Psychosocial benefits of insulin pump therapy in children with diabetes type 1 and their families: The pumpkin multicenter randomized controlled trial

Diabetes distress in urban Black youth with type 1 diabetes and their caregivers: associations with glycemic control, depression, and health behaviors

OBJECTIVES

Adolescents with type 1 diabetes (T1D) and their caregivers endorse high diabetes distress (DD). Limited studies have documented the impact of DD on Black youth. The aims of the present study were to (1) describe DD among a sample of Black adolescents with T1D and their caregivers, (2) compare their DD levels with published normative samples, and (3) determine how DD relates to glycemic outcomes, diabetes self-management, parental monitoring of diabetes, and youth depressive symptoms.

METHODS

Baseline data from a multicenter clinical trial were used. Participants (N = 155) were recruited from 7 Midwestern pediatric diabetes clinics. Hemoglobin A1c (HbA1c) and measures of DD, parental monitoring of diabetes care, youth depression and diabetes management behaviors were obtained. The sample was split into (1) adolescents (ages 13-14; N = 95) and (2) preadolescents (ages 10-12; N = 60). Analyses utilized Cohen's d effect sizes, Pearson correlations, t-tests, and multiple regression.

RESULTS

DD levels in youth and caregivers were high, with 45%-58% exceeding either clinical cutoff scores or validation study sample means. Higher DD in youth and caregivers was associated with higher HbA1c, lower diabetes self-management, and elevated depressive symptoms, but not with parental monitoring of diabetes management.

CONCLUSIONS

Screening for DD in Black youth with T1D and caregivers is recommended, as are culturally informed interventions that can reduce distress levels and lead to improved health outcomes. More research is needed on how systemic inequities contribute to higher DD in Black youth and the strategies/policy changes needed to reduce these inequities.

Humanistic burden of pediatric type 1 diabetes on children and informal caregivers: systematic literature reviews

BACKGROUND

Diagnosis of children with type 1 diabetes (T1D) imposes an unprecedented burden on children and their caregivers.

OBJECTIVE

To assess the burden of T1D on children and their informal caregivers, both after a recent diagnosis or after a longer duration of disease.

METHODS

A series of systematic literature reviews were performed to explore the burden of T1D on children with the disease and their primary informal caregivers, based on the time of diagnosis. After the extraction of the qualitative and quantitative data from the included studies, two literature-based conceptual frameworks were developed: on the burden of pediatric T1D on children, and on informal caregivers. A third conceptual framework on the shared burden of pediatric T1D on both children and informal caregivers as part of the same family unit was also developed.

RESULTS

The review of literature has identified a series of factors that affect the quality of life of children with T1D and their informal caregivers, with a direct impact on physical, emotional, and social outcomes. Generally, female patients and older adolescents experience more worry and stress that affects their quality of life. Other categories of factors affecting the child's and caregiver's burden include social, emotional, and physical factors, treatment-related and disease-related factors, as well as their coping abilities. Anxiety, depression, stress, and worry were commonly found among children and caregivers, starting with the diagnosis of T1D and continuing over time in relation to new challenges pertaining to aging or the disease duration.

CONCLUSION

T1D causes a significant burden to affected children and their caregivers, both independently and through transactional interaction within the family unit. Disease burden can be reduced by strengthening individuals for the benefit of the whole family.

Hybrid Closed Loop Systems Improve Glycemic Control and Quality of Life in Historically Minoritized Youth with Diabetes

Background: We assessed changes in glycemic control and person-reported outcome measures (PROMs) with t:slim X2 insulin pump with Control-IQ technology use among historically minoritized youth who are least likely to access hybrid closed loop (HCL) technology. Methods: This single-arm, prospective pilot study enrolled 15 publicly insured, insulin pump-naïve, non-Hispanic Black youth ages 6 to <21 years with type 1 diabetes and hemoglobin A1c (HbA1c) ≥10% in a 6-month study of HCL use. The primary outcome was absolute change in time in range (TIR) (70-180 mg/dL). Secondary outcomes included other continuous glucose monitor metrics, PROMs, and diabetic ketoacidosis (DKA) incidence. Results: For 13 youth (median 14.8 years, 53.3% female, HbA1c 11.7%) who completed the study, baseline TIR of 12.3% (6.3-27.1%) increased 23.7%-points (16.9, 30.5%; P < 0.001) or 5.7 h per day. Percent time >250 mg/dL decreased 33.9%-points (-44.8, -23.1%; P < 0.001) or 8.1 h per day from a baseline of 69.4% (51.6, 84.0%). Median time in HCL was 78.3% (59.7, 87.3%). Youth received 10.1 (9.2, 11.9) boluses per day, 71.7% (63.8, 79.3%) of which were HCL-initiated autoboluses. Diabetes-specific quality of life increased among parents (P < 0.001) and youth (P = 0.004), and diabetes distress decreased in both groups (P < 0.001, P = 0.005). Improvements in glycemia did not correlate with any baseline youth or parent PROMs. DKA was high at baseline (67 episodes/100-person years) and did not increase during the intervention (72 episodes/100-person years, P = 0.78). Conclusion: Improvements in glycemic control and quality of life exceeding pivotal trial findings without increased safety risks among historically minoritized youth emphasize the need for equitable access to HCL systems. ClinicalTrials.gov: clinicaltrials.gov ID (NCT04807374).

Evidence from clinical trials on high-risk medical devices in children: a scoping review

BACKGROUND

Meeting increased regulatory requirements for clinical evaluation of medical devices marketed in Europe in accordance with the Medical Device Regulation (EU 2017/745) is challenging, particularly for high-risk devices used in children.

METHODS

Within the CORE-MD project, we performed a scoping review on evidence from clinical trials investigating high-risk paediatric medical devices used in paediatric cardiology, diabetology, orthopaedics and surgery, in patients aged 0-21 years. We searched Medline and Embase from 1st January 2017 to 9th November 2022.

RESULTS

From 1692 records screened, 99 trials were included. Most were multicentre studies performed in North America and Europe that mainly had evaluated medical devices from the specialty of diabetology. Most had enrolled adolescents and 39% of trials included both children and adults. Randomized controlled trials accounted for 38% of the sample. Other frequently used designs were before-after studies (21%) and crossover trials (20%). Included trials were mainly small, with a sample size <100 participants in 64% of the studies. Most frequently assessed outcomes were efficacy and effectiveness as well as safety.

CONCLUSION

Within the assessed sample, clinical trials on high-risk medical devices in children were of various designs, often lacked a concurrent control group, and recruited few infants and young children.

IMPACT

In the assessed sample, clinical trials on high-risk medical devices in children were mainly small, with variable study designs (often without concurrent control), and they mostly enrolled adolescents. We provide a systematic summary of methodologies applied in clinical trials of medical devices in the paediatric population, reflecting obstacles in this research area that make it challenging to conduct adequately powered randomized controlled trials. In view of changing European regulations and related concerns about shortages of high-risk medical devices for children, our findings may assist competent authorities in setting realistic requirements for the evidence level to support device conformity certification.

Insulin Pump Utilization in 2017-2021 for More Than 22,000 Children and Adults With Type 1 Diabetes: A Multicenter Observational Study

This large type 1 diabetes cohort study showed that insulin pump utilization has increased over time and that use differs by sex, insurance type, and race/ethnicity. Insulin pump use was associated with more optimal A1C, increased use of continuous glucose monitoring (CGM), and lower rates of diabetic ketoacidosis and severe hypoglycemia. People who used an insulin pump with CGM had lower rates of acute events than their counterparts who used an insulin pump without CGM. These findings highlight the need to improve access of diabetes technology through provider engagement, multidisciplinary approaches, and efforts to address health inequities.

Burden of care and a sense of loneliness in caregivers of children with type 1 diabetes. a cross-sectional study

BACKGROUND

Treatment of type 1 diabetes is a process involving not only sick children, but also their caregivers.

AIM

To assess the burden of care and sense of loneliness in caregivers of children with type 1 diabetes. Also, an analysis was conducted of the connection between sociodemographic factors characterizing caregivers and the clinical factors characterizing sick children and between the burden of care and the sense of loneliness.

MATERIALS AND METHODS

The study included 125 caregivers of children with type 1 diabetes. In order to collect the research data, the Caregiver Burden Scale and the Revised UCLA Loneliness Scale were used.

RESULTS

In the research group, the total result in the caregiving burden scale was 2.14, which remains within the average burden level. Caregivers showed the highest burden level in the General Strain Subscale. The analysis showed that mothers experience a greater burden of care than fathers in the General Strain Subscale and that caregivers of younger children are more burdened with care within the Isolation and Disappointment Subscales. Moderate high degree of loneliness was shown in 4.8% of caregivers. A higher burden of care for caregivers of children with type 1 diabetes is accompanied by a higher sense of loneliness.

CONCLUSIONS

The results of this study may help healthcare professionals plan a holistic, family-centered care program that will take into account factors that increase the burden of care: younger age of the affected child, motherhood, caregiver unemployment, feelings of loneliness, lower education, caregiver unemployment, blood glucose meter measurements, and frequent night-time blood glucose measurements.

