Challenges of optimizing glycaemic control in children with Type 1 diabetes: a qualitative study of parents' experiences and views

Fear of hypoglycemia in parents of children with type 1 diabetes trained for intranasal glucagon use

OBJECTIVE

To investigate fear of hypoglycemia (FoH) in parents of children with type 1 diabetes (T1D) before and after undergoing training to learn intranasal (IN) glucagon administration.

METHOD

In this pre-test/post-test uncontrolled study 364 caregivers of patients with T1D (6-18 years) completed questionnaires measuring sociodemographic characteristics, diabetes-related factors (e.g., type of insulin therapy, glycemic control), and parents' trait anxiety. Parents' FoH was assessed at baseline (T0, training) and after nine months (T1). Two repeated-measure mixed analyses of covariance (ANCOVA) compared the FoH at T0 and at T1 and analyzed the moderating roles of anxiety proneness and type of insulin therapy, as well as of anxiety proneness and use of sensor. Age, T1D duration, HbA1c values, and SES were included as covariates.

RESULTS

Parental FoH at T1 (M = 1.72; SE = 0.06/M = 1.57; SE = 0.09) was significantly lower than parental FoH at T0 (M = 1.89; SE = 0.06/M = 1.77; SE = 0.09). The group with high trait-anxiety had a higher level of FoH (M = 2.05; SE = 0.08/M = 1.89; SE = 0.12) than the group with low trait-anxiety (M = 1.57; SE = 0.08/M = 1.46; SE = 0.09) at both time points. SES was negatively associated with FoH at T0 (t = -2.87; p = .004/t = -2.87; p = .005). No other significant effects were found.

CONCLUSIONS

Training and educating parents on IN glucagon use can help them effectively manage hypoglycemic episodes and alleviate the fear that generally accompany such events.

Prevalence and associations of impaired awareness of hypoglycemia in a pediatric type 1 diabetes population - The Norwegian Childhood Diabetes Registry

AIMS

To determine the prevalence and associations of impaired awareness of hypoglycemia (IAH) in pediatric type 1 diabetes.

METHODS

Nationwide, population-based cross-sectional study with 51 % participation. Participants (n = 1329; 53 % males) aged 2-19 years (median 13.3) with type 1 diabetes ≥ 6 months (median 4.6 years) self-assessed hypoglycemia awareness with a validated questionnaire ('Clarke'). Parents responded for children aged < 9 years (n = 235). We estimated associations between IAH and clinical data in the Norwegian Childhood Diabetes Registry.

RESULTS

The overall prevalence of IAH was 22 %, but gradually decreased from 53 % in preschoolers to 12 % in adolescents aged ≥ 16 years. IAH was associated (adjusted OR; 95 %CI) with episodes of severe hypoglycemia (6.0; 3.04, 11.8) and diabetic ketoacidosis (3.45; 1.37, 8.68) the preceding year, increased fear of hypoglycemia (highest quartile vs. lowest: 2.27; 1.51, 3.40), female sex (1.41; 1.05, 1.90), and HbA1c ≥ 8.5 % (69 mmol/mol) vs. 7.5-8.4 % (58-68 mmol/mol) (1.48; 1.01, 2.18), but not with disease duration, use of insulin pump or continuous glucose monitoring, or HbA1c < 7.5 % (58 mmol/mol).

CONCLUSIONS

IAH is prevalent in pediatric diabetes and more likely reported in young children. IAH is associated with severe hypoglycemia and fear of hypoglycemia, but good metabolic control seems achievable without increased risk of IAH.

Barriers and Facilitators to Uptake of Continuous Glucose Monitoring for Management of Type 2 Diabetes Mellitus in Youth

PURPOSE

The purpose of this study was to identify factors impacting the acceptability of continuous glucose monitoring (CGM) in adolescents and young adults (AYAs) with type 2 diabetes mellitus (T2DM).

METHODS

In this single-center study, semistructured interviews were conducted with AYAs with T2DM and their parents to determine attitudes about CGM, including barriers and facilitators. Interviews were audio-recorded, transcribed, and evaluated using thematic analysis.

RESULTS

Twenty AYAs and 10 parents participated (n = 30 total). AYAs were mean age 16.5 years (SD 2.2, range = 13.7-20.1) and had median diabetes duration of 1.3 years. Most were female (65%) and from minoritized background (40% non-Hispanic Black, 10% Hispanic, 5% Asian). Seven (35%) used CGM. The primary facilitator elicited was convenience over glucose meter use. Important barriers included the impact of physically wearing the device and drawing unwanted attention, desire for AYA privacy, and inadequate education about the device.

CONCLUSIONS

In this diverse sample of AYAs with T2DM and their parents, CGM was generally regarded as convenient, although concerns about worsening stigma and conflict with parents were prevalent. These findings can guide the development of patient-centered approaches to CGM for AYAs with T2DM, a critical step toward reducing inequities in diabetes technology uptake.

