Frequency of diabetes team contacts in children and adolescents using insulin pumps

Background: The purpose of this study is to assess if a relationship exists between A1c within target (≤ 7.5%) and frequency of patient-initiated contact with diabetes team, in children with type 1 diabetes (T1DM) on an insulin pump. Additionally, to determine factors impacting frequency of contact. Methods: This was a retrospective study of children with T1DM on an insulin pump. Frequency of contact, type of contact, and A1c were collected. Study participants filled out a questionnaire at study entry. Results: One hundred and seventy-six participants were enrolled, with a mean age of 13 years. The median duration of T1DM was 6 years with a median duration of pump use, 3.6 years. One hundred and sixteen subjects (66%) contacted the diabetes team for insulin dose adjustments between clinic visits with a mean (standard deviation [SD]) of 1.2 (± 1.7) contacts, 90% of which were by e-mail. There was no significant relationship between achieving target A1c and frequency of contact. However, increasing age and longer duration of pump use were associated with decreased frequency of contact. Common barriers to contact included being too busy and technical problems with software. Conclusions: There was no significant relationship between the frequency of patient-initiated contact with diabetes team and A1c. Overall, there was low frequency of contact in the cohort. Older children and children with longer duration of pump use had fewer contacts with low rates of self-directed pump adjustments. These results raise the importance of defining strategies to increase patient engagement and empower diabetes data review

The Health Initiative Program for Kids (HIP Kids): Effects of a 1-Year Multidisciplinary Lifestyle Intervention on Adiposity and Quality of Life in Obese Children and Adolescents -- A Longitudinal Pilot Intervention Study

BACKGROUND: Though recent data suggest that multidisciplinary outpatient interventions can have a positive effect on childhood obesity, it is still unclear which program components are most beneficial and how they affect quality of life (QoL). The aim of this study was to determine if a 1-year multidisciplinary, family-centered outpatient intervention based on social cognitive theory would be effective in (i) preventing further increases in BMI and BMI z-score, and (ii) improving QoL in obese children and adolescents. METHODS: Obese children and adolescents 8-17 years of age and their families participated in this 1-year longitudinal pilot intervention study. The intervention consisted of fifteen 90-minute educational sessions led by a dietitian, exercise specialist, and social worker. Anthropometric measures, body composition, and QoL (Pediatric Quality of Life Inventory 4.0), were assessed at baseline, 3 months, and 12 months. Laboratory values were measured at baseline and 12 months. The primary outcome measures were change in BMI and BMI z-score, secondary outcome measures included change in QoL and body composition. A paired sample t-test was used to assess within-group differences and 95% confidence intervals were reported for the mean differences. RESULTS: 42 obese children and adolescents (21 girls) completed the 1-year intervention (mean age 12.8 ± 3.14 years). Mean baseline BMI was 31.96 ± 5.94 kg/m(2) and BMI z-score was +2.19 ± 0.34. Baseline QoL (self-assessments and parental assessments) was impaired: mean baseline scores were 74.5 ± 16.5 and 63.7 ± 19.4 for physical functioning and 69.0 ± 14.9 and 64.0 ± 18.3 for emotional functioning, respectively. At 12 months, BMI z-score had decreased (-0.07 ± 0.11, 95% CI: -0.11 to -0.04). BMI (0.80 ± 1.57 kg/m(2), 95% CI 0.31 to 1.29) and fat-free mass (4.02 ± 6.27 kg, 95% CI 1.90 to 6.14) increased, but % body fat and waist circumference did not. Both the parent-reported physical (11.3 ± 19.2, 95% CI 4.7 to 17.9) and emotional (7.7 ± 15.7, 95% CI 2.3 to 13.0) functioning QoL scores and the children\u27s self-reported physical (5.3 ± 17.1, 95% CI 0.5 to 11.1) and emotional (7.9 ± 14.3, 95% CI 3.2 to 12.7) functioning scores significantly improved. CONCLUSIONS: Following a 1-year intervention, the participants\u27 BMI z-scores and QoL improved, while other adiposity-related measures of body composition remained unchanged. TRIAL REGISTRATION: UMIN Clinical Trials Registry UMIN000015622

Timing of CGM initiation in pediatric diabetes: The CGM TIME Trial.