Cystic Fibrosis-Related Diabetes Workshop: Research Priorities Spanning Disease Pathophysiology, Diagnosis, and Outcomes

Cystic fibrosis (CF) is a recessive disorder arising from mutations in the gene encoding the cystic fibrosis transmembrane conductance regulator (CFTR) protein. CFTR is expressed in numerous tissues, with high expression in the airways, small and large intestine, pancreatic and hepatobiliary ducts, and male reproductive tract. CFTR loss in these tissues disrupts regulation of salt, bicarbonate, and water balance across their epithelia, resulting in a systemic disorder with progressive organ dysfunction and damage. Pancreatic exocrine damage ultimately manifests as pancreatic exocrine insufficiency that begins as early as infancy. Pancreatic remodeling accompanies this early damage, during which abnormal glucose tolerance can be observed in toddlers. With increasing age, however, insulin secretion defects progress such that CF-related diabetes (CFRD) occurs in 20% of teens and up to half of adults with CF. The relevance of CFRD is highlighted by its association with increased morbidity, mortality, and patient burden. While clinical research on CFRD has greatly assisted in the care of individuals with CFRD, key knowledge gaps on CFRD pathogenesis remain. Furthermore, the wide use of CFTR modulators to restore CFTR activity is changing the CFRD clinical landscape and the field's understanding of CFRD pathogenesis. For these reasons, the National Institute of Diabetes and Digestive and Kidney Diseases and the Cystic Fibrosis Foundation sponsored a CFRD Scientific Workshop, 23-25 June 2021, to define knowledge gaps and needed research areas. This article describes the findings from this workshop and plots a path for CFRD research that is needed over the next decade.

Cystic Fibrosis-Related Diabetes Workshop: Research Priorities Spanning Disease Pathophysiology, Diagnosis, and Outcomes

Cystic fibrosis (CF) is a recessive disorder arising from mutations in the gene encoding the cystic fibrosis transmembrane conductance regulator (CFTR) protein. CFTR is expressed in numerous tissues, with high expression in the airways, small and large intestine, pancreatic and hepatobiliary ducts, and male reproductive tract. CFTR loss in these tissues disrupts regulation of salt, bicarbonate, and water balance across their epithelia, resulting in a systemic disorder with progressive organ dysfunction and damage. Pancreatic exocrine damage ultimately manifests as pancreatic exocrine insufficiency that begins as early as infancy. Pancreatic remodeling accompanies this early damage, during which abnormal glucose tolerance can be observed in toddlers. With increasing age, however, insulin secretion defects progress such that CF-related diabetes (CFRD) occurs in 20% of teens and up to half of adults with CF. The relevance of CFRD is highlighted by its association with increased morbidity, mortality, and patient burden. While clinical research on CFRD has greatly assisted in the care of individuals with CFRD, key knowledge gaps on CFRD pathogenesis remain. Furthermore, the wide use of CFTR modulators to restore CFTR activity is changing the CFRD clinical landscape and the field's understanding of CFRD pathogenesis. For these reasons, the National Institute of Diabetes and Digestive and Kidney Diseases and the Cystic Fibrosis Foundation sponsored a CFRD Scientific Workshop, 23-25 June 2021, to define knowledge gaps and needed research areas. This article describes the findings from this workshop and plots a path for CFRD research that is needed over the next decade.

Differences in positive expectancy of hybrid closed loop (HCL) insulin delivery systems do not explain racial differences in HCL use

Aims

Hybrid closed loop (HCL) insulin delivery systems improve glycemia and quality of life among youth with type 1 diabetes (T1D), however there are inequities in use. We aimed to evaluate whether differences in positive expectancy of HCL systems may explain differences in use.

Methods

Fifteen publicly-insured, non-Hispanic Black (NHB) youth with hemoglobin A1_C (HbA1c) ≥ 10% enrolled in a study exploring changes in glycemia and person reported outcomes (PRO) during 6 months of Tandem t:slim X2 insulin pump with Control-IQ technology. At baseline youth and parents completed PROs, including Insulin Delivery Systems: Perceptions, Ideas, Reflections and Expectations (INSPIRE) survey assessing positive expectancy of HCL use, and Problem Areas in Diabetes (PAID) survey assessing diabetes-related distress. Differences between this cohort and the Tandem Control-IQ pediatric pivotal trial (DCLP5) cohort were assessed.

Results

As compared to the DCLP5 cohort (0% NHB, 10% publicly-insured), baseline glycemic indicators were suboptimal (M_HbA1c 11.9 ± 1.4% vs 7.6 ± 0.9%, p < 0.0001; continuous glucose monitor (CGM) time-above-range > 180 mg/dL 82 ± 15% vs 45 ± 18%, p < 0.0001). INSPIRE scores in both cohorts were equally high among youth (80 ± 10 vs 77 ± 13, p = 0.41) and parents (88 ± 14 vs 85 ± 11, p = 0.37). PAID scores were higher among parents (68 ± 19 vs 43 ± 16, p < 0.0001), but not youth (43 ± 16 vs 35 ± 16, p = 0.09) in the historically marginalized cohort as compared to the DCLP5 cohort.

Conclusions

Despite differences in glycemic control and diabetes related burden, positive expectancy of HCL systems is comparable among historically marginalized youth with T1D and the predominantly non-Hispanic White, privately insured DCLP5 cohort. These findings suggest that differences in perceptions of HCL technology may not explain inequities in use.

A Longitudinal View of Disparities in Insulin Pump Use Among Youth with Type 1 Diabetes: The SEARCH for Diabetes in Youth Study

Objective: To evaluate changes in insulin pump use over two decades in a national U.S. sample. Research Design and Methods: We used data from the SEARCH for Diabetes in Youth study to perform a serial cross-sectional analysis to evaluate changes in insulin pump use in participants <20 years old with type 1 diabetes by race/ethnicity and markers of socioeconomic status across four time periods between 2001 and 2019. Multivariable generalized estimating equations were used to assess insulin pump use. Temporal changes by subgroup were assessed through interactions. Results: Insulin pump use increased from 31.7% to 58.8%, but the disparities seen in pump use persisted and were unchanged across subgroups over time. Odds ratio for insulin pump use in Hispanic (0.57, confidence interval [95% CI] 0.45-0.73), Black (0.28, 95% CI 0.22-0.37), and Other race (0.49, 95% CI 0.32-0.76) participants were significantly lower than White participants. Those with ≤high school degree (0.39, 95% CI 0.31-0.47) and some college (0.68, 95% CI 0.58-0.79) had lower use compared to those with ≥bachelor's degree. Those with public insurance (0.84, 95% CI 0.70-1.00) had lower use than those with private insurance. Those with an annual household income <$25K (0.43, 95% CI 0.35-0.53), $25K-$49K (0.52, 95% CI 0.43-0.63), and $50K-$74K (0.79, 95% CI 0.66-0.94) had lower use compared to those with income ≥$75,000. Conclusion: Over the past two decades, there was no improvement in the racial, ethnic, and socioeconomic inequities in insulin pump use, despite an overall increase in use. Studies that evaluate barriers or test interventions to improve technology access are needed to address these persistent inequities.

Continuous subcutaneous insulin infusions: Closing the loop

CONTEXT

Continuous subcutaneous insulin infusions (CSIIs) and continuous glucose monitors (CGMs) have revolutionized the management of diabetes mellitus (DM). Over the last two decades the development of advanced, small, and user-friendly technology has progressed substantially, essentially closing the loop in the fasting and post-absorptive state, nearing the promise of an artificial pancreas. The momentum was mostly driven by the diabetes community itself, to improve its health and quality of life.

EVIDENCE ACQUISITION

Literature regarding CSII and CGM was reviewed.

EVIDENCE SYNTHESIS

Management of DM aims to regulate blood glucose to prevent long term micro and macrovascular complications. CSIIs combined with CGMs provide an integrated system to maintain tight glycemic control in a safe and uninterrupted fashion, while minimizing hypoglycemic events. Recent advances have allowed to 'close the loop' by better mimicking endogenous insulin secretion and glucose level regulation. Evidence supports sustained improvement in glycemic control with reduced episodes of hypoglycemia using these systems, while improving quality of life. Ongoing work in delivery algorithms with or without counterregulatory hormones will allow for further layers of regulation of the artificial pancreas.

CONCLUSION

Ongoing efforts to develop an artificial pancreas have created effective tools to improve the management of DM. CSIIs and CGMs are useful in diverse populations ranging from children to the elderly, as well as in various clinical contexts. Individually and more so together, these have had a tremendous impact in the management of DM, while avoiding treatment fatigue. However, cost and accessibility are still a hindrance to its wider application.

The Effectiveness of Insulin Pump Therapy Versus Multiple Daily Injections in Children With Type 1 Diabetes Mellitus in a Specialized Center in Riyadh

Objectives

Comparison of continuous subcutaneous insulin infusion (CSII) with multiple daily injections (MDI) in achieving glycemic control in youths with type 1 diabetes mellitus (T1DM).

Methods

Retrospective cohort study including 2 matched groups of youths with T1DM treated by CSII or MDI in a tertiary specialized children's hospital in Saudi Arabia. Children and adolescents aged up to 18 years, diagnosed with T1DM and using CSII or MDI, from the period 2016 to 2018. Patients on MDI were newly-diagnosed patients with T1DM who had the disease for only 1 year duration; all CSII patients had at least 1 to 2 years of T1DM but who had just started on pumps in the past 3 months. We excluded patients with other autoimmune diseases, non-ambulatory patients and those admitted to hospital for non-diabetes reasons. Primary outcome was HbA1c at 1, 2, and 3 years, with weight gain as a secondary outcome. Ambulatory glycemic profile was analyzed from a subset of patients using intermittently scanned continuous glucose monitoring (isCGM).

