The global burden of youth diabetes: perspectives and potential

Testing Usability and Feasibility of a Mobile Educator Tool for Pediatric Diabetes Self-Management: Mixed Methods Pilot Study

BACKGROUND

Mobile interventions hold promise as an intervention modality to engage children in improving diabetes self-management education, attitudes, and behaviors.

OBJECTIVE

This pilot study aimed to explore the usability, acceptability, and feasibility of delivering a mobile diabetes educational tool to parent-child pairs in a clinical setting.

METHODS

This mixed methods pilot study comprised two concurrent phases with differing study participants. Phase 1 used user testing interviews to collect qualitative data on the usability and acceptability of the tool. Phase 2 used a single-arm pre- and poststudy design to quantitatively evaluate the feasibility and preliminary efficacy of the intervention. Study participants (English-speaking families with youth aged 5-14 years with insulin-dependent diabetes) were recruited from an urban hospital in Massachusetts, United States. In phase 1, parent-child pairs were invited to complete the intervention together and participate in 90-min user testing interviews assessing the tool's usability and acceptability. Interview transcripts were analyzed using a directed content analysis approach. In phase 2, parent-child pairs were invited to complete the intervention together in the clinical setting. Measures included parental and child knowledge, attitudes, and behaviors related to diabetes management (self-report surveys) and child hemoglobin A1c levels (medical record extractions); data were collected at baseline and 1-month follow-up. Pre- and postoutcomes were compared using paired t tests and the Fisher exact test.

RESULTS

A total of 11 parent-child pairs (N=22) participated in phase 1 of the study, and 10 parent-child pairs (N=20) participated in phase 2 of the study. Participants viewed the mobile educational tool as acceptable (high engagement and satisfaction with the layout, activities, and videos) and identified the areas of improvement for tool usability (duration, directions, and animation).

CONCLUSIONS

The findings from this pilot study suggest that the mobile educational tool is an informative, engaging, and feasible way to deliver diabetes self-management education to parents and children in an urban hospital setting. Data will inform future iterations of this mobile diabetes educational intervention to improve usability and test intervention efficacy.

Potential therapeutic applications of exosomes in different autoimmune diseases

Autoimmune diseases are caused by self-immune responses to autoantigens, which damage body tissues and severely affect the patient's quality of life. Therapeutic drugs are associated with adverse side effects and their beneficial effects are limited to specific populations. Evidence indicates that exosomes which are small vesicles secreted by most cell types and body fluids, and may play roles in both immune stimulation and tolerance since they are involved in many processes such as immune signaling, inflammation and angiogenesis. Exosomes have also emerged as promising tools for therapeutic delivery, given their intrinsic features such as stability, biocompatibility and a capacity for stealth. In this review, we summarize existing literature regarding the production, efficacy, action mechanism, and potential therapeutic uses of exosomes in the contexts of autoimmune diseases such as type 1 diabetes mellitus, multiple sclerosis, systemic lupus erythematosus, rheumatoid arthritis, and Sjogren's syndrome.

Expression of recombinant glutamic acid decarboxylase in insect larvae and its application in an immunoassay for the diagnosis of autoimmune diabetes mellitus

Autoimmune Diabetes Mellitus (DM) is a chronic disease caused by the selective destruction of insulin producing beta cells in human pancreas. DM is characterized by the presence of autoantibodies that bind a variety of islet-cell antigens. The 65 kDa isoform of glutamate decarboxylase (GAD65) is a major autoantigen recognized by these autoantibodies. Autoantibodies to GAD65 (GADA) are considered predictive markers of the disease when tested in combination with other specific autoantibodies. In order to produce reliable immunochemical tests for large scale screening of autoimmune DM, large amounts of properly folded GAD65 are needed. Herein, we report the production of human GAD65 using the baculovirus expression system in two species of larvae, Rachiplusia nu and Spodoptera frugiperda. GAD65 was identified at the expected molecular weight, properly expressed with high yield and purity in both larvae species and presenting appropriate enzymatic activity. The immunochemical ability of recombinant GAD65 obtained from both larvae to compete with [³⁵S]GAD65 was assessed qualitatively by incubating GADA-positive patients’ sera in the presence of 1 μM of the recombinant enzyme. All sera tested became virtually negative after incubation with antigen excess. Besides, radiometric quantitative competition assays with GADA-positive patients’ sera were performed by adding recombinant GAD65 (0.62 nM–1.4 µM). All dose response curves showed immunochemical identity between proteins. In addition, a bridge-ELISA for the detection of GADA was developed using S. frugiperda-GAD65. This assay proved to have 77.3% sensitivity and 98.2% of specificity. GAD65 could be expressed in insect larvae, being S. frugiperda the best choice due to its high yield and purity. The development of a cost effective immunoassay for the detection of GADA was also afforded.

