Abstracts for the 42nd Annual Meeting of the

Abstracts for the 42nd Annual Meeting of the
Volume 17 • Supplement 24 • October 2016
Editor in Chief
Mark A. Sperling, Pittsburgh, USA
Abstracts for the 42nd Annual
Meeting of the International Society
for Pediatric and Adolescent
Diabetes (ISPAD)
26–29 October 2016
Valencia, Spain
Volume 17
•
Supplement 24
•
October 2016
Abstracts for the 42nd Annual Meeting of the International Society
for Pediatric and Adolescent Diabetes (ISPAD)
26–29 October 2016
Valencia, Spain
Disclaimer
This abstract book has been produced using author-supplied copy. Editing has been restricted to some corrections of
spelling and style where appropriate. No responsibility is assumed for any claims, instructions, methods or drug dosages
contained in the abstracts; it is recommended that these are verified independently.
pedi_12448.indd 1
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Volume 17
•
Supplement 24
•
October 2016
TABLE OF CONTENTS
• Invited Abstracts
• Oral Sessions
Oral Session I: Diabetes Technologies
Oral Session II: Diabetes Epidemiology
Oral Session III: Education and Psychosocial Issues
Oral Session IV: Diabetes Chronic Complications and Associated
Diseases
Oral Session V: Diabetes Genetics, Immunology and Environmental
and Monogenic diabetes
Oral Session VI: Diabetes Care
Oral Session VII: DM2 & DM in Developing Countries
Oral Session VIII: Nutrition and DM in Developing Countries
• Poster Tours
Poster Tour 1: Chronic Complications
Poster Tour 2: Diabetes Care
Poster Tour 3: Diabetes Education
Poster Tour 4: Diabetes in Developing Countries
Poster Tour 5: Diabetes Technology
Poster Tour 6: Diabetes Technology & New Insulins and Pharmocologic
Agents
Poster Tour 7: Psychosocial Issues
Poster Tour 8: Latebreakers: Monogenic Diabetes, Genetics and
Immunology
Poster Tour 9: President’s Choice
Poster Tour 10: Chronic & Acute Complications
Poster Tour 11: Diabetes Care
Poster Tour 12: Diabetes Epidemiology
Poster Tour 13: Genetics, Immunology and the Environment
Poster Tour 14: Monogenic Diabetes
Poster Tour 15: Nutrition, Exercise & Epidemiology
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10
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17
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23
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30
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36
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43
46
49
52
55
58
61
64
67
70
73
76
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Poster Tour 16: Psychosocial Issues
82
Poster Tour 17: Latebreakers: Psychosocial Issues and Diabetes Technology 85
Poster Tour 18: President’s Choice
87
Poster Tour 19: Diabetes Care
90
Poster Tour 20: Epidemiology
94
Poster Tour 21: Education and Psychological Issues
97
Poster Tour 22: Epidemiology, Acute and Chronic Complications
& Associated Diseases
100
Poster Tour 23: Monogenic Diabetes
103
Poster Tour 24: New Insulins and Pharmacologic Agents
106
Poster Tour 25: Psychosocial Issues
109
Poster Tour 26: Latebreakers: Diabetes in Developing Countries
and other topics
112
Poster Tour 27: President’s Choice
115
Posters for Display
118
• Author Index
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DOI 10.1111/pedi.12449
INVITED ABSTRACTS
Exercise: part of diabetes treatment or only for the fittest? – JDRF?
INV1
Sports nutrition
F. Annan1
1
Alder Hey Children’s Hospital, Liverpool, United Kingdom
Nutrition is an integral part of the management of Type 1 Diabetes.
For the active child and young person with T1D good nutrition is a
key factor in both optimising glycaemic control during exercise and
maximising sports performance. The IOC consensus statement on
training the elite child athlete recommends "a strong support system
to ensure a balanced lifestyle including proper nutrition, adequate
sleep, academic development, psychological well-being and opportunities for socialisation". This recommendation applies to children with
Type 1 Diabetes.
Sports nutrition advice for child athletes with Type 1 Diabetes is
adapted from evidence for sports nutrition in adults and glycaemic
management in children.
Requirements for nutrition for performance and recovery will be
reviewed with a focus on the roles of carbohydrate, protein and fluid.
The review will cover nutrition before, during and after exercise,
based on the type and duration of exercise being undertaken and
insulin adjustment strategies used.
Key references for this presentation include:
IM Mountjoy, N Armstrong, L Bizzini, et al.OC consensus statement: “training the elite child athlete” Br J Sports Med 2008;42:3
163–164
Thomas DT, Erdman KA, Burke LM. Position of the Academy of
Nutrition and Dietetics, Dietitians of Canada, and the American College of Sports Medicine: Nutrition and Athletic Performance. J Acad
Nutr Diet. 2016 Mar;116(3):501–28.
Desbrow B, McCormack J, Burke LM, Cox GR, Fallon K, Hislop M,
et al. Sports Dietitians Australia position statement: sports nutrition
for the adolescent athlete. Int J Sport Nutr Exerc Metab. 2014
Oct;24(5):570–84.
Rare monogenetic diabetes
INV2
Berardinelli-Seip syndrome and other
lipodystrophies: diagnosis and treatment
C. Vigouroux1
1
Saint-Antoine Research Center, Inserm U938, Paris, France
Berardinelli-Seip syndrome, also named Congenital Generalized Lipodystrophy (CGL), is a rare and severe monogenic syndrome of insulin
resistance, transmitted as an autosomal recessive trait, mainly in consanguineous families. Inactivating mutations in four genes, causing
the clinically related CGL type 1 to 4, impair the cellular pathways of
adipocyte differentiation through different mechanisms, leading to
the association of fat loss, insulin resistance, severe dyslipidemia and
fatty liver disease, further complicated with diabetes. Early diagnosis,
mainly based on clinical signs, is needed for adequate care, family
screening and genetic counseling. Recombinant leptin therapy, which
addresses one of the endocrine defects related to fat loss, is effective
for the prevention and the treatment of metabolic complications.
However, its restricted availibity outside North America and Japan
limits its utilization for routine care.
Beside CGL, other rare lipodystrophic syndromes, with lipoatrophy
being generalized or partial, genetically-determined or acquired, cover a
broad spectrum of clinical phenotypes including multisystem pediatric
or adult diseases. Accelerated ageing syndromes, DNA repair abnormalities, auto-immune or inflammatory diseases can also result in limited
fat storage in adipose tissue and its metabolic consequences. These
recently described diseases further reveal that each aggression against
differentiation, regulation and/or maintenance of adipose tissue, or dysregulation of triglyceride storage within adipocyte lipid droplets, has
major consequences for whole-body metabolic homeostasis.
Obesity and Insulin resistance
INV3
Metabolic Markers of Beta Cell Failure in Youth
Insulin Resistance: Do They Conform to Standards?
S. Arslanian1
1
University of Pittsburgh, Children’s Hospital of Pittsburgh of UPMC,
Pediatrics, Pittsburgh, United States
Pediatr Diabetes October 2016; 17 (Suppl. 24): 5–9
Youth prediabetes and type 2 diabetes have emerged as major consequences of childhood obesity imposing a serious public health burden.
The traditional and widely accepted standards to either diagnose type
2 diabetes or capture heightened risk for future type 2 diabetes,
i.e. pre diabetes, are the fasting and 2-hr glucose concentrations during
an oral glucose tolerance test (OGTT). Considering that insulin resistance, impaired β-cell function and impaired incretin effect constitute
wileyonlinelibrary.com/journal/pedi
© 2016 The Authors.
Pediatric Diabetes © 2016 John Wiley & Sons A/S
5
6
the pathophysiological mechanisms of youth prediabetes and type
2 diabetes, there is increasing interest to identify simple biomarkers
that can detect impairment in β-cell function presaging type 2 diabetes.
Among these are the fasting, the 1-hr, and the 2-hr glucose concentrations during the OGTT which signal impaired β-cell function, measured
by the clamp-derived disposition index (β-cell function relative to insu-
INVITED ABSTRACTS
lin sensitivity), and proclaim risk of progression to type 2 diabetes.
Additionally however, recent cross-sectional studies demonstrate that
the shape of the OGTT-glucose response curve can differentiate type
2 diabetes risk in adults, but data are limited in pediatrics. This presentation will discuss the nontraditional metabolic biomarkers that herald
β-cell failure and risk of type 2 diabetes in obese youth.
Pandemic and Potential solutions: Improving Diabetes in emerging
economies
INV4
Pandemic and potential solutions: improving
diabetes in emerging economies - China
J. Fu1
1
Children’s Hospital of Zhejiang University School of Medicine,
Hangzhou, China
It has brought an increasing amount of attention to childhood diabetes and the impact on economic development. The cost for diabetesrelated health expenditure in China is >500 billion dollars in 2015.
The incidence is increasing in China, particularly in
children < 15 years. We conducted a nationwide study from China’s
14 medical centers for15 years including 4 million patients. T1DM
has occurrence rate of 89.6% of all diabetes.China ranks No.4 in the
number of children with T1DM (<15 years).The overall annualincidence increase isestimated around 3% globally. But there are strong
geographic difference, with 3 times higher in well developed areas in
China such as Beijing, Shanghai. According to the retrospective study
the mean age at diagnosis decreased significantly to 11.21 years in
2013. A steep rise in diabetes incidence was observed in the under
5 year’s age group.
China is struggling with the growing challenge of childhood obesity
and rapid increase in type 2 diabetes. The prevalence of obesity and
overweight increased 3-fold in 10 years.The prevalence of overweight
was 11.0 % and obesity 8.9 % in our multicenter study, aged 7–16 years
old. The prevalence of childhood T2DM in China doubled from
4.1/100,000 in the first 5 years to 10.0/100,000 in the recent 5 years.
Withthe growing increase in diabetes, we are trying to improve the
awareness of society to childhood diabetes.Chinese professionalsconducted the project MANAGEMENT PROGRAM FOR CHILDREN WITH
DIABETES IN CHINA,which has established32 pediatric diabetes centers in 26 cities in Chinafrom Nov. 2011 to Mar. 1, 2015. We organized78 diabetescamps to deliver knowledge of diabetes care and set
up a network for communication. Over 1300 children and 2600 parents benefit.Meanwhile,Spring Bud Plan-Chinese children diabetes
cooperative group was initiated involving 48 pediatric diabetic centers. Outpatient management of diabetes and 3C diabetic management is seeing its advantage.
Obesity and Insulin resistance
INV5
Endocrine-metabolic consequences of low and high
weight at birth
L. Ibañez1
1
University of Barcelona, Barcelona, Spain
Infants born small-for-gestational-age (SGA) are at higher risk for
adult diseases, including diabetes and hypertension. Longitudinal
studies have disclosed that those risks may be modulated by early
nutrition, so that breast-feeding confers a relatively low risk and
protein-enriched formula-feeding is followed by a relatively high
risk. In early infancy, the catch-up of SGA infants is characterized
by a recovery of lean versus fat mass; in late infancy, SGA-breastfed
infants combine a low adiposity and a high insulin sensitivity with
normal IGF-I and HMW adiponectin levels; in contrast, SGA infants
fed enriched formulas normalize their body composition by gaining
more fat; this normalization is accompanied by a fall in HMW adipo-
nectinemia and by elevated IGF-I levels, and thus, by a less favorable cardio-metabolic profile. Eventually, catch-up SGA children tend
to become hyperinsulinemic, and to display more hepatic fat and a
thicker carotida by the age of 3–6 yr; the development of overweight amplifies these abnormalities and increases further the risk
for an early and rapidly progressive puberty, and a shorter adult
stature.