Results

A total of 168 youths with T1DM (n = 129 in the MDI group, n = 39 in the CSII group) were included. The CSII group consistently had lower HbA1c levels compared to the MDI group throughout a 3-year follow up period: 8.1% versus 10.1, P-value < .001 at 1 year, 7.5% versus 10.1% at 2 years, P-value  < .001, 8.9% versus 10.3% at 3 years, P-value = .033. Body mass index significantly increased in both groups at 1 year, although greater in CSII group. In a subgroup using isCGM (n = 37 on MDI and n = 29 on CSII), the CSII group had a lower average blood glucose (194 mg/dL vs 228 mg/dL, P-value = .028) and a lower estimated HbA1c level (8.4% vs 9.6%, P-value = .022).

Conclusion

Treatment with CSII resulted in lower HbA1c compared to MDI in our cohort, which was sustained over a 3-year period.

Psychosocial aspects of continuous subcutaneous insulin infusion in children with type 1 diabetes in Egypt; a limited resources country perspective

BACKGROUND

Novel innovations continue to emerge in type-1 diabetes (T1D) management aiming to improve glycemic control. Assessing the psychosocial outcomes of different treatment modalities is specifically crucial among children with T1D and differs from one population to another.

OBJECTIVES

To compare the health related quality of life (HRQoL) and confidence in diabetes self-management (CIDS) among children with T1D on continuous subcutaneous insulin infusion (CSII) versus multiple daily injections (MDI) and to correlate them with the efficacy of glycemic control, Mini-International Neuropsychiatric Interview for Children and Adolescents(MINI-KID) depression module and socioeconomic-standard scale.

METHODS

This real life study (ClinicalTrials.gov number NCT04756011) included 60 children with T1D (30 on CSII and 30 on MDI), aged 6-18 years. Disease duration, insulin therapy, average self-monitoring of blood glucose (SMBG) and HbA1C were assessed. CIDS, socioeconomic-standard, MINI-KID depression and HRQoL scales were applied.

RESULTS

Children with T1D on CSII have significantly higher HRQoL and CIDS than those on MDI (P < 0.001). A significant negative correlation is found between HRQoL and insulin daily dose(P = 0.022), HbA1C(P < 0.001), average SMBG(P < 0.001) and MINI-KID depression scale(P < 0.001). A significant positive correlation is found between HRQoL and CIDS(P < 0.001) and health care, home sanitation, family possessions and occupation socioeconomic scores(P = 0.033, P = 0.001, P < 0.001 and P = 0.006, respectively). Multivariate regression analysis revealed that HRQoL is most associated with MINI-KID depression scale (P = 0.004) and annual total cost(P < 0.001).

CONCLUSION

Children with T1D on CSII have significantly better HRQoL, CIDS and HbA1C with less depression than those on MDI.

The role of protective psychological factors, self-care behaviors, and HbA1c in young adults with type 1 diabetes

OBJECTIVE

To investigate whether protective psychological factors in young adults with type 1 diabetes are associated with more optimal self-care behaviors and HbA1c, and to explore possible mediators between protective psychological factors and HbA1c.

RESEARCH DESIGN AND METHODS

This cross-sectional study examined the associations between protective psychological factors (optimism, positive efficacy expectancies, and self-compassion), maladaptive psychological factors (depression, anxiety, and stress), self-care behaviors, and HbA1c in 113 young adults (17-25 years) with type 1 diabetes in Auckland, New Zealand. Pearson's correlations, multiple linear regressions, and multiple mediation analyses were used to examine associations and mediators.

RESULTS

Higher positive efficacy expectancies (beliefs about coping with difficulties) were associated with more optimal HbA1c (β = -0.26, 95% CI: -1.99 to -0.45) and more optimal self-care behaviors (β = 0.33, 95% CI: 0.28 to 0.92) in the adjusted models. Higher levels of self-compassion were associated with more optimal self-care behaviors (β = 0.27, 95% CI: 0.09 to 0.43). Depression was associated with less optimal self-care behaviors (β = -0.35, 95% CI: -1.33 to -0.43) and stress was associated with less optimal HbA1c (β = 0.26, 95% CI: 0.27 to 1.21). Mediation results suggested that self-care behaviors mediated the relationship between all three of the protective psychological factors and more optimal HbA1c, and that lower stress also mediated the relationship between higher self-compassion and more optimal HbA1c.

CONCLUSIONS

This study adds to the emerging literature that protective psychological factors may play an adaptive role in improving health outcomes in young adults with type 1 diabetes. Interventions targeting protective psychological factors present a promising approach to optimizing wellbeing and self-care in youth with type 1 diabetes.

Disordered eating behaviour in adolescents with type 1 diabetes on continuous subcutaneous insulin infusion; relation to body image, depression and glycemic control

BACKGROUND

Disordered eating behaviour (DEB) represents a significant morbidity among people with type-1 diabetes (T1D). Continuous-subcutaneous insulin infusion (CSII) improves glycemic control and psychological wellbeing in those with T1D. However, its relation to DEB remains obscure.

OBJECTIVES

To compare DEB among adolescents with T1D on CSII versus basal-bolus regimen and correlate it with body image, HbA1C and depression.

METHODS

Sixty adolescents with T1D (30 on CSII and 30 on basal-bolus regimen), aged 12-17 years were studied focusing on diabetes-duration, insulin therapy, exercise, socioeconomic standard, hypoglycemic attacks/week and family history of psychiatric illness. Anthropometric measures, HbA1C, binge eating scale (BES), body image tool, patient health questionnaire-9 (PHQ9) and the Mini-KID depression scale were assessed.

RESULTS

Among the studied adolescents with T1D, six had DEB (10%), 14 had poor body-image perception (23.3%), 42 had moderate body-image perception (70%) and 22 had depression (36.7%). Adolescents with T1D on CSII had significantly lower BES (p = 0.022), Mini-KID depression (p = 0.001) and PHQ9 (p = 0.02) than those on basal-bolus regimen. BES was positively correlated to depression (p < 0.001), HbA1C (p = 0.013) and diabetes-duration (p = 0.009) and negatively correlated to body-image (p = 0.003).

CONCLUSION

DEB is a prevalent comorbidity among adolescents with T1D, with higher frequency in those on basal-bolus regimen than CSII.

Practical aspects of diabetes technology use: Continuous glucose monitors, insulin pumps, and automated insulin delivery systems

There have been tremendous advances in diabetes technology in the last decade. Continuous glucose monitors (CGM), insulin pumps, and automated insulin delivery (AID) systems aim to improve glycemic control while simultaneously decreasing the burden of diabetes management. Although diabetes technologies have been shown to decrease both hypoglycemia and hyperglycemia and to improve health-related quality of life in individuals with type 1 diabetes, the impact of these devices in individuals with cystic fibrosis-related diabetes (CFRD) is less clear. There are unique aspects of CFRD, including the different underlying pathophysiology and unique lived health care experience and comorbidities, that likely affect the use, efficacy, and uptake of diabetes technology in this population. Small studies suggest that CGM is accurate and may be helpful in guiding insulin therapy for individuals with CFRD. Insulin pump use has been linked to improvements in lean body mass and hemoglobin A1c among adults with CFRD. A recent pilot study highlighted the promise of AID systems in this population. This article provides an overview of practical aspects of diabetes technology use and device limitations that clinicians must be aware of in caring for individuals with CF and CFRD. Cost and limited insurance coverage remain significant barriers to wider implementation of diabetes technology use among patients with CFRD. Future studies exploring strategies to improve patient and CF provider education about these devices and studies showing the effectiveness of these technologies on health and patient-reported outcomes may lead to improved insurance coverage and increased rates of uptake and sustained use of these technologies in the CFRD community.

Impact of virtual care on health-related quality of life in children with diabetes mellitus: a systematic review protocol

INTRODUCTION

Diabetes mellitus is the most common endocrine disorder in children, and the prevalence of paediatric type 1 and type 2 diabetes continue to rise globally. Diabetes clinical care programs pivoted to virtual care with the COVID-19 pandemic-driven social distancing measures. Yet, the impact of virtual care on health-related quality of life in children living with diabetes remains unclear. This protocol reports on the methods that will be implemented to conduct a systematic review to assess the health-related quality of life and metabolic health impacts of virtual diabetes care.

METHODS AND ANALYSIS

We will search MEDLINE, Embase, EMCare, PsycInfo, Web of Science, and the grey literature for eligible studies. We will screen title, abstract, and full-text papers for potential inclusion and assess the risk of bias and the overall confidence in the evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. A meta-analysis will be conducted if two studies report similar populations, study designs, methods, and outcomes.This systematic review will summarise the health-related quality of life outcomes for virtual diabetes care delivery models.

ETHICS AND DISSEMINATION

No ethics approval is required for this systematic review protocol as it does not include patient data. The systematic review will be published in a peer-reviewed journal and presented at international conferences.

PROSPERO REGISTRATION NUMBER

CRD42021235646.