Glycemic control and correlates in a group of sub Saharan type 1 diabetes adolescents

OBJECTIVES

This study aims to describe the prevalence of glycemic control and related factors in a population of Sub-Saharan African T1D patients. We carried out a cross-sectional study including children and adolescents from seven different centers of the Changing Diabetes in Children (CDiC) program. All children enrolled in the program where recruited after parental consent. Diabetes history, daily practice anthropometrics parameters and HbA1c were assessed for each participant.

RESULTS

We enrolled 95 children adolescents, aged from 06 to 19 years. The mean HbA1c was 9.2 ± 2.5% and 67.4% of participant had poor glycemic control. There was an association between study level of the patients (p = 0.03), healthy eating habits (p < 0.001), diabetes duration (p < 0.001) and level of glycemic control on univariate analysis. On multivariate analysis, diabetes diagnosed for more than 2 years was associated to a good control compared to those with diagnosis that is more recent. Glycemic control of adolescents with type1 diabetes remain very poor in Cameroon despite the implementation of free diabetes care through the program CDiC.

Glycemic control and correlates in a group of sub Saharan type 1 diabetes adolescents

Objectives

This study aims to describe the prevalence of glycemic control and related factors in a population of Sub-Saharan African T1D patients. We carried out a cross-sectional study including children and adolescents from seven different centers of the Changing Diabetes in Children (CDiC) program. All children enrolled in the program where recruited after parental consent. Diabetes history, daily practice anthropometrics parameters and HbA1c were assessed for each participant.

Results

We enrolled 95 children adolescents, aged from 06 to 19 years. The mean HbA1c was 9.2 ± 2.5% and 67.4% of participant had poor glycemic control. There was an association between study level of the patients (p = 0.03), healthy eating habits (p < 0.001), diabetes duration (p < 0.001) and level of glycemic control on univariate analysis. On multivariate analysis, diabetes diagnosed for more than 2 years was associated to a good control compared to those with diagnosis that is more recent. Glycemic control of adolescents with type1 diabetes remain very poor in Cameroon despite the implementation of free diabetes care through the program CDiC.

Factors Associated with C-peptide Levels after Diagnosis in Children with Type 1 Diabetes Mellitus

C-peptide is the best indicator of endogenous insulin secretion in patients with diabetes. This study investigated the relationship between C-peptide levels and clinical/laboratory parameters of children with type 1 diabetes mellitus (T1DM), as measured at 6-month intervals after diagnosis. We retrospectively reviewed the data of 34 children with newly diagnosed T1DM. The study subjects were subdivided into a rapid progression group with C-peptide levels <0.6 ng/mL at 36 months (n=27; Group A) and a slow progression group with C-peptide levels >0.6 ng/mL at 36 months (n=7; Group B). Patients in Group A had a younger mean age at diagnosis (A: 9±4.3 years vs. B: 13.6±3.6 years; p=0.013) and lower body mass index (BMI) (A: 15.5±2.5 kg/m² vs. B: 18.7±3.3 kg/m²; p=0.035). There were fewer asymptomatic patients with glucosuria in Group A, with these patients showing more severe symptoms, such as diabetic ketoacidosis (p=0.035), than those in Group B. Group A also had lower initial C-peptide levels (A: 0.5±0.46 ng/mL vs. B: 1.87±1.08 ng/mL; p=0.001). There were no significant intergroup differences in sex, family history, baseline hemoglobin A1c (HbA1c), potential of hydrogen (pH), autoantibodies or serum insulin. Simple correlation analyses showed that C-peptide levels were correlated with age and BMI, but not with pH, insulin, or HbA1c. Younger patients, who had a lower BMI, significant symptoms with complications, and/or a low initial C-peptide level, tended to show a rapid rate of decrease in C-peptide levels. Early intensive insulin therapy to preserve beta-cell function should be considered in these groups.

