Michele A. O'Connell

Does epilepsy occur more frequently in children with Type 1 diabetes

Aim:  Hypoglycaemic seizures are common in children with diabetes and electroencephalogram abnormalities are well recognised in this patient group. Elevated antibodies to glutamic acid decarboxylase, a major auto‐antigen in Type 1 diabetes, are also implicated in a number of neurological disorders. Despite these associations, the question of whether children with diabetes are more prone to epilepsy, possibly as a result of lowered seizure threshold, has not been previously studied. We aimed to determine the prevalence and type of epilepsy in a large paediatric diabetes clinic.

Evaluation of an Algorithm to Guide Patients With Type 1 Diabetes Treated With Continuous Subcutaneous Insulin Infusion on How to Respond to Real-Time Continuous Glucose Levels A randomized controlled trial

OBJECTIVE To evaluate an algorithm guiding responses of continuous subcutaneous insulin infusion (CSII)–treated type 1 diabetic patients using real-time continuous glucose monitoring (RT-CGM). RESEARCH DESIGN AND METHODS Sixty CSII-treated type 1 diabetic participants (aged 13–70 years, including adult and adolescent subgroups, with A1C ≤9.5%) were randomized in age-, sex-, and A1C-matched pairs. Phase 1 was an open 16-week multicenter randomized controlled trial. Group A was treated with CSII/RT-CGM with the algorithm, and group B was treated with CSII/RT-CGM without the algorithm. The primary outcome was the difference in time in target (4–10 mmol/l) glucose range on 6-day masked CGM. Secondary outcomes were differences in A1C, low (≤3.9 mmol/l) glucose CGM time, and glycemic variability. Phase 2 was the week 16–32 follow-up. Group A was returned to usual care, and group B was provided with the algorithm. Glycemia parameters were as above. Comparisons were made between baseline and 16 weeks and 32 weeks. RESULTS In phase 1, after withdrawals 29 of 30 subjects were left in group A and 28 of 30 subjects were left in group B. The change in target glucose time did not differ between groups. A1C fell (mean 7.9% [95% CI 7.7–8.2to 7.6% [7.2–8.0]; P < 0.03) in group A but not in group B (7.8% [7.5–8.1] to 7.7 [7.3–8.0]; NS) with no difference between groups. More subjects in group A achieved A1C ≤7% than those in group B (2 of 29 to 14 of 29 vs. 4 of 28 to 7 of 28; P = 0.015). In phase 2, one participant was lost from each group. In group A, A1C returned to baseline with RT-CGM discontinuation but did not change in group B, who continued RT-CGM with addition of the algorithm. CONCLUSIONS Early but not late algorithm provision to type 1 diabetic patients using CSII/RT-CGM did not increase the target glucose time but increased achievement of A1C ≤7%. Upon RT-CGM cessation, A1C returned to baseline.

Demographic and personal factors associated with metabolic control and self-care in youth with type 1 diabetes: A systematic review

Optimal use of recent technological advances in insulin delivery and glucose monitoring remain limited by the impact of behaviour on self‐care. In recent years, there has been a resurgence of interest in psychosocial methods of optimizing care in youth with type 1 diabetes. We therefore sought to examine the literature for demographic, interpersonal and intrapersonal correlates of self‐care and/or metabolic control. Studies for this systematic review were obtained via an electronic search of Medline, Embase, Cumulative Index to Nursing and Allied Health Literature and PsycINFO databases.

An Algorithm Guiding Patient Responses to Real-Time-Continuous Glucose Monitoring Improves Quality of Life

OBJECTIVE This study evaluated the impact on quality of life (QoL) of an algorithm guiding the responses of continuous subcutaneous insulin infusion (CSII)-treated type 1 diabetes (T1D) patients using real-time (RT)-continuous glucose monitoring (CGM). RESEARCH DESIGN AND METHODS Sixty CSII-treated T1D participants (13-70 years old, glycosylated hemoglobin [HbA1c] ≤ 9.5%), including adult and adolescent subgroups, were randomized in age-, gender-, and HbA1c-matched pairs. Phase 1 was an open 16-week multicenter randomized controlled trial; Group A received CSII/RT-CGM with the algorithm, and Group B received CSII/RT-CGM without algorithm. Phase 2 was the 16-32-week follow-up study; Group A returned to usual care (CSII without RT-CGM), and Group B was provided with algorithm at 16 weeks. QoL was assessed by DQOL (adults) and DQOLY (adolescents) questionnaires at baseline, 16 weeks, and 32 weeks. Higher scores (range 1-5) indicate poorer QoL. Analysis was by analysis of variance (between group for baseline-16 weeks) and paired two-tailed t tests (within group for baseline and 32 weeks) with significance at P < 0.05. RESULTS Withdrawals left 28 of 30 patients in Group A and 27 of 30 patients in Group B at 32 weeks. In Phase 1, QoL in Group A (2.16 [0.44] baseline to 1.86 [0.40] at 16 weeks) improved compared with Group B (2.03 [0.47] to 2.03 [0.50]) (P = 0.002). Change in QoL correlated with changes in HbA1c (R = 0.36; P = 0.007). In Phase 2, Group A QoL was better at 32 weeks compared with baseline (2.16 [0.44] vs. 2.02 [0.43]) (P = 0.04) but was not in Group B (2.03 [0.47] vs. 1.99 [0.51]) (P = not significant). CONCLUSIONS An algorithm guiding CSII-treated T1D responses to RT-CGM improved QoL, which persisted post-RT-CGM withdrawal. Algorithm provision at RT-CGM initiation was required to benefit QoL.