Breastfed, large-for-gestational-age (LGA) infants from non-diabetic
mothers are more adipose as newborns, despite having lower levels
of myostatin -a myokine inhibiting the differentiation of myoblasts-,
and longer telomeres. By the end of early infancy, these infants
become relatively lean and develop a favorable endocrine-metabolic
profile including high insulin sensitivity. By age 2 years, LGA subjects
become relatively “muscular” -by gaining more lean mass- and tall;
this pattern of body composition may subsequently protect these
individuals against metabolic complications of overweight and explain
their lower risk for diabetes as adults.
7
INVITED ABSTRACTS
Emerging diabetes therapeutics (ADA symposium)
INV6
New approaches for islet immune-isolation and
delivery
D.G. Anderson1
1
Massachusetts Institute of Technology, Cambridge, United States
The fibrotic reaction to implanted biomaterials is a fundamental challenge to the development of immuno-isolation devices. Here we
describe our work developing new biomaterials and devices for the
purposes of enabling islet transplantation. In particular we describe
the development of a large library of synthetic hydrogel materials,
and the characterization of their biocompatibility in vivo. Data will be
presented on the nature of the immune response to these and conventional biomaterials. Several lead materials have been identified
with significantly improved biocompatibility in rodents and primates.
When formulated into microcapsules these materials allow for longterm islet survival and function in rodents and primates.
INV7
Neurodevelopment and KATP channels: evolution
and new pharmacologic approach
K. Busiah1
1
Necker-Enfants Malades Hospital - Assistance Publique Hôpitaux de
Paris, Paris, France
ATP-sensitive potassium (KATP) channels are cell metabolic sensors
that couple cell metabolic status to electric activity, thus regulating
many cellular functions. Structurally, KATP channels are four identical inwardly rectifying potassium channel subunits (Kirx) forming
the pore, associated to four identical high-affinity sulphonylurea
receptor subunits (SURx). In the brain, as in the pancreatic β-cells,
the Kir6.2/SUR1 channel is the dominant KATP isoform. In pancreatic β-cells, KATP channels modulate insulin secretion in response
to fluctuations in plasma glucose level, thus regulating glucose
homeostasis. In the brain, their functions and the pathways they
control are partly understood. Neonatal diabetes mellitus (NDM) is
due to gain-of-function mutations in KATP channel subunits and is
associated with neurodevelopmental disorders ranging from developmental delay and epilepsy (DEND) or intermediate DEND syndrome to developmental coordination disorder associated or not
with hypotonia or attention deficit. Sulfonylurea treatment acts
through closure of the KATP channels, which enables insulin secretion from the β-cell and modest but measureable improvements in
neurodevelopmental outcomes. However, sulfonylurea drugs have
limited ability to cross the blood–brain barrier in animal models.
Early treatment with sulfonylureas improves visuomotor performance in patients with permanent NDM. Rapid identification of
mutations and switching to sulfonylurea treatment at a younger
age might provide further benefit with regard to neurodevelopmental outcomes. Our group developed a suspension of glibenclamide that is more suitable for use in pediatric patients as its
dosage can be adjusted to patients needs with great precision.
Pharmacokinetic studies reported it to be better absorbed than
glibenclamide tablets and metabolic studies reported same efficiency as tablets in infants and young children affected with NDM
(ClinicalTrial.gov NCT02375828).
Epidemiology and Economic Burden on healthcare system by
childhood DM
INV8
Is the incidence of type 1 diabetes in children and
adolescents really increasing?
E. Mayer-Davis1
1
University of North Carolina at Chapel Hill, Department of Nutrition,
Chapel Hill, United States
Type 1 diabetes (T1D) diagnosed in youth presents a substantial clinical and public health burden due to both the challenges of daily disease
management and the risk for serious acute and chronic complications.
Previous reports documented that the incidence of T1D has increased
worldwide over the past three decades. Data from Australia demonstrated a 5-year cyclical variation in T1D incidence in youth from
2000–2011 in both sexes and in all age groups studied. In Finland with the world’s highest reported incidence of T1D - analyses sug-
gested a stabilization of the incidence of T1D from 2005–2011. Similar
findings indicating a plateau in incidence were reported from Norway.
On the other hand, data recently reported form the SEARCH for Diabetes in Youth study in the United States showed that a linear trend of
increasing incidence of T1D from 2002–2012 was the best fit to the
data, rather than a non-linear function. In this presentation, we will
present data from around the world and will consider potential reasons
for variable results across studies and countries on the topic of
whether the incidence of T1D is increasing over time. These results
are important indicators of the potential impact of T1D on the lives of
young individuals, on the health care system and on society in general.
Variation in incidence trends may generate new directions for research
on the environmental or behavioral triggers of T1D diabetes in youth
that may change over time, and that therefore may be important in
eventual efforts for prevention.
8
INVITED ABSTRACTS
Diabetes Registries: Comparing outcomes to improve care
INV9
Nordic countries / USA & Australia registries
J. Svensson1
1
Herlev University Hospital, Copenhagen, Herlev, Denmark
Objectives: There is an increasing use of benchmarking within and
between countries. Resources are used to collect data and present
data. Is it purely an academic exercise or do our patients benefits
from benchmarking? The purpose of this lecture is to describe the
Nordic and American and Australian benchmarking, to highlight
results regarding improved outcome for children with diabetes and
discuss why and how benchmarking works.
Methods: Literature review of studies from the Nordic National registers, America and Australia including long-time follow-up and feedback to participating center including center specific results before
and after.
Results: There are numerous registers and collaborating net-works
worldwide with the purpose of improving outcome for children with
diabetes. There are substantial differences among countries and centers not easily explained by the treatment or population characteristics. Some differences between centres may be nullified by the
opposite results from other centres hiding valuable information. Several studies have shown improved HbA1c and reduction in hypoglycemic events, though some studies show limited improvement. Only
items with a high accuracy and completeness can be addressed for
interpretation and more soft variables such as good communications
skills and beliefs are difficult to measure. Beneficial outcome may be
due to exchange of guidelines, exchange of good clinical practice or
the direct comparison of results changing our beliefs of what is possible. The mindset of the healthcare providers (or patients) may be as
important as treatment including target settings.
Conclusions: Benchmarking and national registers is often associated
with improved care the challenge is to translate it into specific guidelines and identify factors responsible for improved outcome. Our own
mindset and convictions may be challenge by the best results seen in
centers comparable to our own.
The state of art on Diabetes Complications
INV10
Effects of type 1 diabetes on cognition and the
brain
A.M. Arbelaez1
1
Washington University, Saint Louis, United States
The human brain undergoes dynamic changes in brain structure and
metabolic demand throughout childhood. Glycemic extremes, such
as hypoglycemia and hyperglycemia, occur more frequently in children and adolescents with T1DM. Thus, brain developmental trajectories are altered depending on the age and severity at which
these extremes are experienced. Studies utilizing various neuroimaging techniques have shown that glycemic extremes can differentially affect the developing brain. Severe hypoglycemia has been
associated with smaller gray matter volumes in superior temporal
regions, whereas exposure to hyperglycemia has been associated
with smaller gray matter volume in the medial parietal area, greater
gray matter volume in the right prefrontal region. There are only a
few of cognitive studies with large sample size that examine glycemic control variables in a reliable manner. Some studies in adults
and children have documented an association between severe
hypoglycemia and lower cognitive outcomes compared to controls
or those without severe hypoglycemia. Moreover, cross-sectional
studies of youth suggest that exposure to chronic hyperglycemia
may lead to subtle differences in cognitive and academic function.
Recent data suggest that this association can be detected quite
early in young children and youth with recent onset diabetes. However, longitudinal prospective studies over a wide range of glycemic
extremes are needed to better determine the effects of glycemic
extremes in the brain.
Motivational Interviewing to engage adolescents with Diabetes
INV11
Motivational interviewing to engage adolescents
with diabetes
D. Christie1
1
UCLH, London, United Kingdom
For young people trying to keep diabetes under control the behaviours
can appear simple e.g.; following a healthy diet, regular self-monitoring
and exercise. However clinicians and parents are often frustrated by
the gap between the “ideal” and ’reality’. Young people have conflicting motivations and pressures; a change in behaviour feels too big, the
rewards too distant, the personal or financial costs too high or maybe
it was never their idea to change in the first place. Attention has
turned to the potential of Motivational Interviewing in the paediatric
setting, particularly with the adolescent age group. Motivational
Interviewing is a directive person-centred therapeutic style that invites
individuals to explore ambivalence and find solutions that fit for them
if they identify the situation as a problem. Early trials support the use
of MI in type one diabetes in adolescents, either as a stand-alone
treatment or as an adjunct to other treatments where it can be a
method of engaging patients in the programmes thus enabling the programmes to be more effective. The presentation describes the core
principles and key skills of motivational interviewing and offers clinical
examples with young people and parents living with diabetes.
Christie, D., Martin, C. (Eds.), (2012). Psychosocial Aspects of Diabetes: Children, Adolescents and Their Families London: Radcliffe.
Christie, D., Channon, S.(2014).
Using motivational interviewing to engage adolescents and young
adults with diabetes Practical Diabetes, 31 (6), 252–256. doi:10.1002/
pdi.1878
9
INVITED ABSTRACTS
Is Diabetes an Emotional Burden in adolescents and young adults
with T1DM?
INV12
I wish they understood how much of an impact it
has on everyone in the family’: parents’ views of
living with type 1 diabetes in the family
INV13
We’re all in this together - reducing the burden, an
issue for the whole family and the diabetes team
C. Hendrieckx1
1
Murdoch Childrens Research Institute, Cell Biology, Melbourne,
Australia
1
Deakin University, The Australian Centre for Behavioural Research in
Diabetes, Geelong, Australia
This presentation will share findings of the Diabetes MILES Youth
Study, the first large-scale, Australian survey of parents and adolescents focused on the psychological aspects of diabetes.
Youth (aged 10 to 19 years) and their parents were invited to complete an online survey about their experiences of living with type
1 diabetes, their emotional well-being, family relationships and support. Parents completed questions about their own general emotional
well-being as well as diabetes-specific measures (parental diabetesrelated distress, fear of hypoglycaemia and hyperglycaemia); about
their child’s diabetes management, history of hypoglycaemia and
DKA, diabetes-specific self-efficacy and responsibilities.
In total, 826 parents or carers (mean age 46 6years, 88%
mothers) of an adolescent with type 1 diabetes took part in the
study. Overall, few parents reported severe anxiety symptoms (8%)
or had impaired emotional well-being (12%). However, one in four
parents experienced high levels of distress related to their child’s diabetes. Looking more closely to their concerns, it was clear that parents experienced both fear of hyperglycaemia (and its long-term
consequences) as well as fear of hypoglycaemia. Parents were often
concerned about their child’s diabetes management being ´off track´
and many felt they acted as ’diabetes police’. In general, respondents
scored high on the diabetes self-efficacy scale, but they felt least confident in having the conversation with their child about the realities
of long-term complications. These findings indicate that the difficulties parents face in keeping the child’s glucose levels within targets
affect their psychological well-being and family relationships.
The Diabetes MILES Youth survey provided an opportunity for parents’ voices to be heard, as illustrated by this parent: ’Thank you for
providing the opportunity to detail what I experience on a daily basis.’