Clinical and Laboratory Characteristics of Childhood Diabetes Mellitus: A Single-Center Study from 2000 to 2013

We examined the clinical and laboratory characteristics of children newly diagnosed with diabetes mellitus (DM) in a single-center study. We retrospectively reviewed the data of 155 children with DM between January 2000 and December 2013. Of 155 diabetic children, 87 (56.1%) were diagnosed with type 1 DM (T1DM) and 68 (43.9%) with type 2 DM (T2DM). Mean ages at diagnosis were 8.95±3.89 years (T1DM) and 13.76±2.23 years (T2DM), respectively (p<0.001). There were significant differences in HbA1c, C-peptide, and glutamic acid decarboxylase antibody levels between the T1DM and T2DM groups. Annual numbers of children with DM have increased, and since 2011 the number of children with T2DM has surpassed the number with T1DM. The most common clinical symptom in T1DM was polyuria, and 26.4% of children with T1DM presented initially with diabetic ketoacidosis. In contrast, 60.3% of T2DM children showed glucosuria in a school urine screening, and only 19.1% presented with polydipsia. The rate of positivity for at least more than one islet autoantibody was 77.1% in T1DM and 26.3% in T2DM. Serum C-peptide levels in T2DM were increased up to 12 months after onset and remained >3.59 ng/mL for 36 months. However, serum C-peptide levels in T1DM were slightly increased up to 6 months after onset and gradually decreased to 0.32 ng/mL for 36 months. The prevalence of children with DM has increased over the last 14 years, and the proportion of T2DM patients has rapidly increased since 2009. Because childhood DM is associated with several metabolic and cardiovascular complications, children should be screened for early detection of DM, especially asymptomatic T2DM in children and adolescents.

Organization and regional distribution of centers for the management of children and adolescents with diabetes in Italy

Background

The incidence of type 1 diabetes in childhood is increasing by 3 % per year, placing growing demands on healthcare professionals and medical expenditures. Aim of this study wars to assess the organization of care to children with diabetes in Italy.

Methods

During 2012 a structured questionnaire was sent to all of the members of Italian Society of Paediatric Endocrinology and Diabetology (ISPED). Questions examined organizational structure of Centers, personnel dedicated to the care of children with diabetes, number of subjects followed, local legal legislation supporting centres.

Results

A total of 68 centers taking care to 15,563 children and adolescents with diabetes under 18 years of age were identified with a prevalence of 1.4 per 1,000 people. A wide variation in the organizational background was also reported. Fourty-four centers were organized as outpatient departments, 17 as simple units, 5 as complex units and 2 as simple departmental structures. Most centers had a multidisciplinary team. Ten out of twenty Italian regions had introduced supportive regional legislation, but it was fully applied only in six of them.

Conclusion

Great differences between regions were found in organizational structures, staffing levels and supportive legislation. The national legislation on diabetes was broadly implemented throughout the country regions. Further efforts are needed to improve standards and consistency of pediatric diabetes care in Italy.

Efficacy of Insulin Pump Therapy on Diabetes Treatment Satisfaction and Glycemic Control Among Patients with Type 1 Diabetes Mellitus in Saudi Arabia: A Prospective Study

INTRODUCTION

The aim of this study was to explore the impact of insulin pump therapy on diabetes treatment satisfaction and glycemic control among patients with type 1 diabetes mellitus (T1DM) in Saudi Arabia.

METHODS

A 6-month, prospective study was conducted among 47 patients (aged 17-24 years) with T1DM who attended the Insulin Pump Clinic at Prince Sultan Military Medical City, Riyadh, Saudi Arabia, between April 2014 and November 2014. The respondents were purposively and conveniently selected and were interviewed using the Arabic version of the Diabetes Treatment Satisfaction Questionnaire at baseline, 3, and 6 months. Demographics and clinical variables including hemoglobin A1c (HbA1c) were also collected.

RESULTS

The mean (±standard deviation) age of the study cohort was 19.1 ± 1.93 years. Seventeen patients were male (36.2%) and 30 were female (63.8%). Compared to baseline, significant positive differences were found in treatment satisfaction among female patients and patients with long-standing T1DM at 6 months. Frequency of hyperglycemia and hypoglycemia declined significantly in female patients at 6 months and in patients who had a shorter duration of T1DM. Furthermore, significant positive differences were found in HbA1c levels among female patients and among those who had a shorter duration of T1DM compared to baseline. Both female and male patients and those with a shorter duration of T1DM showed a significant decline in insulin necessity at 6 months when compared to baseline.

CONCLUSION

Although multiple daily injections is a feasible preference for insulin supply, insulin pumps should also be considered for patients with T1DM as it appears to increase patients' treatment satisfaction, decrease the frequency of hypoglycemia, hyperglycemia, and reduce HbA1c levels.

Daycare attendance, breastfeeding, and the development of type 1 diabetes: the diabetes autoimmunity study in the young

BACKGROUND

The hygiene hypothesis attributes the increased incidence of type 1 diabetes (T1D) to a decrease of immune system stimuli from infections. We evaluated this prospectively in the Diabetes Autoimmunity Study in the Young (DAISY) by examining daycare attendance during the first two years of life (as a proxy for infections) and the risk of T1D.