The Turkish version of the problem areas in diabetes-parents of teens (P-PAID-T): Cross-cultural adaptation, reliability, and validity

OBJECTIVE

To examine the Turkish validity and reliability of the Problem Areas in Diabetes- Parents of Teens (P-PAID-T) scale and its psychometric properties for determining the parents' diabetes-related distress.

METHODS

The study included the parents of 200 adolescents with T1DM for at least a year. P-PAID-T and a demographic data form were used for data collection. Davis technique was used for the content validity of the scale. The scale's reliability was tested using test-retest, and its internal reliability was analyzed with Cronbach's alpha test. Exploratory Factor Analysis (EFA) was used to analyze the factor structure. Confirmatory Factor Analysis (CFA) was used to evaluate the fit of the scale.

RESULTS

69.5% (n = 139) of the participants were mothers. Compared to the fathers, the mothers' mean P-PAID-T score was significantly higher. Parents of sons, who used insulin injections for their children, and had a college degree or higher education level had higher P-PAID-T scores. The test-retest correlation coefficient of the scale was 0.977. The Cronbach α value of the scale was 0.901. The results of confirmatory factor analysis were x2/df = 2.931, GFI = 0.736, CFI = 0.711, NFI = 0.628, NNFI = 0.660, RMSEA = 0.141.

CONCLUSION

The Turkish version of P-PAID-T was a valid and reliable screening tool for measuring diabetes stress in parents of adolescents with T1DM.

PRACTICE IMPLICATIONS

Nurses could use the Turkish version of P-PAID-T to monitor parental diabetes distress and organize interventions; also Turkish P-PAID-T could facilitate research on diabetes distress for parents of adolescents with T1DM.

New therapies towards a better glycemic control in youths with type 1 diabetes

Type 1 diabetes (T1D) is the most frequent form of diabetes in pediatric age, affecting more than 1.5 million people younger than age 20 years worldwide. Early and intensive control of diabetes provides continued protection against both microvascular and macrovascular complications, enhances growth, and ensures normal pubertal development. In the absence of definitive reversal therapy for this disease, achieving and maintaining the recommended glycemic targets is crucial. In the last 30 years, enormous progress has been made using technology to better treat T1D. In spite of this progress, the majority of children, adolescents and young adults do not reach the recommended targets for glycemic control and assume a considerable burden each day. The development of promising new therapeutic advances, such as more physiologic insulin analogues, pioneering diabetes technology including continuous glucose monitoring and closed loop systems as well as new adjuvant drugs, anticipate a new paradigm in T1D management over the next few years. This review presents insights into current management of T1D in youths.

Comparison of two advanced hybrid closed loop in a pediatric population with type 1 diabetes: a real-life observational study

OBJECTIVE

The Advanced Hybrid Closed Loop (AHCL) systems have provided the potential to ameliorate glucose control in children with Type 1 Diabetes. The aim of the present work was to compare metabolic control obtained with 2 AHCL systems (Medtronic 780G system and Tandem Control IQ system) in a pediatric real-life clinical context.

RESEARCH DESIGN AND METHODS

It is an observational, real-life, monocentric study; thirty one children and adolescents (M:F = 15:16, age range 7.6-18 years, mean age 13.05 ± 2.4 years, Diabetes duration > 1 year) with T1D, previously treated with Predictive Low Glucose Suspend (PLGS) systems and then upgraded to AHCL have been enrolled. CGM data of the last four weeks of "PLGS system" (PRE period) with the first four weeks of AHCL system (POST period) have been compared.

RESULTS

For both AHCL systems, Medtronic 780G and Tandem Control IQ, respectively TIR at 4 weeks significantly increased, from 65.7 to 70.5% (p < 0.01) and from 64.8 to 70.1% (p < 0.01). (p < 0.01). The comparison between CGM metrics of the 2 evaluated systems doesn't show difference at baseline (last four weeks of PLGS system) and after four weeks of AHCL use.

CONCLUSIONS

To our knowledge, this study is the first real-life one comparing 2 AHCL systems in a pediatric population with T1D. It shows an improvement in glucose control when upgrading to AHCL. The comparison between the two AHCL systems did not show significant differences in the analyzed CGM metrics, meaning that the algorithms currently available are equally effective in promoting glucose control.

Parents' experiences of using remote monitoring technology to manage type 1 diabetes in very young children during a clinical trial: Qualitative study

AIMS

To explore parents' experiences of using remote monitoring technology when caring for a very young child with type 1 diabetes during a clinical trial.

METHODS

Interviews were conducted with parents of 30 children (aged 1-7 years) participating in a trial (the KidsAP02 study) comparing hybrid closed-loop insulin delivery with sensor-augmented pump therapy. In both arms, parents had access to remote monitoring technology. Data analysis focused on identification of descriptive themes.