E. Northam1
Recent advances in insulin delivery systems, as well as new and
improved insulins hold great promise for improved outcomes for
youth with TIDM. Yet the emotional burden of the disease remains
stubbornly high and there is evidence that human behaviour continues to undermine the translation of treatment advances into better
outcomes for patients. Media driven reports of an imminent “cure”
create uncertainty and disappointment for families, while the
demands of implementing promising new technologies may exceed
the financial, cognitive and emotional resources of many individuals
and actually increase stress and a sense of failure. As Acerini (2016)
points out, evidence that “high tech” = “high quality” = better metabolic outcomes is lacking. Hope is essential, but misguided hope will
engender resentment and undermine trust. Most clinicians are
acutely aware of the important role that emotional factors play in diabetes management, but the desire for a prescriptive template for
reducing stress and promoting psychological wellbeing in their
patients, while understandable, may be unrealistic. It is most unlikely
that “one size will ever fit all”. This presentation will review what we
currently know and what we still need to learn about the psychology
of diabetes management. Pitfalls, predicaments and cautionary tales
will be noted, and some suggestions for a way forward will be
offered.
Acerinit C. The rise of new technology in diabetes care. Not all
that is new is necessarily better. Pediatric Diabetes 2016;
doi:10.11111pedi.12366
DOI 10.1111/pedi.12450
ORAL SESSIONS
Oral Session I - Diabetes Technologies
O01
CGM in healthy children aged 2-8 years
F. Sundberg1,2, A. Reims1,2, G. Forsander1,2
1
Sahlgrenska University Hospital, Queen Silvia Childrens Hospital,
Gothenburg, Sweden, 2University of Gothenburg, Sahlgrenska Academy,
Gothenburg, Sweden
Objective: To describe glycemic patterns monitored with CGM in
healthy children aged 2-8 years.
Methods: Participants were healthy siblings, aged 2-7.9 years, of
children with diabetes using CGM. Height and weight were measured
by staff at the hospital. HbA1c was measured with DCA Vantage,
with reference value 27-42 mmol/mol. Fasting plasma glucose and
two-hour postprandial glucose value after a defined meal was measured with Hemocue prior to inclusion. Each child used one Dexcom
G4 sensor placed on the arm or the buttock and calibrated according
to the manufacturer’s instructions. Data were downloaded to the
Diasend system and analyzed with SPSS.
Results: 13 healthy children (9 girls) participated, with mean age 5.5
(1.7; range 2.1-7.9) years, BMI-SDS 0.06 (0.85; range −1.5-1.6),
HbA1c IFCC 32 (2.7) mmol/mol, and HbA1c NGSP 5.1% (0.24%).
Their fasting p-glucose was 5.0 (0.40) mmol/l and two-hour postprandial p-glucose was 5.9 (0.74) mmol/l. They provided 1895
(107; range 1637-1985) glucose values each.
Mean glucose value was 5.3 (0.33) mmol/l. Mean glucose variability expressed as SD was 1.0 (0.21). Altogether 84% (6.8; range
72-94%) of values were in the range 4-7 mmol/l, while 10% (7.9%)
of values were < 4.0 mmol/l, 3.3% (3.6%) were < 3.5 mmol/l and
0.77% (1.2%) were < 3.0 mmol/l. The median frequency of values
below 4.0, 3.5, and 3.0 mmol/l was 7%, 2%, and 0%, respectively
(range 1-27%, 1-11%, and 0-3%). Nadir glucose 4.5 (0.31) mmol/l
was at 5 a.m. and the highest value was 5.9 (0.59) mmol/l at 9 p.m. Only 6.2% (4.4%) of values were > 7.0 mmol/l, while 0.62%
(1.2%) were > 9 mmol/l, and 0.077% (0.28%) were > 11 mmol/l.
Conclusions: Normoglycemia in children aged 2-8 years as monitored
with CGM was 4.6-6.0 mmol/l, with a diurnal pattern of lower plasma
glucose in the morning (3.9-5.1 mmol/l) and higher in the evening
(4.7-7.1 mmol/l). Glucose values < 4.0 mmol/l were uncommon and
values < 3.5 mmol/l were rare.
O02
Overnight glucose control during and after physical
activity with closed-loop system GlucoSitterTM in
youth with type 1 diabetes
M. Macedoni1, K. Dovc2, N. Bratina2, D. Lepej3, R. Nimri4, M. Phillip4,
E. Atlas5, I. Muller5, T. Danne6, O. Kordonouri6, T. Biester6,
T. Battelino2,7
1
Study University of Milano, Department of Pediatrics, Ospedale dei
Bambini Vittore Buzzi, Milano, Italy, 2University Children’s Hospital,
UMC Ljubljana, Department of Pediatric Endocrinology, Diabetes and
Metabolic Diseases, Ljubljana, Slovenia, 3University Children’s Hospital,
UMC Ljubljana, Department of Pulmonology, Ljubljana, Slovenia,
4
National Center for Childhood Diabetes, Schneider Children’s Medical
10
© 2016 The Authors.
Pediatric Diabetes © 2016 John Wiley & Sons A/S
Center of Israel, Jesse Z. and Sara Lea Shafer Institute for Endocrinology
and Diabetes, Petah-Tikva, Israel, 5DreaMed Diabetes Ltd, Petah-Tikva,
Israel, 6Kinder- und Jugendkrankenhaus ’Auf der Bult’, Diabetes Centre
for Children and Adolescents, Hannover, Germany, 7Faculty of Medicine,
Ljubljana, Slovenia
Objective: The aim of this clinical study was to investigate the safety
and efficacy of closed-loop (CL) insulin delivery during physical activity and the night after in children and adolescents with type 1 diabetes (T1D).
Methods: This study is a two-arm, open-label, randomized, in-hospital, crossover, ongoing clinical trial of 20 children and adolescents
with T1D. They performed two exercise protocols: moderate (55% of
maximal oxygen uptake-VO2max) physical activity, and a combination
of moderate activity with incorporated high intensity sprints (55/80%
VO2max) either on CL (DreaMed GlucoSitterTM) or open-loop (OL) in
random order. In OL group pump was disconnected during the exercise and basal insulin dose was reduced by 20% for 4 hours after the
exercise.
Results: This interim analysis included 10 subjects (5 girls), median
age was 15,73 years (IQR:13,43-15,91 years) and median was HbA1c
7,8% (IQR:7,4-8,05%). There was no statistical difference in percentage of time in hypoglycemia below 3,9 mmol/l (1,3% (IQR:0,0-4,65%)
for CL and 0,0% (IQR:0,0-0,4%) for OL). Event rate of hypoglycemia
below 3,3 mmol/l was low in both groups (3 vs 1 in OL). In the
VO2max 55/80% exercise protocol, the proportion of time with glucose values within target range (3,9-10 mmol/l) was significantly
higher in the CL (85,9% (IQR:76,1-91,2%) compared to OL (67,8%
(IQR:52,2-79,9%, P=0.0488)). Subjects did not spend any time in
hyperglycemia above 13,9 mmol/l (0,0% (IRQ:0,0-0,0%) in CL compared to 6,3% (IQR:0,0-16,3%, P=0.0469) in OL). In the VO2max 55%
protocol these differences did not reach statistical significance.
Conclusions: CL insulin delivery during and overnight after physical
activity was safe and effective in maintaining glucose values in
desired range without increased risk of hypoglycemia in the hospital
environment.
Trial registration: ClinicalTrials.gov NCT02657083
Disclosure: M.M. received funding from 2015 ISPAD Research Fellowship Grant.
O03
At-home and hotel use of a hybrid closed-loop
(HCL) system in a pivotal trial
F. Kaufman1, S. Weinzimer2, A. Criego3, S. Garg4, R. Slover4,
B. Buckingham5, T. Ly5, B. Bode6, W. Tamborlane2, T. Bailey7,
R. Brazg8, J. Ilany9, S. Anderson10, J. Shin1
1
Medtronic plc, Northridge, United States, 2Yale University, New Haven,
United States, 3International Diabetes Center, Minneapolis, United
States, 4University of Colorado Denver, Barbara Davis Center, Aurora,
United States, 5Stanford University School of Medicine, Stanford, United
States, 6Atlanta Diabetes Associates, Atlanta, United States, 7AMCR
Institute, Escondido, United States, 8Rainier Clinical Research Center,
Renton, United States, 9Sheba Medical Center, Tel-Hashomer, Israel,
10
University of Virginia, Charlottesville, United States
wileyonlinelibrary.com/journal/pedi
Pediatric Diabetes October 2016; 17 (Suppl. 24): 10–35
11
ORAL SESSIONS
7
Percentage of time in range
Range
Run-In (sensor)
Study (sensor)
Hotel (i-STAT)
>300 mg/dL
2.34.2
1.71.9
1.69.38
>180 mg/dL
27.413.7
24.59.2
25.121.24
71 to 180 mg/dL
66.712.2
72.28.8
72.520.53
≤70 mg/dL
5.94.1
3.32.0
2.44.82
≤50 mg/dL
1.01.1
0.60.6
0.20.83
Plus-minus values are means standard deviations.
Objectives: A hybrid closed-loop (HCL) insulin delivery system was
evaluated to establish its safety in adults and adolescents during
unsupervised (home) and supervised (hotel) use.
Methods: Participants with type 1 diabetes for ≥2 years, >6 months’
insulin pump use, and no recent severe hypoglycemia or DKA used
the Medtronic HCL system, consisting of an investigational glucose
sensor and transmitter, and a new pump platform with a control algorithm. After a 2-week run-in phase, all subjects were assigned to a 3month study phase conducted at home, with a 6-day, 5-night hotel
stay that included frequent reference (i-STAT) venous glucose measurements. Endpoints included the% of glucose values below, within,
and above the target range of 71-180 mg/dL.
Results: There were no episodes of severe hypoglycemia or DKA.
The Table summarizes sensor glucose (SG) values throughout the
study and i-STAT values during the hotel stay. The% of in-target SG
values (all subjects) increased from 66.7% in the run-in to 72.2% in
the study phase, and increased from 60.4% to 67.2% among the
30 adolescents age 14-21, with corresponding decreases in SG values
above and below the target range (p< 0.001 for each). SG and i-STAT
glucose distributions were in good agreement (Table). The MARD for
the sensors compared to i-STAT reference values was 10.3 9.0
(median, 8.2%).
Conclusions: The HCL system was safe and was associated with
reductions in the percentage of above- and below-target glucose
values. Reference glucose measurements confirmed the results
derived from the fourth-generation sensors.
[Distributions of glucose concentrations]
O04
Pivotal trial of a hybrid closed-loop system in adults
and adolescents with type 1 diabetes
S. Weinzimer1, R. Slover2, A. Criego3, B. Buckingham4, T. Ly4,
S. Garg2, B. Bode5, T. Bailey6, R. Brazg7, S. Anderson8,
W. Tamborlane1, J. Ilany9, J. Welsh10, F. Kaufman10
1
Yale University, New Haven, United States, 2University of Colorado
Denver, Barbara Davis Center, Aurora, United States, 3International
Diabetes Center, Minneapolis, United States, 4Stanford University School
of Medicine, Stanford, United States, 5Atlanta Diabetes Associates,
Atlanta, United States, 6AMCR Institute, Escondido, United States,
Rainier Clinical Research Center, Renton, United States, 8University of
Virginia, Charlottesville, United States, 9Sheba Medical Center, TelHashomer, Israel, 10Medtronic plc, Northridge, United States
Objectives: A hybrid closed-loop (HCL) insulin delivery system was
evaluated to establish its safety for unsupervised use in adults and
adolescents.
Methods: Participants with type 1 diabetes for ≥2 years, >6 months’
insulin pump use, and no recent severe hypoglycemia or DKA used
the Medtronic HCL system, consisting of an investigational glucose
sensor and transmitter and a new pump platform with a control algorithm. After a 2-week run-in, all subjects were assigned to a 3-month
study phase of system use. Changes in A1C (ΔA1C) and nighttime
hypoglycemia prevalence, defined as the percentage of sensor glucose (SG) values ≤50 mg/dL between 10PM and 7AM were determined in 30 adolescents (age 14-21) and 94 adults (age 22-75).