Enhancing Choices Regarding the Administration of Insulin Among Patients With Diabetes Requiring Insulin Across Countries and Implications for Future Care

There are a number of ongoing developments to improve the care of patients with diabetes across countries given its growing burden. Recent developments include new oral medicines to reduce cardiovascular events and death. They also include new modes to improve insulin administration to enhance adherence and subsequent patient management thereby reducing hypoglycaemia and improving long-term outcomes. In the case of insulins, this includes long-acting insulin analogues as well as continuous glucose monitoring (CGM) systems and continuous subcutaneous insulin infusion systems, combined with sensor-augmented pump therapy and potentially hybrid closed-loops. The benefits of such systems have been endorsed by endocrine societies and governments in patients with Type 1 diabetes whose HbA1c levels are not currently being optimised. However, there are concerns with the low use of such systems across higher-income countries, exacerbated by their higher costs, despite studies suggesting their cost-effectiveness ratios are within accepted limits. This is inconsistent in higher-income countries when compared with reimbursement and funding decisions for new high-priced medicines for cancer and orphan diseases, with often limited benefits, given the burden of multiple daily insulin injections coupled with the need for constant monitoring. This situation is different among patients and governments in low- and low-middle income countries struggling to fund standard insulins and the routine monitoring of HbA1c levels. The first priority in these countries is to address these priority issues before funding more expensive forms of insulin and associated devices. Greater patient involvement in treatment decisions, transparency in decision making, and evidence-based investment decisions should help to address such concerns in the future.

Depression in Diabetic Patients: What Is the Link With Eating Disorders? Results of a Study in a Representative Sample of Patients With Type 1 Diabetes

BACKGROUND AND PURPOSE

Comorbidity between diabetes and depression, and diabetes and eating disorders (ED) conveys significant diagnostic, clinical and therapeutic implications. The present study was conducted on a sample of adult outpatients affected by Type 1 Diabetes (T1DM) to assess lifetime prevalence of ED; current prevalence of depression and Disturbed Eating Behaviors (DEB) and their impact on glycemic control. We hypothesized that patients with depression would have higher rates of lifetime ED and current DEB. We hypothesized a significant and independent association between DEB and the prevalence of depression.

MATERIALS AND METHODS

The study was carried out using a cross-sectional design in a sample of 172 diabetic patients with T1DM aged from 17 to 55 years. Lifetime prevalence of ED according to DSM-5 criteria was assessed by means of the Module H modified of the Structured Clinical Interview for DSM-IV Axis I Disorder (SCID-I). The following questionnaires were used: Beck Depression Inventory-IA version (BDI-IA) and Diabetes Eating Problems Survey-Revised (DEPS-R), to assess respectively the current presence of depression and DEB. Socio-demographic, clinical, and laboratory data were also collected.

RESULTS

High rates of depression (35.5%) and DEB (19.2%) were observed in our sample of 172 adult outpatients with T1DM. Lifetime history of ED was present in 20.9% of the sample and was more frequently diagnosed in patients with current depression (34.4% vs. 13.9%, p = 0.002). Higher levels of DEB at DEPS-R significantly increased the odds of depression (adjOR: 1.09; 95% CI: 1.03-1.15; p = 0.003). The presence of DEB was associated with poor glycemic control. On the other hand, no association was found between depression and metabolic compensation.

CONCLUSION

Adult patients with T1DM and depression should be screened for ED and DEB. Treating DEB could positively impact both mood and glycemic control in this population. Further studies should be carried out on a larger patient population using a longitudinal design and an accurate method of evaluation to explore the complex relationship between diabetes, depression, ED, and DEB. Future research should investigate treatment strategies for DEB in T1DM patients and their impact on both psychopathological and metabolic outcomes.

Relation of Health-Related Quality of Life with Glycemic Control and Use of Diabetes Technology in Children and Adolescents with Type 1 Diabetes: Results from a National Population Based Study

OBJECTIVE

The primary aim was to analyse the association between diabetes-specific health-related quality of life (HRQOL) and HbA1c in children and adolescents with type 1 diabetes. The secondary aims were to evaluate the associations between diabetes-specific HRQOL and age, sex, diabetes duration, and the use of diabetes technology in diabetes treatment. Research Design and Methods. Children with type 1 diabetes (10-17 years, N = 1,019) and parents (children <10 years, N = 371; 10-17 years, N = 1,070) completed the DISABKIDS diabetes-specific questionnaire (DDM-10) as part of the 2017 data collection for the Norwegian Childhood Diabetes Registry. The DDM-10 consists of two subscales-'impact' and 'treatment'-with six and four items, respectively. In the linear regression models, the items and subscales were outcome variables, while HbA1c, age, sex, diabetes duration, insulin pump use, and continuous glucose monitoring (CGM) system use were predictor variables.

RESULTS

Lower HbA1c measurements and male sex were associated with higher HRQOL scores on both DDM-10 scales in the age group 10-17 years, but not in children under 10 years. Parents gave lower HRQOL scores than children in the 10-17 age group. Insulin pump and CGM use were not significantly associated with HRQOL on the impact and treatment scale.

CONCLUSIONS

Low HbA1c and male sex are significantly associated with high HRQOL in children aged 10-17 with type 1 diabetes, but the use of diabetes technology is not positively associated with HRQOL. Differences in child- and parent-reported scores imply that parents might both over- and underestimate their child's HRQOL.

Stable Metabolic Control but Increased Demand for Professional Support in Children with Type 1 Diabetes in the Past Ten Years in Bern/Switzerland: A Quality Control Study

INTRODUCTION

Lower HbA1c targets and increasingly complex diabetes management with substantially increasing costs dominate today's type 1 diabetes therapy in children and adolescents.

OBJECTIVE

To evaluate metabolic control in children and adolescents with type 1 diabetes and assess associated factors, evaluate determinants for frequency of healthcare contacts, and compare actual with historical data.

METHOD

This cross-sectional observational study collected data on 178 children and adolescents with type 1 diabetes treated at the University Children's Hospital in Bern.

RESULTS

Mean HbA1c was 7.9% (63 mmol/mol), 33.1% (59/178) of children reached the target of HbA1c < 7.5% (<59 mmol/mol), and 18.0% (32/178) had an HbA1c value < 7.0% (<53 mmol/mol). Compared to historical data, stable HbA1c levels appeared with a doubled proportion of individuals using insulin pumps. Metabolic control was worse with a longer duration of diabetes and younger age at diagnosis but better when parents came from a Western European country. Age at the consultation, use of diabetes technology and native language influenced the number of healthcare contacts. Younger patients, patients using CSII, and patients without an official Swiss language as mother tongue had more consultations with a healthcare professional than older and native language individuals.

CONCLUSION

The metabolic targets in childhood and adolescent type 1 diabetes are still unmet despite a shift towards more technology. Our study documents a higher demand for support and supervision in specific patient groups. An investment to increase healthcare contacts could help combat the increase in total diabetes cost and significantly improve metabolic control.

Cystic fibrosis-related diabetes: The patient perspective

Cystic fibrosis-related diabetes (CFRD) affects nearly 20% of adolescents and 40-50% of adults. However, the impact on patients and their families is poorly understood. Here, we examine how patients perceive CFRD and identify gaps in our understanding of the patient experience. Despite its relatively high prevalence, data suggest that many individuals are not aware of the possibility of developing CFRD or compare it to other types of diabetes. Annual oral glucose tolerance testing (OGTT) may serve as an opportunity to provide education and prepare individuals for the possibility of developing abnormalities in glucose tolerance. Many cite lack of awareness of CFRD as the most difficult part of the diagnosis. While factors such as older age and a strong support system promote acceptance, most individuals view the diagnosis negatively and struggle to balance the demands of diabetes with other obligations, including airway clearance, nebulizer therapies, supplementation nutrition, and administration of vitamins and medications. Relatively few people with CFRD monitor their blood glucoses consistently, which is attributed to time constraints or an attempt to avoid pain. In addition, many feel that they are not prone to hypoglycemia and are not concerned with long-term complications, anticipating that they will succumb to their pulmonary disease before these become problematic. The adolescent period presents unique challenges for adherence as children work to develop autonomy. Factors that promote CFRD adherence include incorporating management into daily CF routines and the support of knowledgeable providers to help develop an individualized approach to management. Diabetes technology has the potential to reduce treatment burden and improve glycemic control, but data in CFRD are limited, and additional study is needed. Given that CFRD is associated with a decline in health-related quality of life, it is critical that providers understand patients' perspectives and address gaps in understanding and barriers to management.

Barriers to Uptake of Insulin Technologies and Novel Solutions

Diabetes-related technology has undergone great advancement in recent years. These technological devices are more commonly utilized in the type 1 diabetes population, which requires insulin as the primary treatment modality. Available devices include insulin pumps, continuous glucose monitors, and hybrid systems referred to as automated insulin delivery systems or hybrid closed-loop systems, which combine those two devices along with software algorithms to achieve advanced therapeutic capabilities, including automatic modulation of insulin delivery based on sensor-derived glucose levels to minimize abnormal glucose trends. Use of diabetes technology is associated with significant positive health and psychosocial outcomes, yet utilization rates are generally lacking across both adult and pediatric type 1 diabetes populations in the United States and other countries. There are consistent themes in existing barriers to technology uptake reported by individuals with type 1 diabetes or parents of children with type 1 diabetes, including physical burdens associated with wearing the devices, concerns in navigating the technology and the devices’ abilities to meet user expectations, high cost, inadequate resources within the healthcare team to support device use, disparities in technology access, and psychosocial barriers. It is important to understand the common barriers to uptake of not only the automated insulin delivery systems but also their component devices (insulin pumps and continuous glucose monitors) to fully support individuals in utilizing these devices and optimizing health benefits. The purpose of this article is to summarize the current automated insulin delivery devices that are available for use in management of type 1 diabetes, review common barriers to uptake of those systems and their component devices, and provide expert opinion on existing and future solutions to identified barriers.