RESULTS

Remote monitoring technology gave parents improved access to data which helped them pre-empt and manage glucose excursions. Parents observed how, when children were in their own care, they could be more absent while present, as their attention could shift to non-diabetes-related activities. Conversely, when children were others' care, remote monitoring enabled parents to be present while absent, by facilitating oversight and collaboration with caregivers. Parents described how remote monitoring made them feel more confident allowing others to care for their children. Parents' confidence increased when using a hybrid closed-loop system, as less work was required to keep glucose in range. Benefits to children were also highlighted, including being able to play and sleep uninterrupted and attend parties and sleepovers without their parents. While most parents welcomed the increased sense of control remote monitoring offered, some noted downsides, such as lack of respite from caregiving responsibilities.

CONCLUSIONS

Remote monitoring can offer manifold benefits to both parents and very young children with type 1 diabetes. Some parents, however, may profit from opportunities to take 'time out'.

Parental experiences of short term supported use of a do-it-yourself continuous glucose monitor (DIYrtCGM): A qualitative study

AIMS

To investigate the experiences of parents caring for young children with type 1 diabetes type 1 diabetes using a do-it-yourself continuous glucose monitor (DIYrtCGM) in a supported setting.

METHODS

Exit interviews were conducted with parents from 11 families at the end of the MiaoMiao study: a randomised cross-over trial focusing on parental fear of hypoglycaemia. Technical support was provided to participants while using DIYrtCGM during the trial. A convenience sampling approach was used to recruit parents. An in-depth, semi-structured interview approach was used. Thematic analysis was used to identify key themes and subthemes.

RESULTS

Parents identified that remote monitoring enabled proactive management and that overall alarms/glucose alerts were useful. Some parents reported reductions in anxiety, increased independence for their child, and improvements in the child-parent relationship. However, parents also reported regular signal loss with DIYrtCGM, along with complicated apps and challenges troubleshooting technical problems. Despite this, nine of the 11 families continued to use the system after the end of the trial.

CONCLUSIONS

Do-it-yourself continuous glucose monitoring (CGM) was on balance beneficial for the parents interviewed. However, while access to CGM shifted the burden of care experienced by parents, burden did not significantly reduce for all parents, as the improved glycaemic control that they achieved was accompanied with the responsibility for continually monitoring their child's data. Supported use of do-it-yourself CGM may be an achievable, cost-effective option for parents caring for children with type 1 diabetes in countries without funded access to CGM.

Emergency Glucagon: a Focused Review of Psychosocial Experiences of Rescue Drugs for Type 1 Diabetes

PURPOSE OF REVIEW

The purpose of this paper is to describe rescue glucagon types, safety, efficacy, and preferences, as well as to review articles regarding emergency glucagon usage, severe hypoglycemia, and the emotions of both phenomena. We conducted a review of current literature on glucagon usage and the emotional impact of severe hypoglycemia on people with diabetes (PwD) and the caregivers of people with type 1 diabetes (T1D).

RECENT FINDINGS

Minimal research exists pertaining to glucagon and severe hypoglycemic experiences in PwD, which is troubling considering the severity of risks and possible side effects. Recent articles described negative emotions such as fear, anxiety, stress, helplessness, shame, embarrassment, loneliness, frustration, hopefulness, and uncertainty surrounding glucagon usage. There is scarce research regarding PwD's emotions surrounding severe hypoglycemia and rescue glucagon use. Additional research is needed to investigate the emotions and feelings people with T1D and their caregivers' experience pertaining to severe hypoglycemia and emergency glucagon use.

Communication and Social Relations: A Qualitative Study of Families’ Experience with Their Outpatient Pediatric Diabetes Visits

Clinical outpatient visits comprise a relatively small part of the lives of children with diabetes and their families, but there is evidence that these visits have a strong impact on the long-term management of diabetes. Because children with diabetes are looking at frequent hospital visits for the rest of their lives, it is important to explore their experiences to ensure visits meet their needs. This study aimed to investigate families’ experiences with outpatient visits at a pediatric diabetes clinic. Thirteen semi-structured family interviews were conducted. Systematic text condensation was used to analyze the data. With an analytical focus on communication and social relations, nine themes were identified: 1. Discrepancies in perception of diabetes tasks, 2. Talking about adult things, but the children listen, 3. The importance of spoken and written words, 4. Confusion about division of responsibilities, 5. Relief when someone eases the burden, 6. Courtesy when visiting the clinic, 7. Understanding of the family context, 8. Importance of continuous personal relations, and 9. Need for a facilitated peer network. The findings encourage reflection on how to improve communication and underline the importance of establishing a continuous and personal relation between families and health care professionals to improve families’ experience with pediatric outpatient visits.

Characterising common challenges faced by parental caregivers of children with type 1 diabetes mellitus in mainland China: a qualitative study

OBJECTIVES

The mental state of parental caregivers affects outcomes in children with type 1 diabetes mellitus (T1DM). This study aimed to qualitatively examine perception of common challenges among parental caregivers of children with T1DM.