Results: The Figure shows A1C and nighttime hypoglycemia prevalences for adults (Panel A) and adolescents (Panel B) during the run-in
and study phases. Bubble sizes correspond to hypoglycemia prevalence and slopes correspond to ΔA1C. Mean A1C fell from 7.30.9%
to 6.80.6% in adults and from 7.70.8% to 7.10.6% in adolescents. Subjects with nighttime hypoglycemia >1% fell from 34 to
19 (adults) and from 12 to 4 (adolescents). There was no severe
hypoglycemia or DKA in 12,389 patient-days. The MARD for the sensors compared to i-STAT reference values was 10.39.0%
(median, 8.2%).
Conclusions: At-home use of the HCL system was safe during unsupervised home use and was associated with reductions in both A1C
and nocturnal hypoglycemia, particularly in adolescents.
[A1C and nighttime hypoglycemia]
O05
Assessing the impact of insulin pump therapy on
behaviour, mood, cognition and glycaemia in youth
with type 1 diabetes - a randomised controlled trial
M.A. O’Connell1, E.A. Northam1,2, A. Brown1, K. Lee1, J. Papoutsis1,
M. Clarkson Fletcher1, T. Schuster1, A. Jenkins2,3, G. Ambler4,5,
F.J. Cameron1,2
1
The Royal Children’s Hospital and Murdoch Childrens Research
Institute, Melbourne, Australia, 2The University of Melbourne,
Melbourne, Australia, 3St Vincent’s Hospital, Melbourne, Australia, 4The
Children’s Hospital at Westmead, Sydney, Australia, 5The University of
Sydney, Sydney, Australia
Objectives: In response to parental reports of benefit, we have previously shown improved behaviour, mood & cognition following CSII
initiation in a pilot study. This study aimed to re-examine these factors in a randomised controlled trial (RCT).
Methods: RCT at two Australian tertiary centres. Youth with T1D for
>1y, aged 7-15y were randomised to intervention (’I’ -immediate CSII
start, n=56) or control (’C’ -ongoing use of intermittent injections
n=45) groups. Baseline assessments of behaviour & mood (BASC-2),
cognition (standardised tests of intelligence, attention, memory &
executive function) & HbA1c were conducted pre-randomisation and
after 4 months (mo). Primary outcome was difference in parentreported behaviour at 4mo; differences in self-reported behaviour,
mood, cognition & HbA1c were secondary outcomes. T-tests & linear
mixed model analyses were used.
Results: Mean baseline age & HbA1c were similar (11.2 vs 11.0y;
7.9% vs 7.8% in I & C grps respectively). Parent-reported behavior
problems (Cohen’s d 0.41; p< .05) and HbA1c (7.4% vs 8.0%; p=.001)
were significantly lower in the intervention grp at 4mo. Mood (parent
report) & some aspects of cognition (perceptual reasoning, attention,
cognitive flexibility) improved in both groups over the study period
but were not different between groups at 4mo (p>0.05). Selfreported behaviour & mood did not differ.
Conclusions: Parent-reported behaviour problems & HbA1c
decreased significantly with CSII vs intermittent injections over 4mo.
As externalizing behaviour scores have been shown to predict mental
health & glycaemic outcomes, this may have long-term benefits;
12
ORAL SESSIONS
however effect size here was modest. Improvement in mood and
cognition appear to reflect Hawthorn and practise effects respectively rather than any beneficial impact of CSII. This study highlights
issues germane to parental attribution of cause and effect in respect
to diabetes therapies and reiterates the value of RCT when evaluating such modalities.
O06
Flash glucose monitoring in type 1 and type
2 diabetes patients - the first Indian experience of
libre pro
M. Chawla1, P. Gupta1, S. Kachalia1, S. Aversekar1, N. Wadhwa2
1
Lina Diabetes Care Centre, Mumbai, India, 2AUW Global, Mumbai, India
Objectives: FreeStyle Libre Pro Flash Glucose Monitoring (FGM)
technology, a novel automated ambulatory glucose profile (AGP)
reporting system has recently been introduced.
Methods: The utility and usability of FGM glucose monitoring system was evaluated in clinically discrete situations including vulnerability to hypoglycaemia and persistent hyperglycemia.
Results: We evaluated the complete data (sensor AGP and clinical
profile) of 35 type 2 (n=31) or type 1 (n=4) diabetics -FIRST study.
Mean age was 49.3 yrs (T2DM mean 53.3 yrs min 23 max 80 yrs,
T1DM mean 20.25 yrs min 10 yrs - max 37 yrs), 19 males, 16 females.
Most compelling reasons for flash monitoring were fluctuations in
blood glucose with reported episodes of hypoglycaemia (n=22,
T2DM=20, T1DM=2) followed by consistent hyperglycemia despite
advanced therapeutic care (n=13, T2DM=12, T1DM=1). Mean
change in HbA1c (mean −0.19 1.5, 95% CI −0.7- 0.3) after three
months was not statistically significant (baseline mean 8.3 Vs
3 months mean 8.1; 95% CI −0.9051 to 0.5108, p= 0.98). The change
in HbA1c in T2DM (mean SEM - 0.16 0.27, n=31) Vs T1DM
(mean SEM −0.42 1.11, n=4) was not statistically significant
(95% CI −0.8 to 2.5, p=0.06). Change in HbA1c in < 60 years (Mean
SEM 0.20 0.38, n=23) Vs > 60 years (Mean SEM −0.18 0.26, n=12) was statistically significant (95% CI −1.14 to
1.18, p=0.01).
Conclusions: The comprehensive data provided complete glycemic
profile within short time span of 14 days with actionable snapshot
insights into the ’Diabetic Pentad’ comprising fasting, post prandial
glucose, HbA1c, glycemic variability and hypoglycaemia, to customise
the diabetes care approach to address hypoglycaemia and glycemic
variability. The flash technology is a convenient, discreet and user
friendly innovation in the advancement of ambulatory monitoring to
enable physicians’ make more informed treatment decisions. This can
help personalize diabetes treatment plans, allowing better management of diabetes.
O07
Behavioral supports for parents of very young
children with type 1 diabetes (T1D) using
continuous glucose monitoring (CGM)
E. Iturralde1, C. Berget2, B.A. Buckingham1, L.A. DiMeglio3,
K.A. Driscoll2, S.J. Hanes1, A. Lagges3, T.T. Ly1, D.M. Maahs2,
M. Mantravadi3, K.K. Hood1
1
2
Stanford University School of Medicine, Stanford, United States,
University of Colorado Denver, Barbara Davis Center for Childhood
Diabetes, Denver, United States, 3Indiana University School of Medicine,
Indianapolis, United States
Objectives: Diabetes management presents unique challenges for
parents of very young children with T1D. Diabetes-related distress
and hypoglycemia worries are common. Despite increasing use of
CGM in this age group, many children do not reach glycemic goals.
We tested 4 behavioral interventions designed to reduce distress and
hypoglycemia worry and improve glycemic control.
Methods: Parents of 19 children under age 6 (mean age 4.2 1.3)
with T1D for an average of 2.3 1.0 years using CGM were enrolled
from 3 pediatric diabetes centers across the U.S. Behavioral interventions were assigned based on baseline glucose control or CGM use.
Parents received either 4 sessions on managing fear of hypoglycemia
and optimizing insulin treatment, or 4 sessions on distress reduction
and age-specific developmental demands.
Parents completed the Hypoglycemia Fear Survey, the Glucose
Monitoring Satisfaction Scale, and the parent version of the Diabetes
Distress Scale before and after the intervention. CGM data (14-day
download, before and after) were used to calculate time in target
(70-180 mg/dL).
Results: Sixteen families completed 3 or more sessions. Hypoglycemia worries decreased while CGM satisfaction increased; both
changes were significant with medium effect sizes (Table 1). Time in
target increased from 47% to 54%.
Conclusions: Integrating behavioral supports with CGM use has
promise for reducing burden and promoting glycemic target achievement in very young children with T1D.
[Table 1. Change from pre to post]
O08
Introduction of personal insulin pump 640G therapy
with SmartGuard technology reduces the negative
impact of diabetes on life comfort of patients with
type 1 diabetes
W.B. Gawel1, A. Tabor1, O. Szylaj2, G. Deja3, P. Jarosz-Chobot3
1
Medical University of Silesia, Students Scientific Association of
Department of Children Diabetology, Katowice, Poland, 2Upper Silesian
Child Health Centre, Katowice, Poland, 3Medical University of Silesia,
Department of Children Diabetology, Katowice, Poland
Objective: The aim of a study was to assess the quality of life(QoL)
of the patients suffering from type 1 diabetes(DM1) after introducing
personal insulin pump 640G with SmartGuard technology.
Material and methodology: 10 girls and 14 boys (the caregivers in
younger children) with well-controlled DM1 (mean HbA1C was 6.7%;
5.8%-8.75%) were examined , age between 2 and 15, mean 8 years.
The mean time from diagnosis was 3.7 years. Patient were previously
treated with insulin pumps with or without hypoblocade(Medtronic
MiniMed EAL-TIME/ Veo). 2-11 months after introducing 640G
pump therapy two surveys were conducted: standardized PedsQLTM
3.0 Diabetes which measured the QoL in diabetic patients (Survey I)
and the authorial questionnaire (Survey II) which measured the satisfaction of 640G therapy, it consisted of 11 questions, 2 closed and 9 semi-closed-ended.
Results: The mean scores of QoL in Survey I regarding communication (79%), concerns (60%), treatment (76%) and diabetes (69%)
which according to our scale ( 0-19% very low, 20-39%low, 40-59%
moderate, 60-79% high, 80-100% vey high) which means patiens
mean (SD)
mean comparisons
Parent Measures
N
pre-
post-
t
p
Hypoglycemia worries
16
22.3 (7.31)
18.8 (5.19)
2.26
.04
Cohen´s d
.59
CGM satisfaction
16
20.9 (3.16)
23.0 (3.08)
2.24
.04
.55
Diabetes distress
16
25.3 (6.56)
23.9 (5.67)
1.26
.23
.32
ORAL SESSIONS
perceived their Qol high in all categories. The results of Survey II
showed gladness and assurance of the patients with 640G pump
therapy. Over a half of participants (17 people) certified a serious
reduction of both hypo- and hyperglycemia episodes. 8 patients/
caregivers highlighted a better coherence between blood glucose(BG)
measured by sensor and glucose meter(GM) which enabled them to
decrease the frequency of pricking fingers with GM to measure BG
13
and improve quality of life. 11 caregivers noticed greater involvement
of children in controlling the disease and also better cooperation with
640G pump itself.
Conclusions: Patients with DM 1 using 640G pump with SmartGuard
technology are satisfied with the effects of the therapy and their QoL
measured by PedsQL is relatively high regarding this group of
patients.
14
ORAL SESSIONS
Oral Session II - Diabetes Epidemiology
O09
Maternal obesity as a risk factor for early childhood
type 1 diabetes - a nationwide prospective
population based study
U. Samuelsson1, N. Lindell2, A. Josefsson2, A. Carlsson3
1
Linköping University/Div of Pediatrics, Dept of Clinical and
Experimental Medicine, Linköping, Sweden, 2Linköping University/Div of
Obstetrics and Gynocology, Dept of Clinical and Experimental Medicine,
Linköping, Sweden, 3Lund University/Skane University Hospital, Dept of
Clinical Science, Lund, Sweden
Objective: To investigate the possible effects of maternal body mass
index (BMI) and gestational weight gain on the subsequent risk of
childhood type 1 diabetes.