Perceptions of Diabetes Technology Use in Cystic Fibrosis-Related Diabetes Management

Background: Diabetes technologies are associated with improvements in glycemic control and health-related quality of life among people with type 1 diabetes (T1D). Use and perceptions of continuous glucose monitors (CGM) and insulin pumps within the cystic fibrosis (CF) community have not been well studied. Methods: A 30-item online survey addressing cystic fibrosis-related diabetes (CFRD) diagnosis, CGM and insulin pump use, and perceptions of diabetes technologies was sent to a CF community group, including people with CF (pwCF) and parents of children with CF (cwCF). Results: The response rate was 11% (n = 120; 83 pwCF, 35 cwCF). Sixty-one percent of pwCF and 34% of cwCF reported a diagnosis of CFRD. CGM use was reported by 75% (n = 47) of respondents with CFRD but was discontinued by 19% (n = 9), most commonly due to cost and increased worry about glycemia. Insulin pump therapy was reported by 29% (n = 18 of 62) of respondents with CFRD and was discontinued by 28% (n = 5), most commonly due to pain or skin irritation. Overall, 91% agreed or strongly agreed that CGM facilitated CFRD management. Eighty-one percent agreed with at least five of seven positive statements about CGM as compared with 22% for insulin pumps. Potential embarrassment over device wear, concerns about cost, and pain were commonly held negative perceptions of both technologies. Conclusions: As compared with T1D and despite perceived benefits, rates of sustained diabetes technology use are low in the CFRD community. Better insurance coverage to mitigate cost, better patient education, and confirmation that these technologies improve health and patient-reported outcomes may increase uptake.

Expect the unexpected: Adolescent and pre-teens' experience of diabetes technology self-management

OBJECTIVE

Only 17% of adolescents with type 1 diabetes (T1D) are currently meeting their glycemic targets despite advances in diabetes technologies. Self-management behaviors and challenges specific to use of diabetes technologies are insufficiently studied in adolescents. We aimed to describe the experience of diabetes technology self-management, including facilitators and barriers, among preteens/adolescents with low and high A1C.

RESEARCH DESIGN AND METHODS

Youth (10-18 years of age) with T1D who use insulin pump therapy were recruited from the larger quantitative cohort of a mixed methods study for participation in semi-structured qualitative interviews. Maximum variability sampling was used to recruit youth with A1C <7.5% (n = 5) and A1C >9% (n = 5). Participants' personal insulin pump and continuous glucose monitoring data were downloaded and served as a visual reference. Interviews were analyzed using a qualitative descriptive approach.

RESULTS

Participants were 50% female with a median age of 14.9 years and 80% used CGM. The sample was predominantly white (90.0%). Analysis produced four major themes, Bad Day, Expect the Unexpected, Nighttime Dependence, and Unpredictability, It's Really a Team and interconnecting subthemes. Youth characterized ''Bad Days'' as those requiring increased diabetes focus and self-management effort. The unpredictability (''Expect the Unexpected'') of glucose outcomes despite attention to self-management behaviors was considerable frustration.

CONCLUSIONS

Diabetes devices such as insulin pumps are complex machines that rely heavily on individual proficiency, surveillance, and self-management behaviors to achieve clinical benefit. Our findings highlight the dynamic nature of self-management and the multitude of factors that feed youths' self-management behaviors.

State of the science: A scoping review and gap analysis of adolescent insulin pump self-management

PURPOSE

Adolescent diabetes outcomes remain poor despite increased use of diabetes technologies such as insulin pump therapy. Meaningful research examining adolescent insulin pump self-management has been done, however, a summary of these self-management findings has not been published. The aim of this literature review is to map, evaluate, and summarize existing adolescent insulin pump self-management research.

METHOD

A scoping review of three databases was conducted to comprehensively report and synthesize relevant literature published before September 2019.

RESULTS

Of the 1295 titles identified, 18 articles met the inclusion criteria and were included in this scoping review. Key insulin pump self-management behaviors were featured in the literature, most notably self-monitoring of blood glucose (SMBG) and bolus frequency. Several factors were found to influence pump self-management including psychological factors, parental support and self-management transition, insulin pump education and knowledge acquisition, and environmental factors. We uncovered five gaps in the literature including: an unclear delineation of adolescent age; limited minority representation; variability in the definitions and reporting of self-management behaviors; the role of data sharing and remote monitoring was not addressed; and there remains limited inquiry into diabetes burden and distress associated with insulin pump self-management.

PRACTICE IMPLICATIONS

There exists a consensus that well-established behaviors, such as bolus and SMBG frequency, influence glycemic outcomes for adolescent insulin pump users, however, full insulin pump utilization and self-management is poorly understood. Diabetes clinicians should work to support adolescent insulin pump self-management practices by reinforcing bedrock behaviors while fostering supportive factors found to influence pump self-management.

Application of Nano-Insulin Pump in Children with Diabetic Ketoacidosis

Type 1 diabetes is an insulin-dependent type of diabetes that is most common among children. Due to absolute deficiency of insulin in patients, diabetic ketoacidosis (DKA) can easily ensue. Insulin pump can simulate the physiological secretion of islet, but increases the risk of pain and infection in children due to its traumatic effect. This study aimed to analyze the application effect of nano-insulin pump in children with DKA. Children with DKA admitted to our hospital from May 2018 to May 2020 were included in this study and, according to the random number table method, they were divided into two groups, with each group containing 36 cases. The first group received traditional insulin pump infusion (IP), while the second group received nano-insulin pump infusion (NIP). It was found that the reduction of FBG and PBG in NIP group was greater than that in IP group. The recovery time of urine ketone, blood ketone, glucose, venous pH, and other clinical indicators in the NIP group were all lower than those in the IP group (P < 0.05). The length of hospital stay, insulin dosage, incidence of hypoglycemia, and infusion site infection rate in the NIP group were all lower than those in the IP group (P <0.05). The findings indicate that the application of nano-insulin pump in children with DKA had a significant effect and could quickly and obviously correct the levels of blood glucose and ketone body in children.

Newest Diabetes-Related Technologies for Pediatric Type 1 Diabetes and Its Impact on Routine Care: a Narrative Synthesis of the Literature

Purpose of Review

This review aims to address the actual state of the most advanced diabetes devices, as follows: continuous subcutaneous insulin infusions (CSII), continuous glucose monitoring systems (CGM), hybrid-closed loop (HCL) systems, and “Do-it-yourself” Artificial Pancreas Systems (DIYAPS) in children, adolescents, and young adults. This review has also the objective to assess the use of telemedicine for diabetes care across three different areas: education, social media, and daily care.

Recent Findings

Recent advances in diabetes technology after integration of CSII with CGM have increased the popularity of this treatment modality in pediatric age and shifted the standard diabetes management in many countries. We found an impressive transition from the use of CSII and/or CGM only to integrative devices with automated delivery systems. Although much has changed over the past 5 years, including a pandemic period that precipitated a broader use of telemedicine in diabetes care, some advances in technology may still be an additional burden of care for providers, patients, and caregivers. The extent of a higher rate of “auto-mode” use in diabetes devices while using the HCL/DIYAPS is essential to reduce the burden of diabetes treatment.

Summary

More studies including higher-risk populations are needed, and efforts should be taken to ensure proper access to cost-effective advanced technology on diabetes care.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40124-021-00248-7.

The combination of medical devices and medicinal products revisited from the new European legal framework

Medical devices and medicinal products have many similarities in their nature, scope or specific medical purposes, and despite the differences in their principal means of action, they are often used in combination. Indeed, many medicinal products depend on medical devices for their administration, and it is increasingly common for medical devices to contain medicinal substances to support their action. Therefore, the combination of medicinal products and medical devices provides additional benefits for patients. However, their higher technical complexity requires a strengthening of their authorisation and certification requirements. In this regard, more comprehensive requirements and classification rules are introduced by a new European regulation on medical devices that fully applies from May 26^th 2021. On account of their therapeutic significance, this review aims at gaining insight into the borderline between medical devices and medicinal products in this new 2021 regulatory framework. For the first time, any item containing a medical device and a medicinal product will have both parts evaluated. Through exemplification of both marketed and investigational devices incorporating medicinal substances and drug-device combinations, the new European requirements and their implications are thoroughly illustrated herein.

Impact of deprivation on glycaemic control in youth with type 1 diabetes in the southwestern region of France

OBJECTIVES

The objective of this multicenter cross-sectional study was to determine predictors of poor glycaemic control in children with type 1 diabetes mellitus (T1DM), particularly with respect to socioeconomic status (SES).

METHODS

Our study population consisted of 1154 children who attended T1DM follow-up consultation with a pediatric diabetes specialist. Clinical and demographic data were retrieved retrospectively from patients' records. Individual deprivation was defined by an EPICES (Evaluation of the Deprivation and Inequalities of Health in Healthcare Centers) score ≥ 30. Patients were assigned to quintiles of the European Deprivation Index (EDI) based on their area deprivation scores. We used multivariable linear regression models to detect potential associations between glycaemic control and indicators of low SES.

RESULTS

In total, 33% (n = 376) of patients had an EPICES score ≥ 30 and 23% (n = 268) were in the 5th EDI quintile. Multivariable linear regression analysis showed that poor glycaemic control was associated with both individual (β 0.38; 95%CI 0.26-0.5; p < 0.001) and area deprivation (β 0.26; 95%CI 0.08-0.43; p = 0.004). Demographic factors, body mass index (BMI) and insulin regimen were also independently associated with poor glycaemic control (p < 0.001). Interestingly, access to diabetes technologies was not related to SES or either glycaemic control.

CONCLUSION

Low SES is associated with a higher risk of poor glycaemic control, independently of insulin regimen. BMI, age at the time of consultation, duration of diabetes, and insulin regimen. Also have an impact on HbA1c. These parameters need to be considered when developing novel treatment strategies for children with T1DM to better target at-risk patients.