SETTING

Semistructured interviews 45-60 min long were conducted with parental caregivers of children with T1DM. Interview recordings were transcribed and coded in NVivo V.11.0 to observe emergent themes.

PARTICIPANTS

Eligible T1DM caregiving parents (parent(s) and/or legal guardian(s)) were identified from caregivers attending visits with children hospitalised or assessed in the Pediatric Neuroendocrinology Department of Shengjing Hospital, China Medical University in Shenyang from January 2018 to June 2019.

PRIMARY AND SECONDARY OUTCOME MEASURES

Not applicable.

RESULTS

A total of 20 T1DM caregiving parents were interviewed, aged 30-53 years, including 7 fathers and 13 mothers, with their children whose mean age was 10.6±2.45 years. Content analysis revealed 5 major themes with 13 subthemes, including persistent psychological stress (catastrophic emotions, emotional distress and altered self-efficacy), family function change (altered family life patterns and changes in parental role/function), challenges in daily management (technical challenges, emotional regulation, parent-child conflict and transition of care autonomy from parent to child), financial burden (cost burden of treatment and altered family economics), and lack of social support (social activity limitations and insufficient support system).

CONCLUSIONS

The period of emotional disturbance during initial diagnosis, psychological stresses of long-term caregiving, and conflict emerging from transition from parental to child responsibility all can cause psychological response detrimental to parental caregivers and children with T1DM. This work provides compelling evidence for the role of assessment and intervention in parental caregivers' psychological and emotional well-being in diabetes care, as well as for the necessity of improved social and school support for children with T1DM in China.

Fear of hypoglycemia in Italian mothers of children with type 1 diabetes: the mediating role of resilience

Objective

Fear of hypoglycemia for children with diabetes influences parental life and could increase parental stress. The present study aimed to explore the association between resilience, the self-perception of the parental role, and fear of hypoglycemia in mothers of children with type I diabetes (T1DM).

Methods

Ninety mothers (mean age: 44.20 years) of children with a T1DM diagnosis (mean age: 11.48 years) were recruited from an association for parents and completed an online self-report questionnaire packet that includes: Fear of Hypoglycemia Survey, Self-Perception of the Parental Role and Resilience Scale for Adults. Participants were recruited in 2017. Data collection lasted 10 months. Data analysis was performed using the SPSS statistical package, version 22, and the PROCESS macro program by Hayes.

Results

The analysis of the mediation model shows that resilience assumes a mediational role in the relationships between the parental role and preoccupation with hypoglycemia. In particular, the mother's perceived competence and role balance can influence the development and increase of the mother's resilience, which in turn can allow a decrease in the mother's worry about the possible hypoglycemic episode of her child.

Conclusion

The findings suggest that resilience is a significant topic to focus on in interventions designed to increase the self-perception of the parental role and reduce fear of hypoglycemia in mothers.

Benefits and Challenges of Current Closed-Loop Technologies in Children and Young People With Type 1 Diabetes

Recent advances in diabetes technology have led to the development of closed-loop insulin delivery systems for the management of type 1 diabetes. Several such systems are now commercially available for children and young people. While all available systems have been shown to improve glycaemic control and quality of life in this population, qualitative data also highlights the challenges in using closed-loop systems, which vary among different pediatric age-groups. Very young children require systems that are able to cope with low insulin doses and significant glycaemic variability due to their high insulin sensitivity and unpredictable eating and exercise patterns. Adolescents' compliance is often related to size and number of devices, usability of the systems, need for calibrations, and their ability to interact with the system. Given the speed of innovations, understanding the capabilities and key similarities and differences of current systems can be challenging for healthcare professionals, caregivers and young people with type 1 diabetes alike. The aim of this review is to summarize the key evidence on currently available closed-loop systems for children and young people with type 1 diabetes, as well as commenting on user experience, where real-world data are available. We present findings on a system-basis, as well as identifying specific challenges in different pediatric age-groups and commenting on how current systems might address these. Finally, we identify areas for future research with regards to closed-loop technology tailored for pediatric use and how these might inform reimbursement and alleviate disease burden.

Parents' experience of caring for children with type 1 diabetes in mainland China: A qualitative study

BACKGROUND

Parents of children with type 1 diabetes mellitus (T1DM) are under heavy caregiving stress, and parental caregivers' experience can affect the health outcomes of children with T1DM.

AIM

To describe the true inner feelings of parents caring for children with T1DM.

METHODS

Descriptive research methods were used to classify and summarize parents' experience when adapting to the role of caregivers for children with T1DM. The data was sorted and analyzed using content analysis. Themes of parents' experience caring for children with T1DM were refined, and their feelings were deeply investigated.

RESULTS

A total of 4 themes and 12 subthemes were identified: (1) Desire for information (disease-related information, home care information, and channels of information acquisition); (2) Skill guidance needs (insulin injection techniques, skills required for symptom management, and skills for parent-child communication); (3) Seeking emotional support (family support, peer support from other parents of children with T1DM, and professional support); and (4) Lack of social support (needs for financial support and needs for social security).