METHODS

DAISY is a prospective cohort of children at increased T1D risk. Analyses were limited to 1783 children with complete daycare and breastfeeding data from birth to 2 years of age; 58 children developed T1D. Daycare was defined as supervised time with at least one other child at least 3 times a week. Breastfeeding duration was evaluated as a modifier of the effect of daycare. Cox proportional hazards regression was used for analyses.

RESULTS

Attending daycare before the age of 2 years was not associated with T1D risk (HR: 0.89; CI: 0.54-1.47) after adjusting for HLA, first degree relative with T1D, ethnicity, and breastfeeding duration. Breastfeeding duration modified this association, where daycare attendance was associated with increased T1D risk in nonbreastfed children and a decreasing T1D risk with increasing breastfeeding duration (interaction P value=0.02).

CONCLUSIONS

These preliminary data suggest breastfeeding may modify the effect of daycare on T1D risk.

Risk of renal disease in patients with both type 1 diabetes and coeliac disease

AIMS/HYPOTHESIS

Our aim was to study the risk of renal disease in patients with type 1 diabetes (T1D) and coexisting coeliac disease (CD).

METHODS

Individuals with T1D were defined as having a diagnosis of diabetes recorded at ≤30 years of age in the Swedish Patient Register between 1964 and 2009. Individuals with CD were identified through biopsy reports with villous atrophy (Marsh stage 3) from 28 pathology departments in Sweden between 1969 and 2008. We identified 954 patients with both T1D and CD. For each patient with T1D + CD, we selected five age- and sex-matched reference individuals with T1D only (n = 4,579). Cox regression was used to estimate the following risks: (1) chronic renal disease and (2) end-stage renal disease in patients with CD + T1D compared with T1D patients only.

RESULTS

Forty-one (4.3%) patients with CD + T1D and 143 (3.1%) patients with T1D only developed chronic renal disease. This corresponded to an HR of 1.43 for chronic renal disease (95% CI 0.94, 2.17) in patients with CD + T1D compared with T1D only. In addition, for end-stage renal disease there was a positive (albeit statistically non-significant) HR of 2.54 (95% CI 0.45, 14.2). For chronic renal disease, the excess risk was more pronounced after >10 years of CD (HR 2.03, 95% CI 1.08, 3.79). Risk estimates were similar when we restricted our cohort to the following T1D patients: (1) those who had an inpatient diagnosis of T1D; (2) those who had never received oral glucose-lowering medication; and (3) those who had not received their first diabetes diagnosis during pregnancy.

CONCLUSIONS/INTERPRETATION

Overall this study found no excess risk of chronic renal disease in patients with T1D and CD. However, in a subanalysis we noted a positive association between longstanding CD and chronic renal disease in T1D.

Under a nonadherent state, bone marrow mesenchymal stem cells can be efficiently induced into functional islet-like cell clusters to normalize hyperglycemia in mice: a control study

Introduction

Bone marrow mesenchymal stem cells (BMSCs) possess low immunogenicity and immunosuppression as an allograft, can differentiate into insulin-producing cells (IPCs) by in vitro induction, and may be a valuable cell source to regenerate pancreatic islets. However, the very low differentiation efficiency of BMSCs towards IPCs under adherent induction has thus far hindered the clinical exploitation of these cells. The aim of this study is to explore a new way to efficiently induce BMSCs into IPCs and lay the groundwork for their clinical exploitation.

Methods

In comparison with adherent induction, BMSCs of human first-trimester abortus (hfBMSCs) under a nonadherent state were induced towards IPCs in noncoated plastic dishes using a three-stage induction procedure developed by the authors. Induction effects were evaluated by statistics of the cell clustering rate of induced cells, and ultrastructural observation, dithizone staining, quantitative polymerase chain reaction and immunofluorescence assay, insulin and c-peptide release under glucose stimulus of cell clusters, as well as transplantation test of the cell clusters in diabetic model mice.

Results

With (6.175 ± 0.263) × 10⁵ cells in 508.5 ± 24.5 cell clusters, (3.303 ± 0.331) × 10⁵ single cells and (9.478 ± 0.208) × 10⁵ total cell count on average, 65.08 ± 2.98% hfBMSCs differentiated into pancreatic islet-like cell clusters after nonadherent induction. With (3.993 ± 0.344) × 10⁵ cells in 332.3 ± 41.6 cell clusters, (5.437 ± 0.434) × 10⁵ single cells and (9.430 ± 0.340) × 10⁵ total cell count on average, 42.37 ± 3.70% hfBMSCs differentiated into pancreatic islet-like cell clusters after adherent induction (P < 0.01, n = 10). The former is significantly higher than the latter. Calculated according to the cell clustering rate and IPC percentage in the cell clusters, 29.80 ± 3.95% hfBMSCs differentiated into IPCs after nonadherent induction and 18.40 ± 2.08% hfBMSCs differentiated into IPCs after adherent induction (P < 0.01, n = 10), the former significantly higher than the latter. The cell clusters expressed a broad gene profile related to pancreatic islet cells, released insulin and c-peptide in a glucose concentration-dependent manner, and normalized hyperglycemia of streptozocin-induced mice for at least 80 days following xenograft. Blood glucose of grafted mice rose again after their graft removed. A series of examination of the grafts showed that transplanted cells produced human insulin in recipients.