Self-reported insulin pump prescribing practices in pediatric type 1 diabetes

INTRODUCTION

Disadvantaged and minority youth with type 1 diabetes are less likely to be on insulin pump therapy compared to the majority population. Little is known about how pediatric endocrinology providers determine eligibility for insulin pump. We aimed to identify provider factors influencing the decision to initiate insulin pump therapy.

METHODS

We conducted a survey of Pediatric Endocrine Society members who prescribe insulin pump therapy to pediatric patients with type 1 diabetes. The survey collected information about prescriber characteristics, use and adherence to guidelines, eligibility criteria, and objective and subjective factors that influence insulin pump prescription.

RESULTS

The survey was completed by 192 individuals who met eligibility criteria (14.1% response rate). The majority of respondents were attending providers, and were white, non-Hispanic females. A minority of providers (22%) reported following written insulin pump guidelines, and many (70%) reported using personal guidelines to guide patient selection. Most providers had no objective eligibility criteria, aside from standard glucose monitoring. Providers identified patient lifestyle and increased risk of hypoglycemia, as well as patient and family factors such as motivation, realistic expectations of insulin pump use, ability to demonstrate carbohydrate counting, patient request, and ability to communicate as important in the decision to initiate insulin pump.

CONCLUSION

Pediatric endocrinology providers place significant importance on subjective factors and utilize few objective criteria in determining eligibility for insulin pump. In the setting of the known disparities in insulin pump use, providers should utilize objective, consistent criteria to determine which patients are safe to initiate insulin pump.

Use of insulin pump therapy is associated with reduced hospital-days in the long-term: a real-world study of 48,756 pediatric patients with type 1 diabetes

In pediatric diabetes, insulin pump therapy is associated with less acute complications but inpatient pump education may lead to more hospital days. We investigated the number of hospital days associated with pump vs. injection therapy between 2009 and 2018 in 48,756 patients with type 1 diabetes < 20 years of age from the German Diabetes Prospective Follow-up Registry (DPV). Analyses were performed separately for hospitalizations at diagnosis (hierarchical linear models adjusted for sex, age, and migration), and for hospitalizations in the subsequent course of the disease (hierarchical Poisson models stratified by sex, age, migration, and therapy switch). At diagnosis, the length of hospital stay was longer with pump therapy than with injection therapy (mean estimate with 95% CI: 13.6 [13.3-13.9] days vs. 12.8 [12.5-13.1] days, P < 0.0001), whereas during the whole follow-up beyond diagnosis, the number of hospital days per person-year (/PY) was higher with injection therapy than with pump therapy (4.4 [4.1-4.8] vs. 3.9 [3.6-4.2] days/PY), especially for children under 5 years of age (4.9 [4.4-5.6] vs. 3.5 [3.1-3.9] days/PY).Conclusions: Even in countries with hospitalizations at diabetes diagnosis of longer duration, the use of pump therapy is associated with a reduced number of hospital days in the long-term. What is known: • In pediatric diabetes, insulin pump therapy is associated with better glycemic control and less acute complications compared with injection therapy. • However, pump therapy implies more costs and resources for education and management. What is new: • Even in countries where pump education is predominantly given in an inpatient setting, the use of pump therapy is associated with a reduced number of hospital days in the long-term. • Lower rates of hospitalization due to acute complications during the course of the disease counterbalance longer hospitalizations due to initial pump education.

The effect of insulin pump therapy in retinal vasculature in type 1 diabetic patients

BACKGROUND/OBJECTIVES

Continuous subcutaneous insulin infusion (CSII) is a treatment for type 1 diabetes that improves metabolic control and reduces micro and macrovascular complications. The aim of this study was to compare the effect of CSII versus traditional multiple daily injections (MDI) therapy on retinal vasculature.

METHODS

We performed a prospective study with type 1 diabetic patients with no prior history of ocular pathology other than mild diabetic retinopathy. The patients were divided into two groups according to their therapeutic modality (CSII vs MDI). The retinal nerve fiber layers thickness and vascular densities were compared between groups in both macula and optic disc. The correlations between vascular density and clinical features were also determined. Statistical significance was defined as p < 0.05.

RESULTS

The study included 52 eyes, 28 in the insulin CSII group. The mean age was 36.66 ± 12.97 years, with no difference between groups (p = 0.49). The mean glycated hemoglobin (HbA1c) was found to be lower in the CSII group (7.1% ± 0.7 vs 7.5% ± 0.7 p < 0.01). The parafoveal vascular density was found to be higher in the CSII group (42.5% ± 0.4 vs 37.7% ± 0.6, p < 0.01). We found an inverse correlation between HbA1c value and parafoveal vascular densities (p < 0.01, r = -0.50).

CONCLUSION

We found that CSII provided better metabolic control than MDI and this seemed to result in higher parafoveal vascular density. As lower vascular density is associated with an increased risk of diabetic retinopathy, these results suggest that CSII could be the safest therapeutic option to prevent retinopathy.

Early versus delayed insulin pump therapy in children with newly diagnosed type 1 diabetes: results from the multicentre, prospective diabetes follow-up DPV registry

BACKGROUND

Although continuous subcutaneous insulin infusion therapy (ie, insulin pump therapy) is associated with improved metabolic control compared with multiple daily insulin injections in children with type 1 diabetes, it is unclear when it is best to start it after diagnosis. In this study, we aimed to compare the outcomes between early and delayed start of insulin pump therapy in young patients with type 1 diabetes.

METHODS

We based the current study on data from the multicentre, prospective diabetes follow-up registry (ie, Diabetes-Patienten-Verlaufsdokumentation [DPV]). The DPV registry comprises 501 diabetes centres from Germany, Austria, Switzerland, and Luxembourg. We included patients diagnosed with type 1 diabetes between 2004 and 2014, who were aged between 6 months and 15 years at the time of diagnosis, who had started insulin pump therapy either within the first 6 months (ie, the early treatment group) or in the second to third year (ie, the delayed treatment group) after diabetes diagnosis, and who were treated with insulin pump therapy for at least 1 year. The outcome parameters included the glycated haemoglobin (HbA_1c) values, the cardiovascular risk profile, and rates of acute complications and diabetes-associated hospital admissions (ie, hospitalisation) during the most recent documented treatment year with insulin pump therapy. Statistical models were adjusted for age at diabetes diagnosis, year of diagnosis, sex, immigrant background, use of continuous glucose monitoring, centre size, and the German Index of Socioeconomic Deprivation 2012 terciles.

FINDINGS

Our study sample comprised 8332 patients from 311 diabetes centres in Germany, Austria, Switzerland, and Luxembourg. The early treatment group consisted of 4004 (48·1%) of 8332 patients, and the delayed treatment group consisted of 4328 (51·9%). The median diabetes duration during follow-up was 6·7 years (IQR 5·1-8·7 in the early group; 5·0-8·7 in the delayed group) in both groups. Patients with early initiation of insulin pump therapy compared with those with delayed initiation of insulin pump therapy had significantly lower estimated mean HbA_1c values (7·9% [95% CI 7·8-7·9] and 62·6 mmol/mol [95% CI 62·1-63·2] vs 8·0% [8·0-8·1] and 64·1 mmol/mol [63·6-64·6]; p=0·0006), and lower rates of hypoglycaemic coma (incidence risk ratio 0·44 [95% CI 0·24-0·79]; p=0·0064) and hospitalisation (0·86 [95% CI 0·78-0·94]; p=0·0016). A better cardiovascular risk profile was observed in patients with early initiation of insulin pump therapy than in those with delayed initiation: an estimated mean systolic blood pressure of 117·6 mm Hg (95% CI 117·2-117·9) versus 118·5 mm Hg (118·2-118·9), p=0·0007; and HDL cholesterol of 62·8 mg/dL (95% CI 62·2-63·5) versus 60·6 mg/dL (60·0-61·2), p<0·0001; however, diastolic blood pressure; concentrations of LDL cholesterol, non-HDL cholesterol, and triglycerides; and estimated body-mass index standard deviation scores during follow-up did not differ significantly between both groups.

INTERPRETATION

Our findings provide evidence for improved clinical outcomes associated with the early initiation of insulin pump therapy in children with type 1 diabetes.

FUNDING

The German Center for Diabetes Research (Deutsches Zentrum für Diabetesforschung), German Robert Koch Institute, German Diabetes Association, and Diabetes Agenda 2010.

Pharmacotherapy of Children and Adolescents with Type 1 Diabetes Mellitus

Insulin treatment in children and adolescents with autoimmune type 1 diabetes has changed tremendously in the last 20 years with the knowledge of DCCT trial regarding near-normal glucose levels on the micro- and macrovascular outcome. Intensified insulin therapy is now standard of care. Carb counting however was introduced systematically only recently in several countries. In industrialized countries most patients in this age group are treated with continuous subcutaneous insulin injections. Nowadays this is combined with continuous subcutaneous glucose measurement commencing sensor-augmented pump therapy. Predictive low glucose suspend reduces the frequency of hypoglycemic events. Still not available for children is a commercially available closed loop system. However, treatment goals are still frequently not reached especially in the group of adolescents. Therefore several additive drugs are tested to improve treatment results. There are new insulins with faster and longer action profile in the pipeline to better mimic physiologic insulin profiles. Smart insulins may be able to mimic reaction on blood sugar levels. The broad facet of treatment modalities helps pediatric diabetes teams to individualize therapy and so improve patients' health-related quality of life.