OBJECTIVE: To determine whether timing of CGM initiation offering low glucose suspend (LGS) affects CGM adherence in children and youth starting insulin pump therapy. METHODS: A 5-site RCT of pump-naïve subjects (aged 5-18 years) with type 1 diabetes (T1D) for at least 1 year compared simultaneous pump and CGM initiation offering LGS vs standard pump therapy with CGM initiation delayed for 6 months. Primary outcome was CGM adherence (hours per 28 days) (MiniMed™ Paradigm™ Veo™ system; CareLink Pro™ software) over 6 months after CGM initiation. Secondary outcome HbA1c was measured centrally. Linear mixed-models and ordinary least squares models were fitted to estimate effect of intervention, and covariates baseline age, T1D duration, HbA1c, gender, ethnicity, hypoglycemia history, clinical site, and association between CGM adherence and HbA1c. RESULTS: The trial randomized 144/152 (95%) eligible subjects. Baseline mean age was 11.5 ± 3.3(SD) years, T1D duration 3.4 ± 3.1 years, and HbA1c 7.9 ± 0.9%. Six months after CGM initiation, adjusted mean difference in CGM adherence was 62.4 hours per 28 days greater in the Simultaneous Group compared to Delayed Group (P = .007). There was no difference in mean HbA1c at 6 months. However, for each 100 hours of CGM use per 28-day period, HbA1c was 0.39% (95% CI 0.10%-0.69%) lower. Higher CGM adherence was associated with reduced time with glucose \u3e10 mmol/L (P \u3c .001). CONCLUSION: CGM adherence was higher after 6 months when initiated at same time as pump therapy compared to starting CGM 6 months after pump therapy. Greater CGM adherence was associated with improved HbA1c

A core outcome set for studies of gestational diabetes mellitus prevention and treatment

AIMS/HYPOTHESIS: The aim of this systematic review was to develop core outcome sets (COSs) for trials evaluating interventions for the prevention or treatment of gestational diabetes mellitus (GDM). METHODS: We identified previously reported outcomes through a systematic review of the literature. These outcomes were presented to key stakeholders (including patient representatives, researchers and clinicians) for prioritisation using a three-round, e-Delphi study. A priori consensus criteria informed which outcomes were brought forward for discussion at a face-to-face consensus meeting where the COS was finalised. RESULTS: Our review identified 74 GDM prevention and 116 GDM treatment outcomes, which were presented to stakeholders in round 1 of the e-Delphi study. Round 1 was completed by 173 stakeholders, 70% (121/173) of whom went on to complete round 2; 84% (102/121) of round 2 responders completed round 3. Twenty-two GDM prevention outcomes and 30 GDM treatment outcomes were discussed at the consensus meeting. Owing to significant overlap between included prevention and treatment outcomes, consensus meeting stakeholders agreed to develop a single prevention/treatment COS. Fourteen outcomes were included in the final COS. These consisted of six maternal outcomes (GDM diagnosis, adherence to the intervention, hypertensive disorders of pregnancy, requirement and type of pharmacological therapy for hyperglycaemia, gestational weight gain and mode of birth) and eight neonatal outcomes (birthweight, large for gestational age, small for gestational age, gestational age at birth, preterm birth, neonatal hypoglycaemia, neonatal death and stillbirth). CONCLUSIONS/INTERPRETATION: This COS will enable future GDM prevention and treatment trials to measure similar outcomes that matter to stakeholders and facilitate comparison and combination of these studies. TRIAL REGISTRATION: This study was registered prospectively with the Core Outcome Measures in Effectiveness Trials (COMET) database: http://www.comet-initiative.org/studies/details/686/

Evaluation of referrals for short stature: A retrospective chart review

Background: Referrals to paediatric endocrine clinics for short stature are common. Height velocity (HV) is an essential component of the evaluation of short stature as growth deceleration often reflects an underlying paediatric endocrine diagnosis (PED). Access to previous measurements facilitates prompt calculation of HV. Objective: To determine the availability of previous measurements at time of referral for short stature and to determine predictors of a PED. Methods: A retrospective chart review was performed on all referrals for short stature to a single paediatric endocrinologist between January 2008 and December 2014. Standard practice following receipt of a referral for short stature included repeated requests to the referring physician for previous measurements. Results: A total of 324 charts of patients aged 11 months to 18 years were reviewed and 286 were eligible for inclusion. Previous measurements were available in 72.4%, and 44.8% of these were found to have a PED. There was a significant relation between HV\u3c25th percentile and a PED (P\u3c0.0001) and between height deficit (HD) and a PED (P\u3c0.0001). Logistic regression analysis showed that a HV\u3c25th percentile and a HD\u3e2 standard deviations, increased the odds of PED by a factor of 5.12 (P\u3c0.001) and 1.39 (P\u3c0.005), respectively. Conclusion: HV is a significant predictor of a PED. Our higher rate of previous measurement availability is likely due to our effective referral screening protocol. The availability of these measurements, which are essential for HV calculation, are likely to reduce delays in diagnosis and management

