Carine Choleau

Continuous glucose monitoring: physiological and technological challenges.

Over the past decade, several continuous glucose monitoring systems have been developed, representing remarkable technological achievements. Most of the systems monitor glucose invasively in the subcutaneous tissue. It is important to realize that there are discrepancies between blood and interstitial glucose concentration, which (1) may impact the quality of the system calibration and thereby the accuracy of the data, (2) may jeopardize the specificity and the sensitivity of hypoglycaemic alarms based on these systems and (3) must be considered in the design of closed-loop insulin delivery systems. The aim of this review is to make the point that the challenge of developing a continuous glucose monitoring system is not only technological, but must also take into account the physiology of glucose in alternate sites where it is sensed.

Changes in insulin therapy regimens over 10 yr in children and adolescents with type 1 diabetes attending diabetes camps

To describe the changes in insulin therapy regimens of children and adolescents with type 1 diabetes over 10u2009yr and their correlation with hemoglobin A1c (HbA1c).

A Novel Method for Assessing Insulin Dose Adjustments by Patients with Diabetes

Background: Insulin treated diabetic patients often do not adjust their insulin doses. We developed a method to provide a quantitative and qualitative assessment of this behavior. Methods: Fourteen patients provided logbook pages of their self-monitoring of blood glucose (SMBG) data and insulin doses. We compared the actual decisions of patients in real-life to what they would decide on the same SMBG, as an a posteriori exercise. We also compared these decisions and those proposed by 6 diabetologists on the same sets of data to the recommendations made by HumaLink, an automated insulin dosage system. Results: 1) Patients in real-life modified their insulin doses least often. However, given a chance to make these decisions a posteriori, they modified their insulin doses more often. HumaLink proposed changes even more often, and diabetologists were the most aggressive in changing insulin doses. 2) The decisions proposed by the patients in real-life or a posteriori and by the diabetologists were compared to the recommendations made by HumaLink, using a decisions analysis grid (DAG). For these three groups, full disagreement with HumaLink (patient or physician increases while HumaLink decreases and the opposite) was observed for less than 5% of the cases. 3) By comparison to HumaLink, patient decisions seemed guided by the desire to avoid hypoglycemia. By contrast, decisions by diabetologists seemed often to be guided by the desire to avoid hyperglycemia. Conclusion: These methods provide an objective evaluation of insulin dose adjustments by patients with diabetes and may be useful to assess the effectiveness of educational programs.

A novel method for measuring patients' adherence to insulin dosing guidelines: introducing indicators of adherence

BackgroundDiabetic type 1 patients are often advised to use dose adjustment guidelines to calculate their doses of insulin. Conventional methods of measuring patients adherence are not applicable to these cases, because insulin doses are not determined in advance. We propose a method and a number of indicators to measure patients conformance to these insulin dosing guidelines.MethodsWe used a database of logbooks of type 1 diabetic patients who participated in a summer camp. Patients used a guideline to calculate the doses of insulin lispro and glargine four times a day, and registered their injected doses in the database. We implemented the guideline in a computer system to calculate recommended doses. We then compared injected and recommended doses by using five indicators that we designed for this purpose: absolute agreement (AA): the two doses are the same; relative agreement (RA): there is a slight difference between them; extreme disagreement (ED): the administered and recommended doses are merely opposite; Under-treatment (UT) and over-treatment (OT): the injected dose is not enough or too high, respectively. We used weighted linear regression model to study the evolution of these indicators over time.ResultsWe analyzed 1656 insulin doses injected by 28 patients during a three weeks camp. Overall indicator rates were AA = 45%, RA = 30%, ED = 2%, UT = 26% and OT = 30%. The highest rate of absolute agreement is obtained for insulin glargine (AA = 70%). One patient with alarming behavior (AA = 29%, RA = 24% and ED = 8%) was detected. The monitoring of these indicators over time revealed a crescendo curve of adherence rate which fitted well in a weighted linear model (slope = 0.85, significance = 0.002). This shows an improvement in the quality of therapeutic decision-making of patients during the camp.ConclusionOur method allowed the measurement of patients adherence to their insulin adjustment guidelines. The indicators that we introduced were capable of providing quantitative data on the quality of patients decision-making for the studied population as a whole, for each individual patient, for all injections, and for each time of injection separately. They can be implemented in monitoring systems to detect non-adherent patients.