CONCLUSION

Exploring the true experience of parents caring for children with T1DM is of great significance for helping them adapt to their role as caregivers. Nurses should provide professional guidance in terms of information, skills, emotion, and social support to parental caregivers.

Parents' experiences of caring for a young child with type 1 diabetes: a systematic review and synthesis of qualitative evidence

AIMS

To synthesise the qualitative evidence on parents' experiences of caring for a child aged ≤8 years with type 1 diabetes to identify: the challenges they encounter; their views about support received; ways in which support could be improved; and, directions for future research.

METHODS

We searched Medline, EMBASE, CINAHL, PsycINFO and Web of Science databases to identify qualitative studies reporting parents' views and experiences of caring for a child with type 1 diabetes aged ≤8 years. Key analytical themes were identified using thematic synthesis.

RESULTS

Fourteen studies were included. The synthesis resulted in the generation of two overarching themes. Monopolisation of life describes the all-encompassing impact diabetes could have on parents due to the constant worry they experienced and the perceived need for vigilance. It describes how parents' caring responsibilities could affect their wellbeing, relationships and finances, and how a lack of trusted sources of childcare and a desire to enable a 'normal' childhood constrained personal choices and activities. However, use of diabetes technologies could lessen some of these burdens. Experiences of professional and informal support describes how encounters with healthcare professionals, while generally perceived as helpful, could lead to frustration and anxiety, and how connecting with other parents caring for a child with type 1 diabetes provided valued emotional and practical support.

CONCLUSIONS

This synthesis outlines the challenges parents encounter, their views about support received and ways in which support might be improved. It also highlights significant limitations in the current literature and points to important areas for future research, including how sociodemographic factors and use of newer diabetes technologies influence parents' diabetes management practices and experiences. PROSPERO: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019128710.

Our language matters: Improving communication with and about people with diabetes. A position statement by Diabetes Australia

The words used about diabetes affect the physical and emotional health of people living with diabetes. They also affect how individuals and society view people living with, or at risk of, diabetes. People with diabetes, their families, and people at risk of diabetes, need and deserve communications that are clear and accurate, respectful and inclusive, and free from judgement and bias. The aim of this position statement is to help bring about positive change in the language used about diabetes. It is based on 30+ years of research into the experiences of people with diabetes. Changing thelanguage of diabetes can make a powerful and positive difference to the emotional well-being, self-care and health outcomes of people affected by diabetes. It also affects community and government support for funding diabetes care, prevention and research. Diabetes Australia encourages everyone communicating about diabetes, or about people affected by diabetes, to choose and use their words carefully to support all people affected by diabetes. This position statement is intended as a guide for people working in healthcare, the media, government and policy, academia, industry, as well as employers and the community. It may also be helpful for the family and friends of people with diabetes.

A delicate balance between control and flexibility: Experiences of care and support among pre-teenage children with type 1 diabetes and their families

For children with type 1 diabetes, the period of adolescence is associated with higher blood glucose levels and increased psychological distress compared to other age groups. Focusing on pre-teens (9-12 years) with type 1 diabetes and their families has been suggested as key to understanding and reducing these challenges. The aim of this study was to explore: 1, how diabetes affects family life, 2, experiences of and needs for support and 3, how care responsibilities are negotiated among pre-teens with type 1 diabetes and their families. Data were obtained from four interactive workshops with pre-teens (n = 17), their parents (n = 26) and their siblings (n = 14). Dialogue tools, for example quotes and picture cards, were used to facilitate discussion and reflection concerning family life with type 1 diabetes. Data analysis resulted in three themes: 1, diabetes takes up 'a lot of space', 2, giving and receiving support and 3, balancing control and flexibility. While diabetes took up significant space in the families, family members protected each other from their respective frustrations. The findings point to the significance of considering all key family members and their interactions in diabetes interventions. This includes balancing control and flexibility, negotiating responsibilities and building trust.

A concept analysis of psychological distress in parents related to diabetes management in children and adolescents

PURPOSE

To report a concept analysis of parents' psychological distress in the context of diabetes management among children and adolescents. A clear understanding of the possible impact of diabetes management on parents will help to inform how nurses can work with parents to support glycaemic control in children and adolescents.

DESIGN AND METHOD

Concept analysis using Walker and Avant's eight-stage approach was used as a guiding framework. PubMed, OVID (CINAHL, Medline, PsychInfo), the Cochrane library and the Joanna Briggs library were searched for the past 50 years.

RESULTS

Thirty-three studies provided data for the concept analysis. Attributes included difficulty coping, changes in emotional status and manifestations of mental health problems.