Clinic attendance and disengagement of young adults with type 1 diabetes after transition of care from paediatric to adult services (TrACeD): a randomised, open-label, controlled trial

BACKGROUND Care transition from paediatric to adult services for young adults with type 1 diabetes is frequently associated with decreased attendance at outpatient hospital clinics and increased disengagement from specialist services. We aimed to assess the effect of an appointment-management intervention on clinic attendance and disengagement after transition. METHODS We did a randomised, open-label, controlled trial of patients aged 17-19 years with type 1 diabetes. Participants were recruited from a tertiary paediatric diabetes service at the Royal Childrens Hospital (Melbourne, VIC, Australia) and had to be scheduled for transition to adult services at one of eight centres in Melbourne. We randomly assigned participants (1:1), using sequential sealed opaque envelopes, to either appointment management (intervention) or current care (control). The appointment manager acted as the point of contact between intervention group participants and the relevant adult clinics, and provided personalised pre-appointment telephone and short message service (SMS) reminders with automatic rebooking of missed appointments. No contact was initiated with the control group after recruitment, and any self-initiated contact with the investigating team was directed to the participants previous treating paediatric physician. The intervention continued throughout the trial until at least 12 months of follow-up data were obtained for all participants. We assessed the mean frequency of adult clinic attendance and disengagement from services during 0-12 months after transition (primary outcomes) and 12-24 months after transition (secondary outcomes), analysed by intention to treat. We used regression analyses, adjusted for clinic attendance and glycated haemoglobin concentration pre-transition, to analyse the effect of the intervention. This study is registered with the Australian New Zealand Clinical Trials Registry (number ACTRN12611001012965). FINDINGS Between Jan 4, 2012, and Dec 31, 2014, we randomly assigned 120 individuals, 60 to the intervention and 60 to control. During 0-12 months after transition, the mean number of clinics attended was 2·3 (SD 1·1) in the intervention group and 2·3 (1·4) in the control group (p=0·84; adjusted β 0·1, SE 0·2, p=0·88); three (6%) of 49 participants in the intervention group and six (11%) of 55 in the control group disengaged from services (p=0·38; adjusted odds ratio [OR] 0·5, 95% CI 0·1-2·3, p=0·36). At 12-24 months post-transition, mean clinic attendance was 2·5 (SD 1·3) in the intervention group and 1·4 (SD 1·8) in the control group (p=0·001; adjusted β 0·9, SE 0·4, p=0·009); two (6%) of 32 in the intervention group and 18 (49%) of 37 in the control group disengaged from services (p=0·001; adjusted OR 0·1, 95% CI 0·1-0·2, p=0·001). Neither the intervention nor pre-transition clinic attendance had an independent effect on glycated haemoglobin after transition. INTERPRETATION Appointment management did not increase clinic attendance and did not decrease disengagement with services 0-12 months after transition to adult services, but had a positive effect during 12-24 months after transition. FUNDING Australasian Paediatric Endocrine Group and Lilly.

Practical Experience with Continuous Subcutaneous Insulin Infusion Therapy in a Pediatric Diabetes Clinic

Continuous subcutaneous insulin infusion therapy (CSII) is an increasingly popular form of intensive insulin administration in pediatric patients. The use of CSII commenced at our large tertiary referral diabetes clinic as recently as 2002. In the intervening years, demand and enthusiasm from both patients and physicians alike have resulted in a steady ongoing increase in CSII use at our clinic. We currently have >200 active patients using insulin pump therapy. This article reviews our experience with CSII and outlines our current multidisciplinary approach to optimizing glycemic control and outcomes in this patient group.

A novel tool to predict youth who will show recommended usage of diabetes technologies

Controversy exists regarding which individuals will benefit most from commencement of diabetes technologies such as continuous subcutaneous insulin infusion (CSII) or continuous glucose monitoring systems (CGMS), such as ‘real‐time’ sensor‐augmented pumping (SAP). Because higher usage correlates with haemoglobin A1c (HbA1c) achieved, we aimed to predict future usage of technologies using a questionnaire‐based tool.

Long term risk of severe retinopathy in childhood-onset type 1 diabetes: a data linkage study

Objectives: To determine the relationship between glycaemic control trajectory and the long term risk of severe complications in people with type 1 diabetes mellitus, as well as the effects of paediatric and adult HbA1c levels.

The clinician factor: Personality characteristics of clinicians and their impact upon clinical outcomes in the management of children and adolescents with type 1 diabetes

The purpose of this study was to estimate clinician qualities that influence metabolic outcomes in youth with type 1 diabetes.