Childhood overweight and obesity management: A national perspective of primary health care providers\u27 views, practices, perceived barriers and needs

BACKGROUND: Obesity and overweight in children are an escalating problem in Canada and worldwide. Currently, little is known about the manner in which primary health care providers are responding to Canada\u27s obesity epidemic. OBJECTIVE: To determine the views, practices, challenges/barriers, and needs of a national sample of family physicians (FPs) and community paediatricians (CPs) with respect to paediatric obesity identification and management. METHODS: A self-administered questionnaire was mailed to a random sample of 1200 FPs and 1200 CPs across Canada between 2005 and 2006. RESULTS: A total of 464 FPs and 396 CPs participated. The majority of practitioners viewed paediatric obesity as an \u27important\u27/\u27very important\u27 issue. Although the majority reported providing dietary (more than 85%) and exercise (98%) advice to their overweight/obese patients, practitioners\u27 perceived success rate in treating paediatric obesity was limited (less than 22%). Approximately 30% of FPs and 60% of CPs (P\u3c0.05) used the recommended method to identify paediatric obesity. At least 50% of practitioners indicated that too few government-funded dietitians, a lack of success in controlling paediatric patients\u27 weight, time constraints and limited training were key barriers to their success. To support efforts to identify or manage paediatric obesity, practitioners identified the need for office tools, patient educational materials and system-level changes. DISCUSSION: Canadian primary health care providers are not adequately equipped to deal with the paediatric obesity epidemic. Effective assessment tools and treatment resources, dissemination of clinical practice guidelines, enhanced undergraduate medical education and postgraduate continuing medical education, and system-level changes are urgently needed to address this health problem. ©2010 Pulsus Group Inc. All rights reserved

Dynamic regulation of plasma matrix metalloproteinases in human diabetic ketoacidosis

Background: Diabetic ketoacidosis (DKA) in children is associated with cerebrovascular-related complications. We recently reported that DKA facilitates leukocyte adherence to the brain microvascular endothelium. Adhered leukocytes can release enzymes that instigate vascular dysfunction. Our aims were to measure plasma levels of leukocyte-derived matrix metalloproteinases (MMPs) from DKA patients and to correlate plasma MMP concentrations with DKA severity. Methods: Plasma was obtained from children with type 1 diabetes, either in DKA (n = 16) or insulin controlled (CON; n = 16). Antibody microarray and gelatin zymography were used to quantify plasma MMPs and their endogenous tissue inhibitors (TIMPs). MMP concentrations were correlated with DKA severity (blood pH). Quantitative PCR of leukocyte mRNA was used to help determine the origin of plasma MMPs. Results: DKA was associated with altered plasma levels of ↓MMP-2 (P \u3c 0.001), ↑MMP-8 (P \u3c 0.001), ↑MMP-9 (P \u3c 0.05), and ↑TIMP-4 (P \u3c 0.001), as compared with CON. Elevated MMP-8 and MMP-9 were both positively correlated with DKA severity (P \u3c 0.05). DKA was associated with increased leukocyte mRNA for MMP-8, MMP-9, and TIMP-4 (P \u3c 0.005). Conclusion: MMPs are dynamically regulated during DKA. Plasma MMP-8 and MMP-9 concentrations correlate with DKA severity and are known to degrade brain microvascular endothelial cell tight junctions. Thus, leukocyte-derived MMPs might contribute to DKA-associated cerebrovascular complications

Relationship between Birth Weight and Metabolic Status in Obese Adolescents

Objective. To examine the relationships between birth weight and body mass index, percent body fat, blood lipids, glycemia, insulin resistance, adipokines, blood pressure, and endothelial function in a cohort of obese adolescents. Design and Methods. Ninety-five subjects aged 10–16 years (mean age 13.5 years) with a body mass index >95th centile (mean [±SEM] 33.0 ± 0.6) were utilized from two prospective studies for obesity prevention prior to any interventions. The mean term birth weight was 3527 ± 64 g (range 1899–4990 g;). Results. Body mass index z-score correlated positively with birth weight (, ), but not percent body fat. Insulin resistance negatively correlated with birth weight (, ), as did fasting plasma insulin (, ); both being significantly greater for subjects of small versus large birth weight (Δ Homeostasis Model Assessment = 2.5 and Δ insulin = 10 pmol/L for birth weight ud_less_than2.5 kg versus >4.5 kg). Adiponectin, but not leptin, blood pressure z-scores or peripheral arterial tomography values positively correlated with birth weight (, ). Conclusions. Excess body mass index in obese adolescents was positively related to birth weight. Birth weight was not associated with cardiovascular risk factors but represented a significant determinant of insulin resistance.Peer Reviewe