PRACTICE IMPLICATION

Based on the literature synthesis, we suggest all facets of distress related to diabetes can in principle be inferred through the proposed relationship between distress and other interactions of individual coping, caring burden and family relational functioning. The proposed conceptual model linking antecedents' factors and individual characteristics of parents to the concepts of psychological distress may assist researchers to design interventions for supporting diabetes management in children and adolescents.

Broadening the Debate About Post-trial Access to Medical Interventions: A Qualitative Study of Participant Experiences at the End of a Trial Investigating a Medical Device to Support Type 1 Diabetes Self-Management

Increasing ethical attention and debate is focusing on whether individuals who take part in clinical trials should be given access to post-trial care. However, the main focus of this debate has been upon drug trials undertaken in low-income settings. To broaden this debate, we report findings from interviews with individuals (n = 24) who participated in a clinical trial of a closed-loop system, which is a medical device under development for people with type 1 diabetes that automatically adjusts blood glucose to help keep it within clinically recommended ranges. Individuals were recruited from UK sites and interviewed following trial close-out, at which point the closed-loop had been withdrawn. While individuals were stoical and accepting of the requirement to return the closed-loop, they also conveyed varying degrees of distress. Many described having relaxed diabetes management practices while using the closed-loop and having become deskilled as a consequence, which made reverting back to pre-trial regimens challenging. Participants also described unanticipated consequences arising from using a closed-loop. As well as deskilling, these included experiencing psychological and emotional benefits that could not be sustained after the closed-loop had been withdrawn and participants reevaluating their pre- and post-trial life in light of having used a closed-loop and now perceiving this life much more negatively. Participants also voiced frustrations about experiencing better blood glucose control using a closed-loop and then having to revert to using what they now saw as antiquated and imprecise self-management tools. We use these findings to argue that ethical debates about post-trial provisioning need to be broadened to consider potential psychological and emotional harms, and not just clinical harms, that may result from withdrawal of investigated treatments. We also suggest that individuals may benefit from information about potential nonclinical harms to help make informed decisions about trial participation.

Participants' Experiences of, and Views About, Daytime Use of a Day-and-Night Hybrid Closed-Loop System in Real Life Settings: Longitudinal Qualitative Study

OBJECTIVE

To explore individuals' experiences of daytime use of a day-and-night hybrid closed-loop system, their information and support needs, and their views about how future systems could be improved.

RESEARCH DESIGN AND METHODS

Twenty-four adults, adolescents, and parents were interviewed before using a hybrid day-and-night closed-loop system and 3 months later, data were analyzed thematically.

RESULTS

Participants praised the closed loop's ability to respond to high and low blood glucose in ways which extended beyond their own capabilities and to act as a safety net and mop up errors, such as when a mealtime bolus was forgotten or unplanned activity was undertaken. Participants also described feeling less burdened by diabetes as a consequence and more able to lead flexible, spontaneous lives. Contrary to their initial expectations, and after trust in the system had been established, most individuals wanted opportunities to collaborate with the closed loop to optimize its effectiveness. Such individuals expressed a need to communicate information, such as when routines changed or to indicate different intensities of physical activity. While individuals valued frequent contact with staff in the initial month of use, most felt that their long-term support needs would be no greater than when using an insulin pump.

CONCLUSIONS

While participants reported substantial benefits to using the closed loop during the day, they also identified ways in which the technology could be refined and education and training tailored to optimize effective use. Our findings suggest that mainstreaming this technology will not necessarily lead to increased demands on clinical staff.

Gaps in Knowledge and the Need for Patient-Partners in Research Related to Physical Activity and Type 1 Diabetes: A Narrative Review

Regular physical activity (PA) is a cornerstone in the management of complications associated with type 1 diabetes (T1D). Most national guidelines advocate for regular PA for persons living with T1D, however the evidence to support these recommendations has not be reviewed recently. Additionally, in an era of patient-centered care and patient oriented research, the role of patient partners in the area of PA and T1D interventions has never been explored. The purpose of this narrative review is to overcome these two gaps in the literature. Here we review selected epidemiological evidence and identify gaps in research that would add important information to guide practitioners and future guidelines. We also provide an overview of patient-oriented research projects co-developed with persons living with T1D. Significant gaps in the field include: (1) a lack of adequately powered prospective cohort studies using serial measures of PA and hard chronic disease end-points; (2) no multi-centered, highly powered, randomized controlled trials of PA, and long-term health outcomes; (3) little data on the role of new technologies to support PA-related behavior change, and (4) no trials that involved patients in the design and execution of PA-based clinical trials. This review provides a template for scientists and patient partners to develop future research priorities and agendas in the field.

Barriers and facilitators to taking on diabetes self-management tasks in pre-adolescent children with type 1 diabetes: a qualitative study

BACKGROUND

When children with type 1 diabetes approach adolescence, they are encouraged to become more involved in diabetes self-management. This study explored the challenges pre-adolescent children encounter when self-managing diabetes and the factors which motivate and enable them to take on new diabetes-related tasks. A key objective was to inform the support offered to pre-adolescent children.

