Giorda
- Metabolism and Diabetes Unit, ASL TO5, Via De Maria, 1, 10023, Chieri, TO, Italy.
| | - Alessandro Ozzello
- Departmental Service of Diabetology and Metabolic Diseases, ASL TO3, Pinerolo, TO, Italy
| | - Sandro Gentile
- Department of Clinical and Experimental Medicine, Second University of Naples, Naples, Italy
| | | | | | - Fabio Baccetti
- Metabolism and Diabetes Unit, ASL 1, Massa Carrara, Italy
| | | | - Giuseppe Lucisano
- Laboratory of Clinical Epidemiology of Diabetes and Chronic Diseases, Fondazione Mario Negri Sud, Santa Maria Imbaro, CH, Italy
| | - Antonio Nicolucci
- Laboratory of Clinical Epidemiology of Diabetes and Chronic Diseases, Fondazione Mario Negri Sud, Santa Maria Imbaro, CH, Italy
| | - Maria Chiara Rossi
- Laboratory of Clinical Epidemiology of Diabetes and Chronic Diseases, Fondazione Mario Negri Sud, Santa Maria Imbaro, CH, Italy
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16
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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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