Insulinpumpe, kontinuierliche und kapilläre Glukosemessung bei Kindern, Jugendlichen und Erwachsenen mit Diabetes mellitus: Daten des DPV-Registers zwischen 1995 und 2019

Ziel dieser Beobachtungsstudie ist die Beschreibung der aktuellen Nutzung von Diabetestechnologien bei Patienten/-innen mit Diabetes mellitus.

Methode Auswertung von Daten des DPV-Registers zur Nutzung der Insulinpumpentherapie (CSII), kontinuierlicher Glukosemessung (CGM) und der Selbstmessung der Blutglukose (SMBG) aus 497 teilnehmenden Zentren in Deutschland, Österreich, Luxemburg und der Schweiz zwischen 1995 und 2019. Die Daten wurden bei Patienten/-innen mit Diabetes Typ 1 (Alter ≥ 0,5 Jahre) für 5 Altersgruppen ausgewertet. Zusätzlich wurden aktuelle (zwischen 2017 und 2019) Geschlechtsunterschiede in der Verwendung von Diabetestechnologie bei Typ-1-Patienten/-innen untersucht, ebenso wie die Nutzung von Insulinpumpen und CGM für Patienten/-innen mit Insulintherapie bei Typ-2-DM, bei zystischer Fibrose (CFRD), bei anderen Pankreaserkrankungen, neonatalem Diabetes und Maturity Onset Diabetes of the Young (MODY).

Ergebnisse Es zeigte sich bei Patienten/-innen mit Diabetes Typ 1 ein Anstieg der CSII-Nutzung von 1995 bis 2019 von 1 % auf 55 % (2019: < 6 Jahre: 89 %; 6–< 12 Jahre: 67 %; 12–< 18 Jahre: 52 %; 18–< 25 Jahre: 48 %; ≥ 25 Jahre: 34 %). Die CGM-Nutzung erhöhte sich ab 2016 bis 2019 von 9 % auf 56 % (2019: 67 %; 68 %; 61 %; 47 %; 19 % der jeweiligen Altersgruppe). Die SMBG nahmen von 1995 bis 2015 insbesondere in den jüngeren Altersgruppen zu, gefolgt von einem Rückgang seit dem Jahr 2016 (Alle Patienten: 1995: 3,3/Tag; 2016: 5,4/Tag; 2019: 3,8/Tag). Weibliche Patienten mit Typ-1-Diabetes führten häufiger eine CSII und mehr SMBG als männliche Patienten durch (56 %/48 %, jeweils p-Wert: < 0,0001), während sich bei der CGM-Nutzung keine signifikanten Unterschiede zeigten.

Zwischen 2017 und 2019 erfolgte eine Nutzung von Insulinpumpen und CGM bei neonatalem Diabetes (CSII 87 %; CGM 38 %), bei MODY (CSII 14 %; CGM 28 %) und bei CFRD (CSII 18 %; CGM 22 %). CGM und CSII wurden dagegen nur selten von Menschen mit Insulintherapie und Diabetes Typ 2 (CSII < 1 %; CGM 1 %) und bei anderen Pankreaserkrankungen (CSII 3 %; CGM 4 %) genutzt.

Schlussfolgerung Moderne Diabetestechnologien werden derzeit insbesondere von pädiatrischen Patienten/-innen mit Diabetes Typ 1, aber auch von Menschen mit neonatalem Diabetes breit genutzt, von Patienten/-innen mit MODY und CFRD sowie Erwachsenen mit Diabetes Typ 1 in etwas geringerem Maße mit ansteigendem Trend. Dagegen sind diese Technologien in der Therapie des Typ-2-Diabetes und bei anderen Pankreaserkrankungen zurzeit nur wenig verbreitet.

Insulin Pump Therapy Improves Quality of Life of Young Patients With Type 1 Diabetes Enrolled in a Government-Funded Insulin Pump Program: A Qualitative Study

BACKGROUND

The Nova Scotia Insulin Pump Program (NSIPP) subsidizes the cost of insulin pump therapy for young patients (≤25 years) with type 1 diabetes. The first NSIPP evaluation focused on clinical outcomes rather than quality of life. Existing research on insulin pumps and quality of life is mostly survey based, with limited first-voice experiences. In this qualitative study, we examined patient and parent perspectives on how insulin pumps affect quality of life in the context of a government-funded program.

METHODS

In this investigation, we used a phenomenological approach, guided by a conceptual model. In-depth semistructured telephone interviews (median, 37 minutes) were completed with NSIPP enrollees and/or their parents. Saturation was reached after 23 interviews. Verbatim transcripts were coded independently by 2 researchers. Coding discrepancies were discussed and resolved using concept mapping to clarify relationships between codes and to identify main themes.

RESULTS

There were 2 main themes: 1) NSIPP financial support was necessary for those without private insurance and 2) control over life and diabetes with subthemes of social experiences and worry. Participants expressed this theme differently depending on their stage of life. For example, some children experienced shame and even hid their pump, whereas teens were more self-confident with the discreetness of pumps and young adults wore their pump with pride.

CONCLUSIONS

Insulin pump therapy, subsidized through the NSIPP, led to improved quality of life, which was experienced differently depending on stage of life.

Health-related quality of life and metabolic control in immigrant and Italian children and adolescents with type 1 diabetes and in their parents

OBJECTIVE

To determine if the diabetes-specific health-related quality of life (D-HRQOL) of young people with type 1 diabetes (T1D) and their parents is influenced by migrant status.

SUBJECTS AND METHODS

One hundred and twenty-five patients (12.4 ± 3.55 years, males 53.6%) with T1D and their parents (102 mothers, 37 fathers) were enrolled and categorized into: group A (both foreign parents) and group B (both native Italian parents). The Pediatric Quality of Life Inventory™ 3.0 Diabetes Module (PedsQL™ 3.0 DM) was used to evaluate the D-HRQOL. Data on diabetic ketoacidosis (DKA) at T1D onset, insulin therapy, and glycosylate hemoglobin (HbA1c) were also collected.

RESULTS

Group A (n = 40), compared to group B (n = 85), had higher frequency of DKA at T1D onset (P < .001) and a lower use of sensor augmented insulin pump (P = .015). HbA1c values were higher in group A than in group B (P < .001). Patients' "Diabetes symptoms" (P = .004), "Treatment barriers" (P = .001), and "Worry" (P = .009) scales scores were lower in group A than in group B. Mothers of group A had lower scores in "Diabetes symptoms" (P = .030), "Treatment barriers" (P < .001), "Treatment adherence" (P = .018), "Communication" (P = .009) scales, and total score (P = .011) compared to the group B ones. High PedsQL™ 3.0 DM was significantly associated with being Italian, being prepubertal, and having lower HbA1c mean levels.

CONCLUSIONS

Being a migrant confers disadvantages in terms of D-HRQOL and metabolic control in children and adolescents with T1D. Specific educational interventions should be considered in the clinical care of patients with migration background, to improve D-HRQOL and health status.

Nutrition habits of children and adolescents with type 1 diabetes changed in a 10 years span

BACKGROUND

Diet plays a key role in the treatment of type 1 diabetes (T1D). Dietary habits changed rapidly in the last decades and few data are available on recent dietary changes in children and adolescents with T1D.

OBJECTIVE

To test the hypothesis that diet composition changed in a 10-year period in children and adolescents with T1D.

METHODS

Two hundred and twenty-nine T1D subjects (M/F:121/108) aged 6 to 16 years were recruited: 114 (group A) enrolled in 2009, not using CGM and/or CSII, and 115 (group B) enrolled in 2019. Anthropometric biochemical (HbA1c, lipid profile), diet, and insulin therapy parameters were compared between the two groups. Multivariate logistic regression analysis was performed with HbA1c as dependent variable (HbA1c > 58 mmol/mol = 1) and nutritional variables and technology use as independent ones.

RESULTS

Energy intake of group A was not statistically different from that of group B. Group B had a significantly (P < 0.001) higher protein and lipids intake and lower total carbohydrate and fiber intake than group A. HbA1c was significantly (P < 0.01) lower in group B than in group A. Logistic regression analysis showed that MUFA (OR 0.83, 95%CI:0.693-0.998), fiber intake (OR 0.82, 95%CI:0.699-0.0969), and technology use (OR 0.15, 95%CI:0.031-0.685), adjusted for age, gender, BMI, energy intake and diabetes duration, were associated with a HbA1c higher than 58 mmol/mol) (R² = 0.27, P < 0.05).

CONCLUSIONS

In a 10-year period, diet composition of children and adolescents with T1D changed and glucometabolic control improved. Fiber and MUFA intake showed a positive effect on HbA1c, independent from technology use, supporting the importance of educating children with T1D and families to maintain healthy eating habits.

Improving pediatric endocrinology trainees' knowledge about insulin pumps and continuous glucose monitors with online spaced education: Technology Knowledge Optimization in T1D (TeKnO T1D)

OBJECTIVE

We explored the impact of TeKnO T1D, an online, case-based, spaced education curriculum about insulin pump and continuous glucose monitor (CGM) use in pediatric type 1 diabetes management.

METHODS

Pediatric endocrinology fellows (n = 64) were randomized to receive an educational curriculum focused on either insulin pumps or CGMs. Fellows received interactive questions twice weekly via email or mobile app. Median time to completion was 76.5 days. The primary outcome was change in knowledge as measured by performance on multiple-choice questions (MCQ) from the pre-test to the post-test.