METHODS

In-depth interviews using age-appropriate questioning with 24 children (aged 9-12 years) with type 1 diabetes. Data were analysed using an inductive, thematic approach.

RESULTS

Children reported several barriers to taking on self-management tasks. As well as seeking respite from managing diabetes, children described relying on their parents to: perform the complex maths involved in working out carbohydrate content in food; calculate insulin doses if they did not use a bolus advisor; and administer injections or insert a cannula in hard-to-reach locations. Children described being motivated to take on diabetes tasks in order to: minimise the pain experienced when others administered injections; alleviate the burden on their parents; and participate independently in activities with their peers. Several also discussed being motivated to take on diabetes-management responsibilities when they started secondary school. Children described being enabled to take on new responsibilities by using strategies which limited the need to perform complex maths. These included using labels on food packaging to determine carbohydrate contents, or choosing foods with carbohydrate values they could remember. Many children discussed using bolus advisors with pre-programmed ratios and entering carbohydrate on food labels or values provided by their parents to calculate insulin doses. Several also described using mobile phones to seek advice about carbohydrate contents in food.

CONCLUSIONS

Our findings highlight several barriers which deter children from taking on diabetes self-management tasks, motivators which encourage them to take on new responsibilities, and strategies and technologies which enable them to become more autonomous. To limit the need to perform complex maths, children may benefit from using bolus advisors provided they receive regular review from healthcare professionals to determine and adjust pre-programmed insulin-to-carbohydrate ratios. Education and support should be age-specific to reflect children's changing involvement in self-managing diabetes.

Patients' and caregivers' experiences of using continuous glucose monitoring to support diabetes self-management: qualitative study

BACKGROUND

Continuous glucose monitoring (CGM) enables users to view real-time interstitial glucose readings and provides information on the direction and rate of change of blood glucose levels. Users can also access historical data to inform treatment decisions. While the clinical and psychological benefits of CGM are well established, little is known about how individuals use CGM to inform diabetes self-management. We explored participants' experiences of using CGM in order to provide recommendations for supporting individuals to make optimal use of this technology.

METHODS

In-depth interviews (n = 24) with adults, adolescents and parents who had used CGM for ≥4 weeks; data were analysed thematically.

RESULTS

Participants found CGM an empowering tool because they could access blood glucose data effortlessly, and trend arrows enabled them to see whether blood glucose was rising or dropping and at what speed. This predicative information aided short-term lifestyle planning and enabled individuals to take action to prevent hypoglycaemia and hyperglycaemia. Having easy access to blood glucose data on a continuous basis also allowed participants to develop a better understanding of how insulin, activity and food impacted on blood glucose. This understanding was described as motivating individuals to make dietary changes and break cycles of over-treating hypoglycaemia and hyperglycaemia. Participants also described how historical CGM data provided a more nuanced picture of blood glucose control than was possible with blood glucose self-monitoring and, hence, better information to inform changes to background insulin doses and mealtime ratios. However, while participants expressed confidence making immediate adjustments to insulin and lifestyle to address impending hypoglycaemia and hypoglycaemia, most described needing and expecting health professionals to interpret historical CGM data and determine changes to background insulin doses and mealtime ratios. While alarms could reinforce a sense of hypoglycaemic safety, some individuals expressed ambivalent views, especially those who perceived alarms as signalling personal failure to achieve optimal glycaemic control.

CONCLUSIONS

CGM can be an empowering and motivational tool which enables participants to fine-tune and optimize their blood glucose control. However, individuals may benefit from psycho-social education, training and/or technological support to make optimal use of CGM data and use alarms appropriately.

Children's experiences of managing Type 1 diabetes in everyday life: a thematic synthesis of qualitative studies

AIMS

To explore the everyday experiences of children (aged ≤ 12 years) with Type 1 diabetes to identify factors that help or hinder diabetes self-management practices.

METHODS

Eight databases (Embase, Medline, CINAHL, Web of Science, PsychInfo, ASSIA, ERIC and ProQuest Dissertations) were searched in 2016 to identify qualitative studies exploring children's views about self-managing diabetes. Data were extracted, coded and analysed using thematic synthesis.

RESULTS

Eighteen studies from five countries were included in the review. Synthesis of studies' findings resulted in the identification of three overarching analytical themes. The first theme, 'Understandings of diabetes and involvement in self-management', outlines ways in which children understand diabetes and develop self-management responsibilities. The second theme, 'Disruption to life and getting on with it', reports children's frustrations at disruptions to everyday life when managing diabetes, and how attempts to appear normal to family and friends affect self-management practices. The third theme, 'Friends' support', describes how friends' reactions and responses to diabetes affect children's ability to appear normal and willingness to disclose information about diabetes, and support provided by 'informed friends', or peers with diabetes.