High day-to-day glucose variability : A frequent phenomenon in children and adolescents with type 1 diabetes attending summer camp

BACKGROUNDnDay-to-day glucose variability may cause difficulty for patients trying to adjust their insulin dosages and for healthcare providers when they have to make recommendations. The aim of this research was to evaluate the frequency of high variability in a population of diabetic children and adolescents attending summer camp.nnnMETHODS AND RESULTSnThe mean of the daily differences (MODD) in glucose concentrations was calculated from continuous glucose monitoring (CGM) over five consecutive days in 6 diabetic patients. This index was correlated to the MODD calculated from pre-meal and bedtime blood glucose (BG) measurements (r=0.87). We used the MODD calculated on these four BG measurements for five consecutive days to evaluate day-to-day glucose variability in 100 young diabetic patients treated with glargine and ultrarapid analogue insulin. Only one child had a MODD value lower than 36mg/dl, considered a threshold for high day-to-day variability, and 94 children had a MODD value higher than 45mg/dl. The median value was 78mg/dl. The expected positive correlation between the MODD and its standard deviation (r=0.32, P<0.01) suggested that the greater the day-to-day variability, the more variable the variability across five consecutive days.nnnCONCLUSIONSnThe estimation of MODD from four pre-meal BG values correlated to that from CGM, and may represent a simple index of day-to-day glycaemic variability. High day-to-day glucose variability in glucose profile is frequently observed in diabetic children attending summer camp.

Insulin regimens, diabetes knowledge, quality of life, and HbA1c in children and adolescents with type 1 diabetes.

To further describe the changes in insulin therapy regimens and hemoglobin A1c (HbA1c) in children and adolescents with type 1 diabetes, and their associations with diabetes knowledge and quality of life.

Diabetes knowledge in adolescents with type 1 diabetes and their parents and glycemic control

To evaluate diabetes knowledge and skills (DKS) in adolescents (>10u2009year) with type 1 diabetes (T1D) and their parents, and its effect on glycemic control.

PO14 - Fréquence et circonstances de l’acidocétose inaugurale en France, à partir de 1 000 nouveaux cas de diabète de type 1 diagnostiqués dans 139 services de pédiatrie

Introduction L’incidence du diabete de type 1 est en augmentation chez l’enfant, particulierement chez les plus jeunes. Les signes revelateurs du diabete ont souvent une evolution tres aigue chez l’enfant, et l’acidocetose est souvent revelatrice, le risque semblant lie a l’âge et souvent a un retard au diagnostic. Les donnees francaises les plus recentes sont celles de l’etude Eurodiab. L’AJD a debute en novembre 2009 un observatoire national afin d’etablir les circonstances du diagnostic de diabete chez l’enfant et l’adolescent et d’evaluer l’impact d’une campagne nationale de prevention de l’acidocetose. Patients et methodes Les donnees de mille nouveaux cas de diabete de type 1, issus de 139 services de pediatrie, ont ete collectees. Resultats Le diagnostic de diabete de type 1 est plus frequent dans la tranche d’âge 10–15 ans : 26 % ont entre 0 et 4 ans, 34 % entre 5 et 9 ans, et 40 % ont entre 10 et 14 ans. Les signes revelateurs sont la polyuro-polydipsie dans 97 % des cas, l’enuresie dans 35 %. Dans 60 % des cas, ces symptomes etaient presents depuis plus de 2 semaines. 30 % des enfants ont ete amenes a l’hopital a l’initiative de la famille, 9 % sont arrives sous le conseil du pediatre, et 55 % ont ete adresses par un medecin generaliste. L’etat de deshydratation est observe dans pres de 50 % des cas, 25 % des enfants ont des nausees et/ou des difficultes respiratoires et 7 % arrivent en coma. 40 % des enfants arrivent a l’hopital en etat d’acidocetose (pHxa0 Conclusion L’acidocetose inaugurale est encore une complication grave et frequente du diabete. Ces donnees justifient pleinement et vont permettre d’evaluer l’impact de la campagne de prevention de l’acidocetose au diagnostic de diabete qui debute en novembre 2010.

