Psychological care in children and adolescents with type 1 diabetes in a real‐world setting and associations with metabolic control

Background: International guidelines recommend psychosocial care for children and adolescents with type 1 diabetes. Objective: To assess psychological care in children and adolescents with type 1 diabetes in a real-world setting and to evaluate associations with metabolic outcome. Methods: Delivery of psychological care, HbA1c, and rates of severe hypoglycemia and diabetic ketoacidosis (DKA) in children and adolescents with type 1 diabetes from 199 diabetes care centers participating in the German diabetes survey (DPV) were analyzed. Results: Overall, 12 326 out of 31 861 children with type 1 diabetes were supported by short-term or continued psychological care (CPC). Children with psychological care had higher HbA1c (8.0% vs 7.7%, P<.001) and higher rates of DKA (0.032 vs 0.021 per patient-year, P<.001) compared with children without psychological care. In age-, sex-, diabetes duration-, and migratory background-matched children, HbA1c stayed stable in children supported by CPC during follow-up (HbA1c 8.5% one year before psychological care started vs 8.4% after two years, P = 1.0), whereas HbA1c was lower but increased significantly by 0.3% in children without psychological care (HbA1c 7.5% vs 7.8% after two years, P <.001). Additional HbA1c-matching showed that the change in HbA1c during follow-up was not different between the groups, but the percentage of children with severe hypoglycemia decreased from 16.3% to 10.7% in children receiving CPC compared with children without psychological care (5.5% to 5.8%, P =.009). Conclusions: In this real-world setting, psychological care was provided to children with higher HbA1c levels. CPC was associated with stable glycemic control and less frequent severe hypoglycemia during follow-up

Characterization of diabetes following pancreatic surgery in patients with congenital hyperinsulinism

Background: Congenital hyperinsulinism (CHI) is the most common cause of persistent hypoglycaemia in infancy that leads to unfavourable neurological outcome if not treated adequately. In patients with severe diffuse CHI it remains under discussion whether pancreatic surgery should be performed or intensive medical treatment with the acceptance of recurrent episodes of mild hypoglycaemia is justified. Near-total pancreatectomy is associated with high rates of insulin-dependent diabetes mellitus and exocrine pancreatic insufficiency. Little is known about the management and long-term glycaemic control of CHI patients with diabetes after pancreatic surgery. We searched the German/Austrian DPV database and compared the course of 42 CHI patients with diabetes to that of patients with type 1 diabetes mellitus (T1DM). Study groups were compared at diabetes onset and after a follow-up period of 6.1 [3.3–9.7] (median [interquartile range]) years. Results: The majority of CHI patients with diabetes were treated with insulin (85.2% [70.9–99.5] at diabetes onset, and 90.5% [81.2–99.7] at follow-up). However, compared to patients with T1DM, significantly more patients in the CHI group with diabetes were treated with conventional insulin therapy (47.8% vs. 24.4%, p = 0.03 at diabetes onset, and 21.1% vs. 6.4% at follow-up, p = 0.003), and only a small number of CHI patients were treated with insulin pumps. Daily insulin dose was significantly lower in CHI patients with diabetes than in patients with T1DM, both at diabetes onset (0.3 [0.2–0.5] vs. 0.6 IE/kg/d [0.4–0.8], p = 0.003) and follow-up (0.8 [0.4–1.0] vs. 0.9 [0.7–1.0] IE/kg/d, p = 0.02), while daily carbohydrate intake was comparable in both groups. Within the first treatment year, HbA1c levels were significantly lower in CHI patients with diabetes (6.2% [5.5–7.9] vs. 7.2% [6.5–8.2], p = 0.003), but increased to a level comparable to that of T1DM patients at follow-up. Interestingly, in CHI patients, the risk of severe hypoglycaemia tends to be higher only at diabetes onset (14.8% vs. 5.8%, p = 0.1). Conclusions: In surgically treated CHI patients insulin treatment needs to be intensified in order to achieve good glycaemic control. Our data furthermore emphasize the need for improved medical treatment options for patients with diazoxide- and/or octreotide-unresponsive CHI

Comorbidity of attention deficit hyperactivity disorder and type 1 diabetes in children and adolescents: Analysis based on the multicentre DPV registry

