Universal Subsidized Continuous Glucose Monitoring Funding for Young People With Type 1 Diabetes: Uptake and Outcomes Over 2 Years, a Population-Based Study

OBJECTIVE

Continuous glucose monitoring (CGM) is increasingly used in type 1 diabetes management; however, funding models vary. This study determined the uptake rate and glycemic outcomes following a change in national health policy to introduce universal subsidized CGM funding for people with type 1 diabetes aged <21 years.

RESEARCH DESIGN AND METHODS

Longitudinal data from 12 months before the subsidy until 24 months after were analyzed. Measures and outcomes included age, diabetes duration, HbA1c, episodes of diabetic ketoacidosis and severe hypoglycemia, insulin regimen, CGM uptake, and percentage CGM use. Two data sources were used: the Australasian Diabetes Database Network (ADDN) registry (a prospective diabetes database) and the National Diabetes Service Scheme (NDSS) registry that includes almost all individuals with type 1 diabetes nationally.

RESULTS

CGM uptake increased from 5% presubsidy to 79% after 2 years. After CGM introduction, the odds ratio (OR) of achieving the HbA1c target of <7.0% improved at 12 months (OR 2.5, P < 0.001) and was maintained at 24 months (OR 2.3, P < 0.001). The OR for suboptimal glycemic control (HbA1c ≥9.0%) decreased to 0.34 (P < 0.001) at 24 months. Of CGM users, 65% used CGM >75% of time, and had a lower HbA1c at 24 months compared with those with usage <25% (7.8 ± 1.3% vs. 8.6 ± 1.8%, respectively, P < 0.001). Diabetic ketoacidosis was also reduced in this group (incidence rate ratio 0.49, 95% CI 0.33-0.74, P < 0.001).

CONCLUSIONS

Following the national subsidy, CGM use was high and associated with sustained improvement in glycemic control. This information will inform economic analyses and future policy and serve as a model of evaluation diabetes technologies.

Randomized placebo-controlled trial on azithromycin to reduce the morbidity of bronchiolitis in Indigenous Australian infants: rationale and protocol

BACKGROUND

Acute lower respiratory infections are the commonest cause of morbidity and potentially preventable mortality in Indigenous infants. Infancy is also a critical time for post-natal lung growth and development. Severe or repeated lower airway injury in very young children likely increases the likelihood of chronic pulmonary disorders later in life. Globally, bronchiolitis is the most common form of acute lower respiratory infections during infancy. Compared with non-Indigenous Australian infants, Indigenous infants have greater bacterial density in their upper airways and more severe bronchiolitis episodes. Our study tests the hypothesis that the anti-microbial and anti-inflammatory properties of azithromycin, improve the clinical outcomes of Indigenous Australian infants hospitalised with bronchiolitis.

METHODS

We are conducting a dual centre, randomised, double-blind, placebo-controlled, parallel group trial in northern Australia. Indigenous infants (aged ≤ 24-months, expected number = 200) admitted to one of two regional hospitals (Darwin, Northern Territory and Townsville, Queensland) with a clinical diagnosis of bronchiolitis and fulfilling inclusion criteria are randomised (allocation concealed) to either azithromycin (30 mg/kg/dose) or placebo administered once weekly for three doses. Clinical data are recorded twice daily and nasopharyngeal swab are collected at enrollment and at the time of discharge from hospital. Primary outcomes are 'length of oxygen requirement' and 'duration of stay,' the latter based upon being judged as 'ready for respiratory discharge'. The main secondary outcome is readmission for a respiratory illness within 6-months of leaving hospital. Descriptive virological and bacteriological (including development of antibiotic resistance) data from nasopharyngeal samples will also be reported.

DISCUSSION

Two published studies, both involving different patient populations and settings, as well as different macrolide antibiotics and treatment duration, have produced conflicting results. Our randomised, placebo-controlled trial of azithromycin in Indigenous infants hospitalised with bronchiolitis is designed to determine whether it can reduce short-term (and potentially long-term) morbidity from respiratory illness in Australian Indigenous infants who are at high risk of developing chronic respiratory illness. If azithromycin is efficacious in reducing the morbidly of Indigenous infants hospitalised with bronchiolitis, the intervention would lead to improved short term (and possibly long term) health benefits.

Enteral resuscitation and early enteral feeding in children with major burns--effect on McFarlane response to stress

AIM

Early enteral feeding has become standard practice for burned patients. The aim of this study was to determine whether early enteral feeding could be used as an avenue for resuscitation and feeding and the effect it would have on the induction/amelioration of the hormonal stress response.