Methods: Children in the Swedish pediatric diabetes quality register
were matched with four controls from the Swedish Medical Birth
Register. The children, of whom data on their mother’s BMI in early
pregnancy and gestational weight gain were available, were included,
total 16 179 individuals, 3231 children with type 1 diabetes and
12 948 control children.
Results: Mothers to children with type 1 diabetes were more likely
to be obese (p=0.02) and to have diabetes themselves (p< 0.001) as
compared to mothers to control children. The gestational weight gain
did not differ significantly. In mothers without diabetes maternal obesity was a significant risk factor for type 1 diabetes in the offspring
(p< 0.05) but this was not found in mothers with diabetes. Among
the children with type 1 diabetes there were a greater proportion of
children in the youngest age group (age 0-4) the higher the maternal
BMI was. In the oldest age group, 15-19 years of age, the pattern
was reversed. These findings were the same both for boys and girls.
However, further analysis showed that the observed differences were
only seen for non-diabetic mother whereas there was no significant
difference if the mother had diabetes. Furthermore, the proportion of
obese mothers was highest in the youngest age group, 18.2% compared to 7 % in age group 5-9 years of age 4.6% in age group 10-14
years and 10.3% in the oldest age group.
Conclusions: Maternal obesity, in absence of maternal diabetes, is a
risk factor for type 1 diabetes in the offspring, and also influence the
age of onset of type 1 diabetes. This emphasizes the importance of a
normal maternal BMI to potentially decrease the incidence of type
1 diabetes.
O10
Incidence trends for childhood type 1 diabetes
during 1989-2013 in 24 European registries
participating in the EURODIAB study
C. Patterson1, J. Rosenbauer2, A. Neu3, O. Cinek4, T. Skrivarhaug5,
B. Rami-Merhar6, G. Soltesz7, J. Svensson8, C. Castell9, E. Schoenle10,
R. Parslow11, P. Bingley12, G. Dahlquist13, P. Jarosz-Chobot14,
D. Marciulionytė15, E. Roche16, U. Rothe17, N. Bratina18, I. Weets19,
C. Ionescu-Tirgoviste20, M. Kocova21, N. Rojnic Putarek22, C. de
Beaufort23, M. Samardzic24, A. Green25, on behalf of the EURODIAB
collaboration of childhood type 1 diabetes registers.
1
Queen’s University Belfast, Centre for Public Health, Belfast, United
Kingdom, 2German Diabetes Center, Düsseldorf, Germany, 3University
Children´s Hospital, Tübingen, Germany, 4Charles University, Prague,
Czech Republic, 5Oslo University Hospital, Oslo, Norway, 6Medical
University of Vienna, Vienna, Austria, 7Pécs University, Pécs, Hungary,
8
University of Copenhagen, Herlev, Denmark, 9Government of Catalonia
Department of Health, Barcelona, Spain, 10University Children’s Hospital,
Zurich, Switzerland, 11University of Leeds, Leeds, United Kingdom,
12
University of Bristol, Bristol, United Kingdom, 13University of Umeå,
Umeå, Sweden, 14Medical University of Silesia, Katowice, Poland,
15
Lithuanian University of Health Sciences, Kaunas, Lithuania, 16Trinity
College Dublin, University of Dublin, Dublin, Ireland, 17Technical
University of Dresden, Dresden, Germany, 18University Children’s
Hospital, Ljubljana, Slovenia, 19Brussels Free University - VUB, Brussels,
Belgium, 20NC Paulescu National Institute of Diabetes, Nutrition and
Metabolic Diseases, Bucharest, Romania, 21University Children’s
Hospital, Skopje, Macedonia, the Republic of, 22Zagreb University
Hospital, Zagreb, Croatia, 23University of Luxembourg, Luxembourg,
Luxembourg, 24University Children’s Hospital, Podgorica, Montenegro,
25
University of Southern Denmark, Odense, Denmark
Objectives: To describe twenty-five year incidence trends for childhood type 1 diabetes in 24 European registries participating in the
EURODIAB study.
Methods: All registries operate in geographically defined regions and
are based on a clinical diagnosis of type 1 diabetes. Completeness of
registration is assessed by capture-recapture methodology and
exceeded 90% in most registries. Statistical analysis employed the
Joinpoint program to model incidence trends in individual registries
by fitting the most appropriate number of line segments connected at
join points. Mixed effects Poisson regression was used for pooled
analyses with registries defining the random effects.
Results: Twenty four registries in 20 countries registered more than
70,000 new cases diagnosed before the 15th birthday during the
period 1989-2013. Joinpoint fitted simple log-linear increasing trends
in incidence in 14 registries with a further 7 registries showing different trends in two periods but with a predominant increase. Two
registries showed significantly faster rates of increase in boys than
girls while eight found differences in rates of increase by age-group
with the higher rates of increase in the 0-4yr and 5-9yr age-groups
and lowest in the 10-14yr age group. Poisson regression estimated
pooled rates of increase across all registers of 3.9%, 3.8% and 3.1%
per annum in the three age-groups, respectively. Rates of increase
also varied when each five-year period was analysed separately with
the lowest rate of increase in the 2004-2008 period.
…Period…… Annual increase (95%CI)
1989-1993 …… 4.9% (3.1%-6.7%)
1994-1998 …… 2.9% (1.2%-4.6%)
1999-2003 …… 4.6% (2.9%-6.2%)
2004-2008 …… 1.4% (0.1%-2.7%)
2009-2013 …… 3.3% (1.3%-5.3%)
Conclusions: Rates of type 1 diabetes in European children continue
to increase in all age-groups although the rate of increase may have
reduced in more recent periods. The extent to which birth cohort
effects can explain these apparent differences will be assessed.
O11
Risk factors for premature mortality in subjects
with childhood-onset type 1 diabetes: data from
the population-based Brecon Cohort in Wales, UK
between 1979 & 2015
D. Wasag1,2, C. Dayan1, J. Gregory1, J. Harvey2
1
School of Medicine, Cardiff University, Cardiff, UK, Diabetes Research
Group, Divisions of Population Medicine & Infection and Immunity
Institute, Cardiff, United Kingdom, 2Wrexham Academic Unit, Bangor
University, Wrexham, United Kingdom
Objectives: The aim of this study was to examine mortality rates and
causes of death among patients diagnosed with type 1 diabetes
before their 15th birthday in Wales.
Methods: The BRECON childhood onset type 1 diabetes registry
(n=3288), with diagnosis from 1979 to 2013 (capturing >97% of all
new cases from 1995), was used to investigate patterns in causespecific mortality. 43,141 patient-years of diabetes were analysed
and 31 deaths were identified. The observed number of deaths was
15
ORAL SESSIONS
compared with number of deaths seen among different age groups in
Wales, as reported by NHS Wales. Associations of socio-demographic
factors with mortality were assessed using Cox proportional hazard
models. The proposed risk factors included socio-economic status,
the size of centre involved in diabetic care, diabetes duration and
gender.
Results: The overall standardised mortality ration (SMR) was 2.3
(95%CI 1.59-3.23), being highest in the age group 15-20 years, at
3.76 (95%CI 1.54-5.09). Increase in the overall SMR has been
observed in the age groups 10-20 years. The commonest cause of
death was ketoacidosis (n=9), followed by accidents some of which
might be attributed to hypoglycaemia (n=5), and suicide (n=4). All
deaths occurred among individuals diagnosed during and after
puberty (after the age of 10) regardless of diabetes duration, the logrank statistics is 3135.83 (p-value < 0.001). Higher mortality rates
among male subjects have been observed, with hazard ratio of 0.54
(95% CI 0.21-0.99; P=0.048). No statistically significant relationship
has been found between the risk of death and diabetes duration,
socio-economic status, size of centre involved in diabetic care and
family history of diabetes.
Conclusions: Despite advances in diabetic treatment, type 1 diabetes
is still associated with higher mortality rates, particularly in the age
during transition from paediatric to adult care facilities.
O12
Excess mortality in young persons with type
1 diabetes in Sweden
J. Nilsson1, L. Hanberger2, K. Åkesson1,3, U. Samuelsson4
1
Ryhov County Hospital, Department of Pediatrics, Jönköping, Sweden,
Linköping University, Div of Nursing, Department of Medicine and
Health Sciences, Linköping, Sweden, 3Futurum - Academy for Health and
Care, Jönköping County Council, Jönköping, Sweden, 4Linköping
University, Div of Pediatrics, Department of Clinical and Experimental
Medicine, Linköping, Sweden
2
Objectives: To study mortality rates and their relation to metabolic
control during childhood in young persons (≤29 years) with type 1 diabetes (T1D) diagnosed <18 years of age.
Methods: Data on all 12046 subjects registered in the Swedish pediatric diabetes quality registry, SWEDIABKIDS, from 2006 to 2014
were used. To investigate if any of these subjects had died and the
causes of death, data were merged with the Swedish Register for
Cause-Specific Mortality. The incidence of death was compared with
the incidence in the general population (GP). Last registered HbA1c
in SWEDIABKIDS was used.
Results: In total 99 persons ≤29 years of age with T1D were
deceased, incidence 0.84/1000, 3.2 times higher than in the GP. Of
these 51 had died of a documented diabetes-related cause. Among
boys, the excess mortality was 2.1 times higher than in the GP, in
girls 4.9 times higher. The highest mortality rate was found in age
group 25-29 years and 10-14 years, 5.8 times higher than in the
GP. Subjects dead from diabetes related causes had a mean HbA1c
80 30 mmol/mol
(9.5 2.7%). Subjects dead from other causes had a mean HbA1c
65 19 mmol/mol (8.1 1.8%) and those still alive 63 16 mmol/
mol (7.9 1.5%) (p < 0.001). Corresponding figures for boys were
81 27 (9.5 2.5), 66 19 (8.2 1.7) and 62 15 (7.9 1.4), for
girls 80 33 (9.5 3.0), 64 21
(8.0 1.9) and 64 16 (8.0 1.5). The relation between high
HbA1c and excess mortality was most obvious in the highest age
group (25-29 years), especially in girls, 110 34 (12.2 3.1), vs
80 25 (9.5 2.3) in boys.
Conclusions: In this cohort of young subjects with type 1 diabetes,
there was a high mortality rate compared to the GP. HbA1c was
higher in those who died due to the diabetes disease, compared to
death by other causes or to subjects still alive. Good metabolic control during childhood seems essential to decrease mortality rates in
young adults.
O13
Prediction of type 1 diabetes using a genetic risk
model in the diabetes autoimmunity study in the
young (DAISY)
B. Frohnert1, M. Laimighofer2, J. Krumsiek2,3, F. Theis2, C. Winkler3,
J. Norris4, A.-G. Ziegler5,6, M. Rewers7, A. Steck1
1
Barbara Davis Center for Diabetes, Children’s Hospital Colorado,
Aurora, United States, 2Helmholtz Zentrum München, Institute of
Computational Biology, Munich, Germany, 3German Center for Diabetes
Research (DZD), Munich-Neuherberg, Germany, 4University of Colorado
Denver, Epidemiology, Aurora, United States, 5Helmholtz Zentrum
München, Institute for Diabetes Research, Munich, Germany,
6
Technische Universität München, Forschergruppe Diabetes, Klinikum
rechts der Isar, Munich-Neuherberg, Germany, 7Barbara Davis Center for
Childhood Diabetes, Aurora, United States
Objectives: Our objective was to evaluate a previously-reported 10factor weighted genetic model to predict development of type 1 diabetes (T1D) in the Diabetes Autoimmunity Study in the Young
(DAISY) cohort. Performance of the 10-factor model (HLA plus nine
SNPs) was compared to a more limited model (HLA plus two SNPs)
and to HLA alone. We evaluated whether a model derived from firstdegree relatives of T1D patients (FDR) would be effective in DAISY
participants recruited from the general population (GP) as well as
FDR subjects.