Conclusions

Our studies demonstrate that nonadherent induction can greatly promote BMSCs to form pancreatic islet-like cell clusters, thereby improving the differentiation efficiency of BMSCs towards IPCs.

Comparative analysis of different biofactories for the production of a major diabetes autoantigen

The 65-kDa isoform of human glutamic acid decarboxylase (hGAD65) is a major diabetes autoantigen that can be used for the diagnosis and (more recently) the treatment of autoimmune diabetes. We previously reported that a catalytically-inactive version (hGAD65mut) accumulated to tenfold higher levels than its active counterpart in transgenic tobacco plants, providing a safe and less expensive source of the protein compared to mammalian production platforms. Here we show that hGAD65mut is also produced at higher levels than hGAD65 by transient expression in Nicotiana benthamiana (using either the pK7WG2 or MagnICON vectors), in insect cells using baculovirus vectors, and in bacterial cells using an inducible-expression system, although the latter system is unsuitable because hGAD65mut accumulates within inclusion bodies. The most productive of these platforms was the MagnICON system, which achieved yields of 78.8 μg/g fresh leaf weight (FLW) but this was substantially less than the best-performing elite transgenic tobacco plants, which reached 114.3 μg/g FLW after six generations of self-crossing. The transgenic system was found to be the most productive and cost-effective although the breeding process took 3 years to complete. The MagnICON system was less productive overall, but generated large amounts of protein in a few days. Both plant-based systems were therefore advantageous over the baculovirus-based production platform in our hands.

Survival of free and encapsulated human and rat islet xenografts transplanted into the mouse bone marrow

Bone marrow was recently proposed as an alternative and potentially immune-privileged site for pancreatic islet transplantation. The aim of the present study was to assess the survival and rejection mechanisms of free and encapsulated xenogeneic islets transplanted into the medullary cavity of the femur, or under the kidney capsule of streptozotocin-induced diabetic C57BL/6 mice. The median survival of free rat islets transplanted into the bone marrow or under the kidney capsule was 9 and 14 days, respectively, whereas that of free human islets was shorter, 7 days (bone marrow) and 10 days (kidney capsule). Infiltrating CD8⁺ T cells and redistributed CD4⁺ T cells, and macrophages were detected around the transplanted islets in bone sections. Recipient mouse splenocytes proliferated in response to donor rat stimulator cells. One month after transplantation under both kidney capsule or into bone marrow, encapsulated rat islets had induced a similar degree of fibrotic reaction and still contained insulin positive cells. In conclusion, we successfully established a small animal model for xenogeneic islet transplantation into the bone marrow. The rejection of xenogeneic islets was associated with local and systemic T cell responses and macrophage recruitment. Although there was no evidence for immune-privilege, the bone marrow may represent a feasible site for encapsulated xenogeneic islet transplantation.

Glycemic control in diabetic children: role of mother's knowledge and socioeconomic status

The aim of this study is to investigate the role of mother's knowledge and socioeconomic status (SES) of the family on glycemic control in diabetic children. Our sample was taken from successive admissions to the outpatient's diabetes clinics in Tuzla, Bosnia and Herzegovina. Diabetes knowledge was assessed using the Michigan Diabetes Research and Training Center Diabetes Knowledge Test. Glycemic control was assessed by glycosylated hemoglobin (HbA(1C)). The mother's demographics were obtained by self-report. To categorize families' SES, parents' level of education, and current employment were recorded and analyzed using the Hollingshed two-factor index of social position. As expected, higher mother's knowledge was significantly associated with lower HbA(1C) (r = -0.2861705, p = 0.0442). Also, a significant correlation was found between the families' SES and HbA(1C) levels (r = 0.4401921; p = 0.0015). Mothers with more knowledge have children with better metabolic control, and low SES is significantly associated with higher levels of HbA1c. Improvement of mothers' knowledge and family SES may improve glycemic control and ultimately decrease acute and chronic complications of diabetes in children.