METHOD

Eighteen children with <20% TBSA were randomly assigned to either early enteral feeding and resuscitation, or intravenous resuscitation with the induction of enteral feeding delayed. The enteral fluid volume was incrementally increased every 3h with a simultaneous equal reduction in the intravenous volume until all the calculated intravenous fluid requirements for resuscitation and maintenance could be administered enterally. In the second group, intravenous resuscitation continued for 48 h when enteral feeding was introduced. Parameters measured were the clinical responses and outcome as well as the concentrations of insulin, insulin-like growth factor 1, glucagon, cortisone and growth hormone. The estimated and calculated energy expenditure was measured calorimetrically and bowel permeability was assessed using a dual sugar absorption test.

RESULTS

Three children were excluded from the study because of early death from organ failure or carbon monoxide poisoning. Early enteral resuscitation and feeding (ER/EEF) was initiated within a median of 10.7h post-burn in nine children and late enteral feeding introduced on an average 54 h post-burn. The ER/EEF group showed an anabolic response with significantly higher insulin concentrations (p=0.008) and insulin: glucagon ratios (p=0.043). Although blood glucose concentrations were initially slightly elevated (EEF: 10.3g/l, LEF: 8.1g/l), they rapidly returned to within the normal range. The cortisol and IGF1 concentrations did not differ significantly between the two treatment groups. Growth hormone concentrations were significantly higher in the late enteral feeding (LEF) group (p=0.03). The estimated energy expenditure was not different amongst the groups. Small bowel permeability [lactulose:rhamnose (L:R) ratios] decreased significantly over time (p=0.02) in both study groups. No pulmonary aspiration was found. Diarrhoea in the ER/EEF settled quickly (2-4 days), whereas in the LEF group it persisted for longer than a week. The LEF group lost a median of 7.75% (acceptable range=<or=5%) of admission body weight, whereas the ER/EEF group lost a median of 3.01%. Patients in the LEF group required antibiotic treatment for a longer period (p=0.08) and their hospital stay was longer, though not significant.

CONCLUSIONS

Enteral resuscitation and early enteral feeding is a safe and effective method and particularly suited for children in developing countries. It resulted in the amelioration of the hormonal stress response and improved outcome. Enteral resuscitation should not be introduced in a patient in shock or with existing gastrointestinal disease. Complications were minimal.

Mother-infant interactions and infant development are altered by maternal iron deficiency anemia

The aim of this study was to determine whether iron deficiency anemia (IDA) in young South African mothers alters mother-infant interactions and the infant's development. The study was a prospective, randomized, controlled intervention trial with 3 groups of mothers: nonanemic controls and anemic mothers administered either placebo (25 mg ascorbic acid and 10 microg folate) or daily iron treatment (125 mg FeSO(4) plus ascorbate and folate). Mothers of full-term, normal birth weight infants (n = 81) were followed from 10 wk to 9 mo postpartum. Maternal iron status, socioeconomic level, mother-infant interaction [Parent/Caregiver Involvement Scale (PCIS scale)], and infant development (Griffiths scale) were assessed. At baseline, anemic mothers tended (P < 0.10) to be less responsive to, and more controlling of, their infants. Infants of anemic mothers were developmentally delayed at 10 wk in hand-eye movement and overall quotient. Despite normalization of maternal iron status with supplementation in some mothers, the developmental delays were not diminished at 9 mo. At 9 mo, anemic mothers were significantly more "negative" towards their babies, engaged less in goal setting, and were less "responsive" than control mothers. In contrast, the behavior of anemic mothers given iron treatment toward their children was similar to that of the control mothers on all 11 scales of the PCIS. In conclusion, IDA altered mother-child interactions at both 10 wk and 9 mo postpartum. Additionally, infants whose mothers were anemic in the early postpartum scored worse on developmental tests at 10 wk and 9 mo of age.

Maternal iron deficiency anemia affects postpartum emotions and cognition

The aim of this study was to determine whether iron deficiency anemia (IDA) in mothers alters their maternal cognitive and behavioral performance, the mother-infant interaction, and the infant's development. This article focuses on the relation between IDA and cognition as well as behavioral affect in the young mothers. This prospective, randomized, controlled, intervention trial was conducted in South Africa among 3 groups of mothers: nonanemic controls and anemic mothers receiving either placebo (10 microg folate and 25 mg vitamin C) or daily iron (125 mg FeS0(4), 10 microg folate, 25 mg vitamin C). Mothers of full-term normal birth weight babies were followed from 10 wk to 9 mo postpartum (n = 81). Maternal hematologic and iron status, socioeconomic, cognitive, and emotional status, mother-infant interaction, and the development of the infants were assessed at 10 wk and 9 mo postpartum. Behavioral and cognitive variables at baseline did not differ between iron-deficient anemic mothers and nonanemic mothers. However, iron treatment resulted in a 25% improvement (P < 0.05) in previously iron-deficient mothers' depression and stress scales as well as in the Raven's Progressive Matrices test. Anemic mothers administered placebo did not improve in behavioral measures. Multivariate analysis showed a strong association between iron status variables (hemoglobin, mean corpuscular volume, and transferrin saturation) and cognitive variables (Digit Symbol) as well as behavioral variables (anxiety, stress, depression). This study demonstrates that there is a strong relation between iron status and depression, stress, and cognitive functioning in poor African mothers during the postpartum period. There are likely ramifications of this poorer "functioning" on mother-child interactions and infant development, but the constraints around this relation will have to be defined in larger studies.