Methods: DAISY follows children prospectively for development of
islet autoimmunity (IA) and T1D. The 10-factor model included HLA
genotype plus SNPs from PTPN22, INS, IL2RA, ERBB3, ORMDL3,
BACH2, IL27, GLIS3 and RNLS genes. The 3-factor model was
restricted to HLA genotype plus PTPN22 and INS. These were applied
to the DAISY cohort with complete SNP data (n=1941).
Results: Stratification of participants by 10-factor risk score showed
significant differences in risk of T1D over time by Kaplan-Meier analysis: DAISY GP (p=0.00006), DAISY FDR (p=0.0022). The 10-factor
and 3-factor models had improved discrimination of T1D outcome
over HLA type alone in DAISY GP (p=0.03 and 0.03), but there was
no difference in discrimination between these two models. In DAISY
FDR, the 10-factor model showed improved performance over HLA
(p=0.01) and the 3-factor model (p=0.02).
Conclusions: We have shown that a 10-factor risk model, previously
validated in FDR of T1D patients, is able to predict development of
T1D in children from the DAISY cohort. A more minimal 3-factor
model showed similar performance in predicting development of T1D
in GP; however, the 10-factor model had superior performance to
both the 3-factor model and HLA alone in FDR. Differences in model
performance in children with or without family history of T1D may
lead to important insights into risk factors specific to these groups.
O14
Epidemiological trends of youth-onset type
2 diabetes in British Columbia, Canada
S. Amed1, N. Islam2, K. Reimer3, J. Sutherland3
1
University of British Columbia, Pediatrics, Vancouver, Canada,
University of British Columbia, School of Population and Public Health,
Vancouver, Canada, 3BC Ministry of Health, Victoria, Canada
2
Objective: To describe the trends in incidence and prevalence of
youth-onset type 2 diabetes (T2D) in British Columbia (BC), Canada.
Methods: Children < 20 years of age living in BC between April 1st,
2002 to March 30th, 2013 were identified within linked administrative health data (physician billing claims, hospitalization discharge
codes, and prescription dispensations). A validated diabetes casefinding definition and algorithm that differentiates T1D and T2D
were applied to the linked data. Annual age-standardized incidence
[IR] and prevalence rates [PR] were calculated overall, and by sex
over the 10-year period. Linear regression was used to test for temporal trends.
16
ORAL SESSIONS
Results: In 2002/03, 37 (62% female [F]) new cases of T2D were
identified in individuals < 20 years, increasing to 53 (68% F) cases in
2012/13. The overall age-standardized IR (95% CI) per 100,000 was
5.0 (4.49-5.51), while for males and females it was 3.77 (3.15-4.39)
and 6.27 (5.16-7.38), respectively. The age-standardized IR (95% CI)
of T2D increased from 3.45 (2.43-4.80) in 2002/03 to 5.16 (3.866.78) in 2012/13 while in males it increased from 2.53 (1.39-4.36) to
3.23 (1.88-5.24), and in females from 4.43 (2.80-6.73) to 7.21 (5.0510.05). The sex differences in T2D incidence widened from 2010
onwards. The number of prevalent cases increased from 97 (63% F)
in 2002/03 to 219 (63% F) in 2012/13 while the age-standardized
prevalence rate (%) increased from 0.009 (0.007-0.011) to 0.021
(0.018-0.023) increasing the overall age-standardized prevalence by
130%. Females had consistently higher prevalence of T2D than males
over this period.
Conclusions: The incidence and prevalence of youth-onset T2D is
increasing in BC with significant gender differences. Higher rates of
T2D in female youth poses a significant risk to future offspring via
exposure to hyperglycemia in utero. These data are necessary to
guide health service delivery and disease prevention initiatives for
youth-onset T2D.
[SMRs by onset and age at death]
Conclusions: Death from IHD begin to appear from 20 years old in
the early onset group and mortality is non-significantly higher compared with the late onset group. This suggests that childhood T1D
may result in unexpectedly early vascular death.
O16
End-stage renal disease in patients with childhoodonset type 1 diabetes diagnosed during 1973-2012
V. Gagnum1,2, L.C. Stene2,3, G. Joner1,2,4, P.R. Njølstad5,6,
T. Skrivarhaug1,2,7
1
Oslo University Hospital, Division of Paediatric and Adolescent
Medicine, Oslo, Norway, 2Oslo Diabetes Research Centre, Oslo, Norway,
3
Norwegian Institute of Public Health, Division of Epidemiology, Oslo,
Norway, 4University of Oslo, Institute of Clinical Medicine, Oslo, Norway,
5
Haukeland University Hospital, Department of Paediatrics, Bergen,
Norway, 6University of Bergen, KG Jebsen Center for Diabetes Research,
Department of Clinical Science, Bergen, Norway, 7Oslo Diabetes
Research Centre, Norwegian Childhood Diabetes Registry, Oslo, Norway
Objectives: To estimate the cumulative incidence of end-stage renal
disease (ESRD) by sex, age at diagnosis and year of diagnosis in a
nationwide, population-based cohort with childhood-onset type 1 diabetes (T1D) in Norway.
Methods: Data are based on the nationwide, population-based Norwegian Childhood Diabetes Registry and includes all new-onset cases
(age < 15 years) diagnosed with T1D during 1973-82 (n=1,888) and
1989-2012 (n=5,983). The follow-up period was from diagnosis of
diabetes to development of ESRD, death, emigration or to September
30, 2013. We estimated the cumulative incidence of ESRD by years
since diagnosis of diabetes by linking to the nationwide Norwegian
Renal Registry and mortality by linking to the National Population
Registry. We assessed cumulative mortality among patients
with ESRD.
Results: The cohort was followed for maximum 40 years (mean
16.8 years). During 132,143 person-years, 95 (1.2%) individuals
developed ESRD, 58 men and 37 women. Mean years from diagnosis
of diabetes to ESRD was 24.7 years (range 12.1-37.8). The cumulative incidence of ESRD was 0.82% (95% CI 0.56-1.21) at 20 years,
3.21% (2.54-4.05) at 30 years and 5.3% (4.22-6.65) at 40 years.
There was an increasing trend in cumulative incidence of ESRD over
the three age groups at diagnosis (0-4, 5-9 and 10-14 years at diagnosis), p=0.01. No difference in cumulative incidence of ESRD was
identified between men and women, p=0.13, nor between the two
diagnosis cohorts (1973-82 and 1989-2012), p=0.96. The probability
of death 10 years after diagnosis of ESRD was 39.4% (28.4-52.9).
Conclusion: We report relatively low incidence of ESRD among children diagnosed with type 1 diabetes in childhood. Individuals diagnosed at younger age seem to have more favorable outcome.
O15
Premature deaths from ischaemic heart disease in
childhood and young adult onset type 1 diabetes
H.J. Bodansky1, T.C. Evans-Cheung1, R.G. Feltbower1, R.C. Parslow1
1
University of Leeds, Leeds, United Kingdom
Objectives: Ischaemic heart disease (IHD) is a major cause of death
for individuals with type 1 diabetes (T1D). Age at onset of T1D and
risk of IHD death was assessed.
Methods: The Yorkshire Register of Diabetes in Children and Young
Adults includes under 15s (early onset) diagnosed with T1D in Yorkshire from 1978, and 15 to 29 year olds (late onset) diagnosed in
West Yorkshire from 1991. Personal identifiers were linked to Office
for National Statistics (ONS) death certification data. Underlying
cause of death was validated by a specialist clinician. Standardised
mortality ratios (SMRs) were calculated using England and Wales
population and IHD death rates between 1978 to 2014 by 5-year
age group and sex.
Results: The cohort included 6,209 individuals, with 107,492 personyears of follow-up. Out of 233 deaths, 16 were due to T1D with
IHD. Fourteen deaths had early onset (median age at death was
35.1). There were 2 deaths with late onset (median age of death was
43.2). Overall SMR for IHD deaths was 8.5
(95% CI 5.2 - 13.9). SMR for early onset (13.8 (95% CI 8.2 - 23.3))
was non-significantly higher than the SMR for late onset (2.3 (95% CI
0.6 - 9.3)).
Age at death (years)
Early onset
Observed
Expected
SMR (95% CI)
Late onset
Observed
Expected
SMR (95% CI)
20 to 24
2
0.04
50 (12.5, 199.9)
0
0.01
0
0
25 to 29
2
0.09
22.6 (5.6, 90.2)
0
0.04
30 to 34
3
0.16
18.9 (6.1, 58.5)
0
0.11
4.9 (0.7, 34.6)
35 to 39
2
0.25
8 (2, 31.8)
1
0.21
0
40 to 44
3
0.28
10.6 (3.4, 33)
0
0.27
0
12.9 (3.2, 51.7)
0
45 to 49
2
0.15
50 and over
0
0.02
Total
14
1.02
0
13.8 (8.2, 23.3)
0
0.18
1
0.05
19.5 (2.7, 138.3)
2
0.86
2.3 (0.6, 9.3)
17
ORAL SESSIONS
Oral Session III - Education and Psychosocial Issues
O17
Empowering children and young people (CYP) with
diabetes - SEREN, a new structured education
programme in Wales, UK.
StructuredEducation:ReassuringEmpoweringNurturing
R. Pryce1, N. D’Souza2, C. Baker3, K. Thomas4, Y. Davies5, J. ReedScreen6, J. Thomas7
1
Aneurin Bevan University Healthboard, Paediatrics, Newport, United
Kingdom, 2Abertawe Bro Morgannwg University Healthboard,
Paediatrics, Bridgend, United Kingdom, 3Aneurin Bevan University
Healthboard, Dietetics, Newport, United Kingdom, 4Hywel Dda
University Healthboard, Dietetics, Carmarthen, United Kingdom, 5Hywel
Dda University Healthboard, Paediatric Nursing, Carmarthen, United
Kingdom, 6Betsi Cadwaladr University Health Board, Paediatric
Psychology, Bodelwyddan, United Kingdom, 7Betsi Cadwaladr University
Health Board, Paediatric Nursing, Bodelwyddan, United Kingdom
Education in diabetes is a fundamental component of self-management. Health care systems that have structured education from diagnosis have demonstrated improving trends in HbA1c. Within Wales,
education for CYPs was delivered in an informal way and this deficiency was highlighted in the National Paediatric Diabetes Audit year
on year. While structured education is being delivered across some
parts of the UK, there is no overarching programme covering the
entire age range of CYPs with diabetes, from diagnosis to transition
to adulthood.
Objectives: Following basic training in the principles of structured
education, a working group that consisted of Health Care Professionals (HCPs) and parent representatives was set up in 2013, to
develop such a programme. The philosophy of the programme has
been to “Empower the CYP and family to manage diabetes from diagnosis right through and including transition to adult services”.
Methods: Work commenced based on education materials that were
already being used within Wales. It draws on shared interactive and
age appropriate resources and is aligned to the education key stages
for the UK (1, 2, 3+4). The resources include an interactive story
board, age based workbooks and activities. The detailed curriculum
for the educators which is accompanied by an education/assessment
record will enable standardisation of diabetes education across
Wales. The programme is accompanied by a quality assurance process with formal evaluation being planned.
The first module “Diabetes at Diagnosis” for age 11 years+, piloted
in September 2015 helped to refine these resources.
Conclusion: The first phase of the programme was launched in
March 2016 after training of HCPs. The other key stages (with a
Welsh translation) will follow and additional modules such as sport,
pumps, annual updates and transition to comprehensive school and
adulthood are planned.
We would like to take the opportunity to share our journey
with you.