RESULTS

Forty-eight of 64 (75%) learners completed the curriculum and assessments. The pump group improved from 35.0 ± 15% on the pre-test MCQs to 61.1 ± 17% on the post-test, a 12.2 absolute percentage point greater improvement on pump-specific items than the CGM group (P = .03). The CGM group improved from 30.3 ± 15% on the pre-test MCQs to 61.4 ± 21% on the post-test, a 28.7 absolute percentage point greater improvement on CGM-specific items than the pump group (P < .001). Both groups were more likely to report an appropriate level of understanding of their respective technologies after completing the corresponding curriculum. In thematic analysis of qualitative data, fellows indicated that knowledge gains led to improved patient care. There was universal agreement about enjoyment and effectiveness of the curricula.

CONCLUSIONS

TeKnO T1D proved to be an engaging, effective way to improve endocrinology fellows' knowledge and confidence about insulin pumps and CGM use in the management of pediatric type 1 diabetes.

Insulin Pump Therapy

BACKGROUND

Advances in pump technology have increased the popularity of this treatment modality among patients with type 1 diabetes and recently also among patients with type 2 diabetes.

AREAS OF UNCERTAINTY

Four decades after the incorporation of the insulin pump in clinical use, questions regarding its efficacy, occurrence rate of short-term complications as hypoglycemia and diabetes ketoacidosis, timing of pump initiation, and selected populations for use remain unanswered.

DATA SOURCES

A review of the literature was performed using the PubMed database to identify all articles published up till December 2018, with the search terms including insulin pump therapy/continuous subcutaneous insulin delivery. The Cochrane database was searched for meta-analysis evaluating controlled randomized trials. Consensuses guidelines published by the International Society for Pediatric and Adolescent Diabetes, American Diabetes Association, and Advanced Technologies and Treatments for Diabetes year books were additionally reviewed for relevant cited articles.

THERAPEUTIC ADVANCES

Insulin pump therapy offers flexible management of diabetes. It enables adjustment of basal insulin to daily requirements and circadian needs, offers more precise treatment for meals and physical activity, and, when integrated with continuous glucose monitoring, allows glucose responsive insulin delivery. The ability to download and transmit data for analysis allow for treatment optimization. Newer pumps are simple to operate and increase user experience. Studies support the efficacy of pump therapy in improving glycemic control and reducing the occurrence of hypoglycemia without increasing episodes of diabetes ketoacidosis. They also improve quality of life. Recent evidence suggests a role for pump therapy in reducing microvascular and macrovascular diabetes-related complications.

CONCLUSIONS

Insulin pump therapy appears to be effective and safe in people with T1D regardless of age. Future advancements will include incorporation of closed loop and various decision support systems to aid and improve metabolic control and quality of life.

Psychosocial Aspects of Diabetes Technology Use: The Child and Family Perspective

This article offers a systematic review of the literature on psychosocial aspects of technology use in children and adolescents with type 1 diabetes and their families, searching for relevant articles published the past 5 years. Topics included continuous subcutaneous insulin infusion, continuous glucose monitoring, predictive low-glucose suspend, and artificial pancreas systems. The review indicates there are positive and negative psychosocial aspects to diabetes technology use among youth and their families. Although consistent findings were revealed, contradictions exist. Discussed are recommendations for future research and implications for how health care providers can collaborate with families to discuss and manage diabetes technology.

Use of Diabetes Technology in Children: Role of Structured Education for Young People with Diabetes and Families

The current era has witnessed an explosion of advanced diabetes technologies. Young people with diabetes and their families require detailed, structured diabetes education in order to optimize use of such devices. There is need for youth and their families to participate in the selection of particular devices for personal use and comprehensive education regarding the safe and effective use of such technologies. The education process should ensure that youth and their families receive realistic expectations of what the advanced technologies can and cannot do to avoid disappointment and the premature discontinuation of such systems.

Monthly Video-Consultation for Children With Type 1 Diabetes Using a Continuous Glucose Monitoring System: Design of ViDiKi, a Multimethod Intervention Study to Evaluate the Benefit of Telemedicine

BACKGROUND

The introduction of continuous glucose monitoring (CGM) implies new challenges for diabetes care. As CGM systems are often directly linked to a web-based software solution, structured telemedicine care using a video-consultation may be a new option for families who care for children with type 1 diabetes mellitus (T1DM).

METHODS

"ViDiKi" (Virtual Diabetes Outpatient Clinic for Children and Youth) is a multicenter controlled trial carried out in Northern Germany. ViDiKi will examine if monthly telemedical consultations, in addition to regular care, will improve glycemic control and psychosocial outcomes. The primary outcome is glycemic control as measured by a change in glycated hemoglobin (HbA1c). A total of 240 participants aged between one year and 16 years using a CGM with multiple daily injections (MDI) or insulin pump therapy were recruited and assigned to a starter group or a six-month waiting control group. The sample size is designed to detect a between-group difference of 0.5% in HbA1c change at six months. Secondary outcomes are variability of blood glucose, health-related quality of life, self-efficacy, and satisfaction with telemedicine. To gain deeper insight into the experience of using telemedicine, qualitative interviews will be conducted. In a health-economic analysis, the costs of telemedicine and a cost-of-care analysis will be calculated.

CONCLUSIONS

The results from the ViDiKi study shall give important information on the feasibility and putative benefits of telemedicine in children with T1DM and their caregivers.

GERMAN CLINICAL TRAILS REGISTER (DRKS)

DRKS00012645.

Temporal Trends and Contemporary Use of Insulin Pump Therapy and Glucose Monitoring Among Children, Adolescents, and Adults With Type 1 Diabetes Between 1995 and 2017

OBJECTIVE

To investigate temporal trends and contemporary use of insulin pump therapy and glucose monitoring in type 1 diabetes.

RESEARCH DESIGN AND METHODS

In a population-based study, we analyzed the use of insulin pump therapy, continuous glucose monitoring (CGM), and self-monitoring of blood glucose (SMBG) from 1995 to 2017 in patients with type 1 diabetes identified from the Diabetes Prospective Follow-up (DPV) database in Germany and Austria. Patients were stratified by age, sex, migration background, and country.

RESULTS

Among 96,547 patients with type 1 diabetes (median age 17.9 years, 53% males), the percentage using insulin pump therapy increased from 1% in 1995 to 53% in 2017, with the highest rates in the youngest patients (92% in preschoolers, 74% in children, 56% in adolescents aged <15 years, 46% in adolescents aged ≥15 years, 37% in adults). The percentage of patients using CGM increased from 3% in 2006 to 38% in 2017, with the highest rates in the youngest patients (58%, 52%, 45%, 33%, and 15% of respective age-groups). Daily SMBG frequencies increased from 1995 to 2016 and decreased afterward, most prominently in the youngest patients. Between 2015 and 2017, pump therapy was more frequently used in female versus male adolescents and adults (all P < 0.001), while no sex differences were observed for pump use in children <10 years (all P = 1.0) and for CGM use in all age-groups (all P = 1.0).

CONCLUSIONS

Since 1995, insulin pump use has continuously increased, and insulin pump therapy is now standard in patients aged <15 years. CGM use sharply rose in recent years, particularly in young children.

Health-related quality of life in paediatric patients with Type 1 diabetes mellitus using insulin infusion systems. A systematic review and meta-analysis

Background

In 2017, more than 1.1 million children were living with type 1 diabetes mellitus (T1DM) globally. The goal in paediatric diabetes therapy is reaching optimal glycaemic control as early as possible in order to avoid complications and early mortality without compromising the quality of life (QoL) of children. Several different insulin regimens are available for T1DM patients to reach this goal.

Aims

This review set out to analyse whether continuous subcutaneous insulin infusion (CSII) regimens are superior to multiple daily injection (MDI) therapy in T1DM youth regarding QoL. Additionally, it assessed glycaemic control and adverse events as secondary outcomes and discussed potential future public health implications and justifications for using CSII as a first-line therapy in diabetic youth.

Methods

A systematic review and random effects meta-analysis was performed on studies investigating the association between QoL and diabetes treatment regimen. Differences in adverse event rates between groups were analysed using a Mann-Whitney U test. Lastly, differences in glycaemic control were assessed using a random effects meta-analysis.

Results

QoL and glycaemic control was significantly better in CSII subjects at baseline and follow-up. No significant differences in adverse events were found between study groups. No significant changes over time could be shown for either QoL or glycaemic control.

Conclusion

CSII proved to provide similar or slightly better outcomes in all analysed fields. This is consistent with previous research. However, to make credible recommendations, better-designed studies are needed to investigate the impact of CSII in children.

Continuous subcutaneous insulin infusion versus multiple daily injections for type 1 diabetes

To review the literature on continuous subcutaneous insulin infusion (CSII) and multiple daily injections (MDI) to help the family of a 13-year-old girl with type 1 diabetes mellitus on MDI choose the best insulin delivery method for her to improve her glycaemic control. A literature search was performed to assess available evidence regarding CSII use versus MDI use for glycaemic control. We identified 15 relevant articles and present these, with a detailed analysis of a multicentre randomised controlled trial by Mueller-Godeffroy et al. Although CSII use demonstrated a reduction in HbA_1c (-0.18 to -0.7%) in some studies compared to MDI, this finding was not consistent across all studies. Mueller-Godeffroy et al. did not find a statistically significant different in HbA_1c between CSII and MDI patients; however, additional benefits of insulin pump therapy, including improved diabetes-related quality of life and reduced care giver burden, were reported. Further high-quality randomised controlled trials and long-term data are required to assess the benefits of CSII over MDI and the longevity of these methods.