Empiric red cell transfusion in asymptomatic preterm infants

In a prospective randomized trial, asymptomatic very low-birth-weight infants in a neonatal intensive care unit were either electively transfused with red cells to maintain capillary haematocrit greater than 0.35 l/1 (group 1; n = 9), or were not transfused (group 2; n = 10). Individuals from both groups were excluded if they subsequently received non-elective transfusions, necessitated by their clinical condition. Electively transfused infants gained weight more rapidly than their non-transfused counterparts, but the duration of hospitalization was not shortened. Criteria of morbidity, such as patent ductus murmurs, apnoea and failure to thrive, were similar in both groups. We conclude that in the absence of clinical indications, transfusion to achieve a hematocrit greater than 0.35 l/1 as an empiric procedure, improves weight gain but the risks of transfusion are likely to outweigh the benefits.

Comparison of enteral and intramuscular vitamin A supplementation in preterm infants

Vitamin A deficiency associated with preterm delivery is not readily reversible using the recommended supplement of 1500 IU per day. It has been reported that 2000 IU of intramuscular vitamin A administered on alternate days for 28 days will correct the deficiency. The objective of this study was to compare this regime with the practice in our nursery of giving 5000 IU of vitamin A per day with the early introduction of feeds. The vitamin A status of ten preterm infants (mean gestation 30.5 weeks) who received intramuscular vitamin supplementation was compared with that of nine infants (mean gestation 30.7 weeks) given enteral vitamin A. Vitamin A status was evaluated on the 32nd day of life using plasma retinol and retinol-binding protein (RBP) concentrations and a modified relative dose response (RDR) test. Plasma retinol and RBP concentrations were similar in the two groups shortly after birth revealing vitamin A deficiency. By the 32nd day of life, plasma retinol and RBP concentrations had risen significantly in both groups and in 70% the modified RDR was normal. Differences between the groups were not observed irrespective of the method of vitamin A administration. None of the infants developed clinical or biochemical vitamin A toxicity. In most preterm infants who tolerate feeds, vitamin A deficiency can be corrected safely by supplementing the feeds with 5000 IU of vitamin A per day.

Serum erythropoietin concentrations in symptomatic infants during the anaemia of prematurity

A comparison was carried out between a series of neonates who weighed less than 1500 g at birth and received red cell transfusions for symptomatic anaemia of prematurity (group 1, n = 14) and controls of similar gestational age and weight, who remained well and were not transfused during their nursery stay (group 2, n = 10). Mean (SD) haemoglobin concentrations at birth were 163 (12) g/l and 183 (17) g/l (p = 0.004), respectively. Transfusion resulted in significantly better weight gain in six infants who had been growing poorly:mean (SE) 8.8 (2.8) g/day improved to 23.3 (2.1) g/day (p less than 0.002). Geometric mean (SD) serum immunoreactive erythropoietin (SiEp) concentrations (17.7 (1.3) U/l) for the whole group of infants were similar to those of normal adults (17.4 (4.7) U/l) despite considerably reduced haemoglobin values. There was a significant inverse correlation between haemoglobin and log SiEp concentrations in the infants requiring transfusion (r = -0.43; p less than 0.01), but this was not apparent in the untransfused babies. Moreover, at haemoglobin concentrations below 120 g/l the mean (SE) SiEp concentration of 20 (1.08) U/l in group 1 was significantly higher than in group 2 (14 (1.06) U/l; p = 0.002). These data suggest that an increased concentration of SiEp early in the course of the anaemia of prematurity helps to identify those infants who would benefit from red cell transfusions, but that clinical criteria, although ill defined, do so equally well.

Pancreas transplantation in the pig. A trial of various immunosuppressive regimens

Five immunosuppressive regimens which included prednisone, azathioprine and niridazole were compared in pancreatectomized pigs after orthotopic whole-pancreas transplantation. The survival time was longer than in non-immunosuppressed pigs, but only in those given niridazole 500 mg twice daily was this marked. The weekly plasma insulin and glucagon values and responses to the oral glucose load 7 days after transplantation showed that prednisone 1,0 g/d and azathioprine 100 mg/d, or niridazole 500 mg twice daily, were successful immunosuppressive agents. These data add to the increasing evidence that whole-organ pancreas transplantation would be more successful than the use of isolated islets. Specifically, it appears that the pancreas alone may be used, thereby avoiding the complications associated with combined pancreaticoduodenal grafting.