O18
How is diabetes training for persons taking care of
children with type 1 diabetes in kindergarten and
school delivered and funded? Results from a survey
in Germany
T. Kapellen1, J. Wendenburg2, S. von Sengbusch3, K. Mönkemöller4,
N. Lindemann5, D. Paape6, D. Hilgard7, P. Hiermann1
1
University of Leipzig, Department of Womens and Child Health, Leipzig,
Germany, 2Private Practice, Jena, Germany, 3University of Schleswig
Hollstein, Hospital for Children and Adolescents, Lübeck, Germany,
4
Kinderkrankenhaus der Stadt Köln, Köln, Germany, 5University of
Schleswig Hollstein, Kiel, Germany, 6Deutsche Diabetes Hilfe - Menschen
mit Diabetes, Bremen, Germany, 7Gemeinschaftskrankenhaus Herdecke,
Herdecke, Germany
Objective: After onset of type 1 diabetes support for integration in
kindergarten, day care and school is crucial. A structured, but also
individualised, diabetes training for all persons caring for the child
should be performed by the local diabetes team. In close cooperation
with the parents diabetes specific knowledge should be addressed to
avoid fears and to secure reintegration. Lacking a statutory rule diabetes education is provided in different ways in different regions of
Germany.
Methods: The working group "inclusion" within the German association for pediatric diabetology has conducted a nationwide survey. A
questionnaire of 16 Items with categorized answers regarding conduct and financial coverage (most frequently, in second line, rarely)
was sent to 91 pediatric diabetes treatment centers.
Results: 66 pediatric diabetes centers (treating about 9700 children
with diabetes) all over Germany (representing all 16 federal states)
answered the questionnaire completely. Most frequently (90%) qualified members of a pediatric diabetes team conduct the training locally
at the school, kindergarten or day care centre. This initial diabetes
education is financed for about 80% in kindergarten or day care centers and about 70% in schools either by funding, honorary commitment, or is subsidized from hospital sources. In summary a diabetes
training is particularly ensured by personal or private initiative or has
to be covered by support of the local clinic with all the problems that
occur in consultations with the hospital administration.
Conclusion: The working group inclusion therefore calls for a mandatory financial regulation for diabetes training of persons that care for
children in school, kindergarten and day care in Germany. This training is required for integration and care of children with diabetes outside of their usual home care.
O19
Individual quality of life in parents of youth with
type 1-diabetes: exploration of life domains in a
context of Chilean rural area
J. Pelicand, C. Díaz, F. Jara, R. Quezada, J. Tapia
Universidad de Valparaiso, Medicine School - Campus San Felipe, San
Felipe de Aconcagua, Chile
Introduction: Parental involvement are very important in the management of type1-diabetes (T1D) during the childhood. It may cause
parental distress and contribute to diminish parent quality of life
(QoL). The aim of this study is to investigating the individual, as
oposed to predetermined, QoL in parents of children with T1D, in
the specific and unexplored context of rural Chilean area.
Materials and Methods: We conducted an exploratory study with a
methodological mixed design, during 2014-2015, composed by two
phases: (1) The first phase consisted on the exploration of the most
important domains of parents QoL through 12 interviews. (2) The
second phase investigated the QoL of 21 parents through an evaluation adapted from the Shedule for the Evaluation of Individual Quality of Life -Direct Weighting interview, which allows respondents to
nominate and evaluate their own quality of life domains.
Results: 11 life domains were identified through the first phase. During the second phase, the most frequently nominated life domains
were “family”, “finances”,“child health”, “psychological well-being” and
“access to physician trained in diabetes care” respectively, ranked in
terms of importance, domains were “family”, “child health”, “social
network”, “psychological well-being”, and “access to physician trained
in diabetes care”; ranked in order of satisfaction, domains were “family”, “social network”, “psychological weel-being”, “beliefs” and
“finances”. Total QoL scores ranged from 43.1 - 97.7 M= 72.0,
SD=14.3.
18
Conclusions: Parents nominated many life domains not identified by
WHO definition or classic Parent QoL questionnaire related to the
child T1D. These findings are underscoring that parent QoL is multidimensional, with domains which can depend of the geographic place,
like public health system charateristics. These findings should be
replicated with larger sample to be able to associate theses findings
to demographic and diabetes characteristics.
O20
New finding-PSEUDOHYPOGLYCEMIA
M. Saiyed, B. Saboo1, D. Hasnani, F. Patel
Diacare-Diabetes and Hormone Clinic, Ahmedabad, India
India leads in the prevalence of Type I Diabetics according to latest
statistics. A large chunk of these people lies below the poverty line to
whom affordability and accessibility is a huge issue. They do not have
access to a comprehensive Diabetic team.
We have created our own Diabetes At Ur Doorstep (DAUD) team
consisting of diabetic educators who visit the rural remote areas and
provide diabetic education, insulin and check Random blood sugar by
creating a checklist.
The most peculiar finding was sub-optimal insulin dosage due to
fear of hypoglycemia (Pseudo-hypoglycemia). It appeared as if the
Type I kids have adapted to constant hyperglycemia state of RBS
more that 200 mg/dl. The moment there is normoglycemia the
patient starts developing hunger, weakness, perspiration at RBS less
than 140 mg/dl.
This could be attributed to lack of availability of strips (cost issue)
for SMBG, illiteracy, diabetic Education and lack of untrained health
Professionals to deal with this. Or else a child may be anemic or suffering from nutritional deficiency etc. On mental aspect it can be anxiety, personality disorder, hysteria where a patient reports relief of
symptoms after eating. In such cases glucose level is within reference
range while patient is symptomatic.
The end result of this is missed insulin shots, avoidable
shocking &weight gain. Education of patient and family, training of
HCP can play a major role in improving this situation. Monitoring &
making strips & glucometer available at affordable rates along with
proper guidance on diet & exercise through project like DAUD can
make a revolutionary change.
O21
Association between hypothalamus-pituitary
adrenal axis activity and anxiety in prepubertal
children with type 1 diabetes
P. Barat1,2, J. Brossaud1,2, A. Bergeron1, J.-B. Corcuff1,2, M.-P.
Moisan3, A. Lacoste1, V. Vautier1, H. Savel1, P. Perez1
1
2
Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France,
Bordeaux University, Bordeaux, France, 3INRA, Bordeaux, France
Background: Animal models of insulin-dependent diabetes show
hyperactivity of hypothalamus-pituitary adrenal (HPA) axis, independently of hypoglycaemia. Few data exists regarding type 1 diabetes
(T1D) in children.
Objective: To describe HPA axis activity according to the anxiety
levels in prepubertal T1D children.
Method: Prepubertal T1D children and siblings of T1D children
(controls) were included. State-Trait Anxiety Inventory (STAI) test
was performed at inclusion. Glucocorticoids metabolites (LCMS)/creatinine ratio on nocturnal urines and morning salivary cortisol
(SC) were measured at home during 5 consecutive days without identified nocturnal hypoglycaemia. Expressed results were mean of the
five samples for each child. Tetrahydrocortisol (THF) + allo-THF/tetrahydrocortisone (THE) ratio (ie THFs/THE ratio) was considered as
an estimate of type 1 11β-hydroxysteroid dehydrogenase (11βHSD1) activity.
ORAL SESSIONS
Results: Forty-nine T1D children (mean age 9.0+/−1.7 yrs) and
26 controls (9.3+/−1.4 yrs) were recruited. STAI scores were not different between T1D children (29.7+/−6.6) and controls (33.0+/−7.8).
Total glucocorticoid metabolites/creatinine were decreased in T1D
children vs controls (552+/−170 vs 673+/−170 μg/mmol, p< 0.01).
THFs/THE was increased in TD1 children vs controls (0.46+/−0.10 vs
0.41+/−0.09, p=0.02). Salivary cortisol at awakening and 30 minutes
after awakening (SC+30) were not different between groups. In both
groups, STAI scores were associated with SC+30 when adjusted for
BMI (controls b=−1.1, p=0.03; T1D children b=−1.0, p=0.04). STAI
score was associated with THFs when adjusted for BMI in T1D children (b=−0.05, p=0.03) but not in controls.
Conclusion: Subtle changes of HPA axis activity, independently of
recognized hypoglycemia, are present in prepubertal children with
T1D, particularly for nocturnal glucocorticoid synthesis, 11β-HSD1
activity and its associations with anxiety.
O22
Does sleep matter? Associations between child
sleep, glycemic control and parental wellbeing in
the T1D Exchange Clinic Registry
S. Jaser1, N. Foster2, B. Nelson3, J. Kittelsrud4, L. Humphrey5,
L. DiMeglio6, M. Quinn7, S. Willi8, J. Simmons1, fot the T1D Exchange
Clinic Network
1
Vanderbilt University Medical Center, Nashville, United States, 2Jaeb
Center for Health Research, Tampa, United States, 3University of South
Carolina School of Medicine - Greenville, Greenville, United States,
4
Avera McKennan Hospital and University Health Center, Sioux Falls,
United States, 5Children’s Hospital of Orange County, Orange, United
States, 6Indian University School of Medicine, Indianapolis, United
States, 7Boston Children’s Hospital, Boston, United States, 8Children’s
Hospital of Philadelphia, Philadelphia, United States
Objective: Sleep is a modifiable risk factor that may have physiological and behavioral impacts on diabetes outcomes, yet little is known
about the impact of sleep disturbance in children with type 1 diabetes
(T1D). The current study sought to describe sleep patterns in children
with T1D and their parents and to examine associations between
sleep quality (SQ), diabetes outcomes, and parental wellbeing.
Methods: Parents of children 2-12yo (n=515, mean age 9yrs, 47%
female, 86% non-Hispanic white, mean age at diagnosis 4yo, mean
A1c 7.80.9%, frequency of blood glucose monitoring (BGM)
7.42.4 times/day) from the T1D Exchange clinic registry (50 sites)
completed internet-based surveys on their child’s sleep patterns
(Children’s Sleep Habits Questionnaire (CSHQ)), their own sleep patterns (Pittsburgh Sleep Quality Inventory (PSQI)), fear of their child
having a hypoglycemic event, their emotional wellbeing, and nocturnal monitoring habit. Clinical and demographic information were collected. Data were analyzed using general linear regression models.
Results: Mean sleep duration was below the recommended amount
for all age groups (10.9 hrs/night in 2-4yo, 9.5 in 5-12yo, 6.5 in parents). Further, 67% of children and 53% of parents met the criteria
for poor SQ (CSHQ>41;PSQI>5). Children with poor SQ had higher
A1c (7.9% vs 7.6%; P< 0.001). Frequency of BGM (overall and nocturnal) was not associated with child SQ (mean 7.6 times/day vs. 7.4
in poor/good quality;P=0.56). Children’s poor SQ was also associated
with worse parental wellbeing and parental SQ (P< 0.001 for both).
Child and parental SQ were worse when parents exhibited more fear
of hypoglycemia (P< 0.001 for both)), but were not associated with
frequency of nocturnal BGM (P=0.66 and p=0.35, respectively).
Conclusion: Sleep disturbances may negatively impact glycemic control in T1D, and may offer a potential target for interventions to
improve outcomes in children with T1D and to reduce parental
stress.