BackgroundThe interaction between type 1 diabetes mellitus (T1DM) and attention deficit hyperactivity disorder (ADHD) in children and adolescents has been studied rarely. We aimed to analyse metabolic control in children and adolescents with both T1DM and ADHD compared to T1DM patients without ADHD. Patients and methodsAuxological and treatment data from 56.722 paediatric patients (<20 years) with T1DM in the multicentre DPV (Diabetes Prospective Follow-up Initiative) registry were analysed. T1DM patients with comorbid ADHD were compared to T1DM patients without ADHD using multivariable mixed regression models adjusting for demographic confounders. ResultsWe identified 1.608 (2.83%) patients with ADHD, 80.8% were male. Patients with comorbid ADHD suffered twice as often from diabetic ketoacidosis compared to patients without ADHD [10.2; 9.7-10.8 vs [5.4; 5.3-5.4] (P < .0001). We also found significant differences in HbA1c [8.6% (7.3-9.4); 66.7 mmol/mol (56.3-79.4) vs 7.8% (7.0-9.0); 62.1 mmol/mol (53.2-74.7)], insulin dose/kg [0.9 IU/kg (0.7-1.1) vs 0.8 IU/kg (0.7-1.0)], body mass index-standard deviation score (BMI-SDS) [0.2 (-0.5 to 0.8) vs 0.3 (-0.3 to 0.9)], body weight-SDS [0.1 (-0.5 to 0.8) vs 0.3 (0.3 - 0.9)]; (all P < 0.0001), and systolic blood pressure after adjustment [mean: 116.3 vs 117.1 mm Hg)]; (P < 0.005). ConclusionPaediatric patients with ADHD and T1DM showed poor metabolic control compared to T1DM patients without ADHD. Closer cooperation between specialized paediatric diabetes teams and paediatric psychiatry/psychology seems to be necessary to improve diabetes care and metabolic control in this group of patients

Comparative characteristics of older people with type 1 diabetes treated with continuous subcutaneous insulin infusion or insulin injection therapy : data from the German/Austrian DPV registry

Aim: To compare clinical characteristics and outcomes in adults with type 1 diabetes aged ≥ 60 years using continuoussubcutaneous insulin infusion (CSII) vs. insulin injection therapy. Further, to determine the percentage of older adults with type 1 diabetes using CSII. Research design and methods: Retrospective study using data of the Diabetes Prospective Follow-up Registry (DPV). Including percentage CSII use from 2008 to 2018, and the characteristics of 9547 individuals extracted from the DPV in March 2019 (N=1404 CSII; N=8143 insulin injection therapy). Wilcoxon rank sum tests were used for continuous variables and chi-square tests for categorical variables to compare clinical characteristics of people using CSII vs. insulin injection therapy. Adjusted analyses used generalized linear models to compare diabetes-related outcomes. Results: CSII usage has increased in older adults (from 12% in 2008 to 23% in 2018). After adjustment, CSII was associated with lower HbA1c [60.7 mmol/mol (7.7±0.1%) vs. 62.8% (7.9±0.1%)], lower daily insulin dose (0.49±0.02 vs. 0.61±0.01 IU/kg), fewer days in hospital (8.1±0.12 vs. 11.2±0.11 days/person-year), fewer severe hypoglycaemic events (0.16±0.02 vs. 0.21±0.03 events/person-year) and fewer diabetic ketoacidosis (0.06±0.01 vs. 0.08±0.01 events/person-year). Individuals on CSII showed lower rates of microalbuminuria and also have a diagnosis of depression and neuropathy. Conclusions: A growing number of older adults are using insulin pumps. Older age in itself should not be seen as a contraindication for CSII

Diabetes mellitus in pediatric solid organ recipients without and with cystic fibrosis: An analysis from the German-Austrian diabetes database (Diabetes Patienten Verlaufsdokumentation)

Introduction: Posttransplantation diabetes mellitus (PTDM) increases the risk of cardiovascular disease, graft loss, and decreased survival. Follow-up treatment after solid organ transplantation (SOT) needs to focus on, inter alia, maintaining balanced glucose metabolism. This study aimed to ascertain the prevalence of PTDM and describe patient characteristics in the large DPV (Diabetes Patienten Verlaufsdokumentation) pediatric diabetes database. Methods: DPV data of 71902 patients from the January 01, 1995 to January 04, 2015 period were analyzed for patients with and without cystic fibrosis (CF) after SOT (kidney, liver, heart, and lung). Multivariable analysis served to assess differences between SOT patient groups at risk for developing diabetes. Results: Out of 109 SOT patients, 51 had CF; 72.5% received steroids and 62% were additionally given tacrolimus. PTDM developed in 45% of CF patients and 12% of non-CF patients. SOT patients were older at diabetes onset (mean age, 12.50 +/- 3.98 years), shorter (height z-score, -1.67 +/- 1.25), and lighter (weight z-score, -1.59 +/- 1.57) than non-SOT diabetes patients (P < 0.01). With transplantation, glycated hemoglobin (HbA1c) was significantly lower and treatment for hypertension and dyslipidemia was increased. Among SOT patients, weight and body mass index (BMI) z-scores were significantly lower in patients with CF-related diabetes (P < 0.05). Conclusions: SOT was present in 6.6% of children with diabetes, and this might aggravate the risk of cardiovascular disease in populations with already increased rates of hypertension and dyslipidemia. Dystrophy and short stature were also present, particularly in transplant recipients with CF and diabetes. Comorbidities and long-term consequences call for multidisciplinary collaboration