CONCLUSIONS

Although the synthesis has identified how children's everyday life experiences inform ways in which they undertake diabetes self-management, it was not possible to determine new ways to provide support. To help children optimise their glycaemic control, further work should be undertaken to identify their need for support and which takes into account the potential ways in which parents, friends and peers can offer assistance.

Diabetes care provider perceptions on family challenges of pediatric type 1 diabetes

Pediatric healthcare providers' perspectives on barriers to diabetes self-management among youth with type 1 diabetes and strategies to overcome them were explored qualitatively. Family conflict about diabetes care was viewed as a common problem, addressable by behavioral interventions to improve communication and promote family teamwork in diabetes management responsibilities.

Effect of Preoperative Opioid Exposure on Healthcare Utilization and Expenditures Following Elective Abdominal Surgery

OBJECTIVE

To examine the extent to which preoperative opioid use is correlated with healthcare utilization and costs following elective surgical procedures.

SUMMARY BACKGROUND DATA

Morbidity and mortality associated with prescription opioid use is escalating in the United States. The extent to which chronic opioid use influences postoperative outcomes following elective surgery is not well understood.

METHODS

Truven Health Marketscan Databases were used to identify adult patients who underwent elective abdominal surgery between June 2009 and December 2012 (n = 200,005). Generalized linear regression was used to determine the effect of preoperative opioid use on postoperative healthcare utilization (length of stay, 30-d readmission, and discharge destination) and cost (hospital stay, 90-, 180-, and 365-d) after adjusting for number of comorbidities, psychological conditions, and demographic characteristics.

RESULTS

In this cohort, 8.8% of patients used opioids preoperatively. Compared with non-users, patients using opioids preoperatively were more likely to have a longer hospital stay (2.9 d vs. 2.5 d, P <0.001) and were more likely to be discharged to a rehabilitation facility (3.6% vs. 2.5%, P <0.001), adjusting for covariates. Preoperative opioid use was also correlated with a greater rate of 30-day readmission (4.5% vs. 3.6%, P <0.001) and overall greater expenditures at 90- ($12036.60 vs. $3863.40, P <0.001), 180- ($16973.70 vs. $6790.60, P <0.001), and 365- ($25495.70 vs. $12113.80, P <0.001) days following surgery, adjusted for covariates. Additionally, dose-effects were observed regarding readmission, discharge destination, and late healthcare expenditures.

CONCLUSIONS

Preoperative interventions focused on opioid cessation and alternative analgesics may improve the safety and efficiency of elective surgery among chronic opioid users.

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

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 (HbA_1c) and treatment modalities on the frequency of SH; particularly, to explore if a HbA_1c 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. HbA_1c decreased significantly over time (p<0.01), while the number of pump users increased (p<0.01). Stratifying for HbA_1c levels showed the lowest risk of SH in patients with HbA_1c ≤6.7% (≤50 mmol/mol), but in the statistical models adjusting for possible confounders the difference between the HbA_1c 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 HbA_1c group had the same or a lower risk of SH compared with the highest HbA_1c groups. A target HbA_1c ≤6.7% (≤50 mmol/mol) seems achievable without increasing the risk of SH.

Improving communication and recall of information in paediatric diabetes consultations: a qualitative study of parents' experiences and views

Background

Parents of non-adolescent children with type 1 diabetes are responsible for most of their child’s diabetes management tasks. Consultations are used to provide diabetes education, review clinical progress and promote diabetes management tasks. This study explored parents’ experiences of, and views about, their child’s diabetes consultations. The objective was to identify ways in which consultations could be improved to aid communication, understanding and knowledge retention.

Methods

In-depth interviews with 54 parents of children (aged ≤12 years) with type 1 diabetes. Data were analysed using an inductive thematic approach.

Results

Parents’ accounts revealed structural and contextual factors which could hinder effective communication and knowledge acquisition during consultations. Most reported feeling anxious going into consultations and worrying about being reprimanded by health professionals if their child’s glycaemic control had not improved. As a consequence, many parents highlighted problems concentrating and assimilating information during consultations. In extreme cases, worries about being reprimanded led parents to omit or fabricate information when discussing their child’s treatment or even to their cancelling appointments. Many parents described wanting opportunities to speak to health professionals alone because young children could be distracting and/or they did not want to raise distressing issues in front of their child. Parents described the benefits of receiving clinical advice from health professionals familiar with their family circumstances and disliking attending busy clinics and seeing different health professionals on each occasion. Parents also highlighted the benefits of receiving treatment recommendations in a written form after the consultation.

Discussion and conclusions

This study has highlighted unrecognised and undocumented aspects of the consultation which may result in parents leaving uncertain about the main issues discussed and with questions unanswered and support needs unaddressed. Structural and contextual changes to consultations are recommended to improve concentration, knowledge acquisition and retention. These include: sending letters/written summaries after consultations highlighting key decisions, providing opportunities for parents to consult health professionals without their child being present, encouraging parents to ask more questions during consultations, having procedures in place to promote continuity of care and providing parents with consistent and non-contradictory advice.