O08 HbA1c, schémas thérapeutiques, connaissances et qualité de vie chez les enfants et les adolescents ayant un diabète de type 1

Objectif Etudier l’evolution des schemas de traitement par l’insuline chez les enfants et les adolescents ayant un diabete de type 1, et leurs liaisons avec l’HbA1c. Patients et methodes L’etude a inclus 4 293 enfants et adolescents (âge: 12,9 ± 2,6 ans, plus d’un an de diabete), ayant participe aux sejours d’ete de l’Aide aux Jeunes Diabetiques (AJD) de 2009 a 2014. La distribution des differents schemas de traitement, et les liaisons entre Hb1Ac, schemas therapeutiques, connaissance du diabete (questionnaire AJD) et qualite de vie (Ingersoll et Marrero, version courte du Hvidoere Study Group) ont ete evaluees en fonction des annees. Resultats Le pourcentage de jeunes traites par la pompe a augmente jusqu’a environ 45 %, celui des schemas basal bolus s’est maintenu au-dessus de 40 %, alors que les autres schemas ont diminue de facon tres marquee. L’HbA1c a diminue de 0,014 % par an et le pourcentage d’HbA1c ≤ 7,5 % n’a pas augmente, sauf avec la pompe ; celui d’HbA1c > 9 % et > 10 % a diminue de plus de moitie et de facon plus marquee avec la pompe. L’HbA1c est significative-ment plus basse avec la pompe (8,12 ± 1,09 %) et 2-3 injections (8,18 ± 1,28 %) qu’avec le basal bolus (8,32 ± 1,33 %). L’HbA1c est correlee au niveau de connaissance du diabete chez les jeunes de plus de 14 ans, et fortement correlee aux scores de qualite de vie independamment de l’âge. Conclusion Le pourcentage des jeunes qui atteint l’objectif de 7,5 % d’HbA1c progresse peu, alors que le pourcentage de ceux qui sont les plus a risque de complications est en nette diminution. La distribution des HbA1cs evalue mieux l’equilibre glycemique d’une population que la moyenne ou le pourcentage de patients ayant atteint l’objectif. L’HbA1c est plus fortement liee a la qualite de vie qu’aux schemas therapeutiques et a la connaissance du diabete. Declaration d’interet Les auteurs declarent ne pas avoir d’interet direct ou indirect (financier ou en nature) avec un organisme prive, industriel ou commercial en relation avec le sujet presente.

P288 Étude de la technique d’injection d’insuline et des ressentis des jeunes ayant un diabète de type 1

Objectif En France, 18 000 jeunes de moins de 20 ans ont un diabete de type 1, dont 70 % sont traites par multi-injections. Notre objectif etait d’evaluer les techniques d’injection d’insuline et les ressentis (peur et douleur) des patients, puis les correler avec l’equilibre glycemique et la qualite de vie. Patients et methodes Cette enquete a ete realisee dans 14 centres AJD-SSR pediatriques. 407 questionnaires anonymes ont ete completes par les enfants âges entre 10 et 18 ans, traites par multi-injections. En moyenne les patients etaient âges de 13,3 +/−1,9 ans, avaient une duree de diabete de 4,9 +/−3,6 ans. L’HbA1c moyenne etait de 8,3 +/−1,5%. 391 enfants (96 %) utilisaient un stylo. Resultats 33 % des enfants utilisent des aiguilles de 8xa0mm et plus, 62 % des aiguilles de 6xa0mm et moins. Parmi ceux qui utilisent des insulines d’action intermediaire, 1/4 ne la remettent jamais en suspension. Concernant la purge de l’aiguille du stylo : 80 % le font souvent, 14 % parfois et 6 % jamais. 4 % utilisent 3 ou 4 fois la meme aiguille ou seringue. 9 % des enfants disent ne jamais changer de points de piqure sur une meme zone. Parmi ceux qui font un pli (92 % des jeunes interroges), 67 % piquent a 90°, independamment de la longueur de l’aiguille. Parmi ceux qui font un pli a 45°, seulement 20 % lâchent le pli avant d’injecter. 55 % laissent l’aiguille sous la peau plus de 10 sec apres avoir fait l’injection. 68 % des enfants ont remarque la presence de lipodystrophies et plutot dans l’abdomen, 17 % injectent parfois dans ces lipodystrophies. Quelle que soit la zone d’injection, la douleur est percue plus importante avec l’insuline lente. La douleur est plus souvent reportee pour les injections dans les cuisses. 14 % des jeunes rapportent avoir peur de l’injection. La peur de se piquer est correlee significativement a la qualite de vie et a l’HbA1c, independamment de l’âge. Conclusion La technique d’injection doit etre reevaluee regulierement et l’autoevaluation par les patients encouragee pour contribuer a l’efficacite du traitement. L’impact de la douleur et surtout de la peur des injections sur la qualite de vie et l’equilibre metabolique des jeunes doit etre pris en compte.