The association between educational status and diabetes outcomes: results of the DIAS study in children with diabetes type 1 in Germany

Objective To evaluate the association between parents' educational status and diabetes outcomes in German children and adolescents and to compare educational status and individual socioeconomic status (SES). Methods The study included a total of 1781 patients < 18 years old with type 1 diabetes mellitus from 13 German diabetes centers. The analysis was based on data from the DIAS study collected from June 2013 until June 2014 in order to analyse the associations of SES and various diabetes outcomes. The DIAS study measured SES with a composite index based on parents' educational status, occupational status and household income and presented unfavourable outcomes for patients with a low SES. In a secondary analysis of the DIAS data, analyses have been run again with parents' educational status only in order to examine its applicability as a short indicator of SES. Data were collected within the multicenter DPV ( Diabetes Prospective Follow- up) registry. Multivariable regression models ( linear, logistic, negativ-binomial or Poisson- models depending on the distributional characteristics of the outcomes) were applied to analyze the associations of parents' educational status and diabetes outcomes, adjusted for age, sex, diabetes duration, and eventually migration background. Results Low educational status was significantly associated with higher hemoglobin A1C (HbA1c) compared to medium/high educational status (8,1 % compared to 7,8 %, p < 0,0001/ 7,6 %, p < 0,0001), and lower proportion of insulin pump therapy (42,7 % versus 56,3 %, p < 0,0001/52,5 %, p < 0,01). Patients with a background of low educational status also reported fewer daily self- monitored blood glucose (SMBG) measurements, higher Body-Mass-Index, and more inpatient days per year. Severe hypoglycemic events and ketoacidosis were not more frequent in patients with low educational status. The educational status measure was able to discriminate between the social groups as well as the complex SES measure. Conclusion Parents' low educational status is an important predictor for unfavorable outcomes in German children with type-1 diabetes. We should incorporate this aspect in targeted diabetes care and education. As a short and practicable indicator, parents' educational status can estimate the social status of the patients in routine collection of diabetes data

The association between socio-economic status and diabetes care and outcome in children with diabetes type 1 in Germany: The DIAS study (diabetes and social disparities)

Objective To evaluate the association between socioeconomic status (SES) and diabetes outcomes in German children and adolescents. Methods A total of 1829 subjects <18 years old with type 1 diabetes mellitus from 13 German diabetes centers were included from June 2013 until June 2014. Data were collected within the multicenter DPV (Diabetes Prospective Follow-up) registry. SES was measured with a composite index. Multivariable regression models were applied to analyze the association of SES and outcomes adjusted for age, sex, diabetes duration, and migration status. Results Low SES was significantly associated with worse diabetes outcomes: higher hemoglobin A1C (HbA1c) (64.3 mmol/mol), lower proportion of insulin pump therapy (43.6%), fewer daily self-monitored blood glucose (SMBG) measurements (5.7), more inpatient days per patient-year (5.8) compared to patients with medium/high SES (HbA1c: 61.3 mmol/mol, P < 0.001/59.8 mmol/mol, P < 0.0001; proportion of pump therapy: 54.5%, P < 0.01/ 54.9%, P < 0.01; SMBG: 6.0, P < 0.01/ 6.1, P < 0.01; inpatient days: 4.5, P < 0.0001/3.4, P < 0.0001). The inclusion of migration status in the models resulted in only minor changes in the outcomes. Conclusion Despite free health care, low SES is associated with unfavorable diabetes outcomes in Germany. The poorer diabetes outcomes of children with diabetes have been attributed to their migration status and may be partly explained by low SES. Both factors must become part of targeted diabetes care in children and adolescents with type 1 diabetes

The effect of annealing on superdislocation structures and anti-phase energies in Fe3Al alloys

The influence of annealing on 111 superdislocations introduced by prior deformation has been examined in several alloys based on Fe3Al, namely a binary Fe–28% Al alloy, a ternary Fe–28% Al–5% Cr alloy, and a more complex alloy based on Fe–28% Al–5% Cr (where the compositions are in atomic percentages). The 111 superdislocations show signs of the relaxation of the antiphase boundary (APB) between the partials, with the extent of relaxation varying considerably depending on the alloy considered. After longer anneals, particularly after high-temperature annealing, the 111 super-dislocations react to produce 100superdislocations, with the APB between the new partials also providing evidence of APB relaxation at longer times and higher temperatures. It is not possible to provide a complete explanation of the results obtained, which clearly depend sensitively on the alloying additions in the material studied and the influence of these on such factors as order stability in the lattice and extent of solute segregation to the APB fault.Peer Reviewe