19
ORAL SESSIONS
O23
Psychological flexibility in adolescents with type
1 diabetes
J. Laridaen1, L. Goubert2, S. Van Aken3, E. Van Hoecke1, C. Van
Gampelaere2, G. Van Cauwenberge4, C. Fouquaert4, D. Schampers4,
M. Cools3,5
1
Ghent University Hospital, Pediatric Psychology, Ghent, Belgium,
2
Ghent University, Dept. of Experimental-Clinical and Health Psychology,
Ghent, Belgium, 3Ghent University Hospital, Dept. of Pediatric
Endocrinology, Ghent, Belgium, 4Ghent University, Ghent, Belgium,
5
Ghent University, Dept. of Pediatric Endocrinology, Ghent, Belgium
Objectives: Type 1 diabetes (T1D) is challenging to manage, requiring
a complex set of diabetes-related behaviors. Adolescents with T1D
are at increased risk of deteriorating diabetes management, metabolic
control and quality of life (QoL). Moreover, during adolescence,
parental-controlled care gradually shifts to self-management. Therefore, the identification of protective factors specific for this developmental stage becomes particularly relevant. Psychological flexibility
(PF), a construct derived from Acceptance and Commitment Therapy
(ACT), refers to an individual’s ability to act in alignment with life
values and long-term goals (e.g. health, good family relations) in the
presence of interfering (negative) thoughts, emotions and bodily
sensations.
The aim of the study was to examine the association between PF
and diabetes management, metabolic control and emotional functioning in adolescents with T1D.
Methods: A total of 104 adolescents with T1D (age range: 12-18,
mean: 14.83 years, 53% male) and their parents completed questionnaires online and at home, measuring PF (diabetes-related PF, general
cognitive and emotional fusion, general experiential avoidance),
adherence and general QoL. The analyses controlled for HbA1c levels
(mean HbA1c = 7.7%).
Results: After controlling for gender and age, hierarchical regression
analyses revealed a significant contribution of diabetes-specific PF in
explaining adherence (Adj.R2=.15, p=.002) and QoL (Adj.R2=.20, p<
.001), but not metabolic control (HbA1c). General PF significantly
contributed to the explanation of metabolic control (Adj.R2=.07,
p=.008) and QoL (Adj.R2=.15, p< .001), but not adherence.
Conclusions: Our findings demonstrate that being able to act in line
with personal values and long-term goals is associated with better
diabetes management and control and better QoL. Overall, PF shows
promise as a potentially protective characteristic against the burden
of self-management in adolescents with T1D.
O24
The challenge of transition: adolescent and parent
attitudes towards transition and adolescent
diabetes services
V. Mc Darby1,2, K. Gajewska3, D. Cody1
Our Lady’s Children’s Hospital, Crumlin, Dublin, Ireland, 2National
Children’s Research Centre, Dublin, Ireland, 3Royal College of Surgeons in
Ireland, Dublin, Ireland
1
Objectives: Healthcare professionals often make decisions about
how adolescents engage with adolescent diabetes services (e.g. if
seen alone, when to transition, etc.) by consulting with parents rather
than adolescents. This study assessed and compared the attitudes of
adolescents and their parents on different aspects of adolescent diabetes services.
Methods: 82 adolescents aged >12 years (41 males), and their parents (n=82) separately completed an anonymous questionnaire examining attitudes towards aspects of adolescent diabetes services.
Comparison of attitudes was undertaken using chi-squared/logistic
regression for categorical variables and t-tests/ANOVA for continuous variables.
Results: Significant differences were found between adolescents’
and parents’ attitudes towards readiness for transition (p< 0.001) and
age of transition (p< 0.001). Adolescents preferred an earlier age of
transition compared to parents. Significant differences were also
found between both groups in their attitudes towards the age when
adolescents
a. should first be seen by the doctor on their own (p< 0.01), and
when to discuss
b. alcohol (p< 0.01) and
c. sexual health (p< 0.001).
Adolescents preferred to discuss these issues individually, while
parents preferred to be present in the room (p< 0.001, p< 0.01
respectively). Optimal diabetes clinic frequency was every threemonths for both groups but adolescents with poorer control
(HbA1c>8%) preferred to be seen every six-weeks (p< 0.05). Older
adolescents (>15yrs) preferred to begin the process of transition later
(i.e. after completion of second level education) compared to younger
adolescents (p< 0.001).
Conclusions: Adolescents and their parents differ significantly in
their attitudes towards a number of different aspects of adolescent
diabetes services. When making decisions about adolescents’ diabetes care it is important that adolescents, as well as their parents, are
included in the decision making process.
20
ORAL SESSIONS
Oral Session IV - Diabetes Chronic Complications and Associated
Diseases
O25
Fas and Fas ligand expression in children and
adolescents with type 1 diabetes mellitus
M. Salem1, A. Adly2, E. Ismail3, D. Salem3, A. Al Ghazawy4
1
Pediatrics, Cairo, Egypt, 2Ain Shams University, Pediatrics, Cairo, Egypt,
Ain Shams University, Clinical Pathology, Cairo, Egypt, 4Ain Shams
University, Cairo, Egypt
3
Background: Early identification of risk factors and prevention of diabetes complications are of paramount importance in children and
adolescents. Fas and its ligand are typical members of the tumor
necrosis factor (TNF) receptor superfamily. Fas/Fas ligand (Fas/FasL)
interactions may be related to augmentation of proliferation and
inflammatory response. The role of soluble forms, sFas and sFasL in
diabetes remains to be fully elucidated.
Aim: To detrmine the levels of sFas and sFasL in children and adolescents with type 1 diabetic patients and their relation to inflammation,
glycemic control and microvascular complications.
Methods: Eighty children and adolescents with type 1 diabetes were
divided into 2 groups according to the presence of micro-vascular
complications and compared with 40 age- and sex-matched healthy
controls. High sensitivity C-reactive protein (hs-CRP), HbA1c, urinary
albumin creatinine ratio (UACR) as well as soluble Fas (sFas) and
sFasL levels were measured.
Results: sFas and sFasL levels as well as Fas/FasL ratio were significantly higher among patients with and without complications compared healthy controls and the highest levels were found among
patients with complications. sFas/sFasL ratio was significantly
increased in relation to nephropathy (microalbuminuria), peripheral
neuropathy or retinopathy. Significant positive correlations were
found between both sFas and sFasL levels and each of disease duration, systolic and diastolic blood pressure, fasting blood glucose,
HbA1c, triglycerides, total cholesterol, UACR and hs-CRP (p< 0.05).
The cutoff value of sFas/sFasL ratio at 7.27 pg/mL could differentiate
patients with and without micro-vascular complications with a sensitivity of 85% and specificity of 90%.
Conclusions: Elevated sFas/sFasL ratio in type 1 diabetic patients
with micro-vascular complications suggests that inflammation and
apoptosis are involved in the pathogenesis of these complications.
O26
Circulating angiopoietin-2 levels in young patients
with type 1 diabetes mellitus: a link between
inflammation, micro-vascular complications and
subclinical atherosclerosis
M. Abo El-Asrar1, N. Elbarbary1, E. Ismail2, A.S. Abo Bakr1
1
Faculty of Medicine, Ain Shams University, Department of Pediatrics,
Cairo, Egypt, 2Faculty of Medicine, Ain Shams University, Department of
Clinical Pathology, Cairo, Egypt
Background: Angiopoietin-2 is a growth factor involved in the pathophysiology of different vascular and inflammatory diseases such as
arteriosclerosis. Carotid or aortic scans provide non-invasive screening tools for assessment of preclinical atherosclerosis in high-risk
children.
Aim: We assessed serum angiopoietin-2 in children and adolescents
with type 1 diabetes mellitus as a potential marker for diabetic vascular complications in relation to glycemic control, inflammation and
vascular structure.
Methods: Sixty patients with type 1 diabetes were divided into
2 groups according to the presence of micro-vascular complications
and compared with 30 healthy controls. High-sensitivity C-reactive
protein (hs-CRP), hemoglobin A1c (HbA1c), urinary albumin creatinine
ratio, serum angiopoietin-2 levels, carotid and aortic intima media
thickness (CIMT and AIMT) were measured.
Results: CIMT, AIMT and serum angiopoietin-2 levels were significantly increased in patients with and without micro-vascular complications compared with controls and the highest levels were in
patients with complications (p< 0.001). Serum angiopoietin-2 was
higher in patients with microalbuminuria than normoalbuminuric
group (p< 0.001). The cutoff value of serum angiopoietin-2 at 900pg/
mL could differentiate patients with and without micro-vascular complications with a sensitivity of 92.3% and specificity of 100%. The
cutoff values for CIMT and AIMT to detect micro-vascular complications were determined. Multiple regression analysis showed that fasting blood glucose, HbA1c, hs-CRP, CIMT and AIMT were
independently related to angiopoietin-2.
Conclusion: The relation between angiopoietin-2 and assessed parameters of vascular structure in type 1 diabetes reflects a state of subclinical atherosclerosis and highlights the role of disturbed angiogenesis
and vascular inflammation in the occurrence of diabetic complications.
O27
Achieving clinical guideline goals is associated with
better insulin sensitivity (IS) and cardiopulmonary
health in youth with type 1 diabetes (T1D)
P. Bjornstad1,2, M. Cree-Green1, A. Baumgartner1, G. Coe1, L. Pyle1,
J. Regensteiner3, J. Reusch4, K. Nadeau1
1
University of Colorado Denver, Pediatric Diabetes and Endocrinology,
Aurora, United States, 2Barbara Davis Center for Diabetes, Children’s
Hospital Colorado, Pediatric Diabetes and Endocrinology, Aurora, United
States, 3Center for Women’s Health Research, Divisions of General
Internal Medicine and Cardiology, Aurora, United States, 4Veterans
Affairs Hospital, Division of Endocrinology, Center for Women’s Health
Research, Aurora, United States
Objective: Most youth with T1D do not meet the American Diabetes
Association (ADA) and International Society for Pediatric and Adolescent Diabetes (ISPAD) targets for HbA1c, blood pressure (BP), lipids,
and BMI. We hypothesized that ISPAD/ADA goal achievement would
be associated with better IS and cardiopulmonary health in youth
with T1D.
Methods: We assessed the cross-sectional relationship between
ISPAD/ADA goal achievement, IS and cardiopulmonary health in
youth with T1D from the RESISTANT (n=86) and EMERALD (n=41)
studies (n=127; age 15.72.2 years, 52% girls). IS was measured by
glucose infusion rate during a hyperinsulinemic-euglycemic clamp.
Cardiopulmonary fitness was measured as peak oxygen consumption
(VO2peak/kg) during cycle ergometry. EMERALD and RESISTANT
had different cycle ergometry protocols, thus VO2peak analyses were
stratified by cohort. Goal achievement was defined as HbA1c< 7.5%,
BP< 90th percentile, LDL-C < 100mg/dL, HDL-C >35mg/dL, TG <
150mg/dL and BMI < 85th percentile. Participants were stratified
into 3 groups: achieving 1-3 goals (n=52), 4 goals (n=48) and 5-6
goals (n=27). Differences between groups were examined with generalized linear models.
Results: IS was lower in participants who met 1-3 goals (5.243.40
mg/kg/min) vs. those who met 4 goals (7.414.13 mg/kg/min,
p=0.04) and those who met 5-6 goals (8.454.28 mg/kg/min,
p=0.003), and remained significant after adjustments for sex and Tanner stage. The difference in IS between participants who met 1-3
goals and 5-6 goals remained significant after adjusting for BMI
(p=0.03). VO2peak was lower in participants in RESISTANT who met
1-3 goals (25.844.63mL/kg/min) vs. those who met 4 goals
(33.017.81mL/kg/min, p=0.01) and those who met 6 goals
21
ORAL SESSIONS
M.E. Craig1,2, N. Prinz3,4, C.T. Boyle5, K.M. Miller5, S. Du Bose5,
D.M. Maahs6, J. Warner7, F.M. Campbell8, N. Holman9, S.E. Hofer10,
E. Fröhlich-Reiterer11, E. Tham12, B. King13, T.W. Jones14, R. Holl3,4
(33.184.44mL/kg/min, p=0.004). Similar and significant relationships were observed in EMERALD participants for VO2peak.
Conclusions: In youth with T1D, ADA/ISPAD goal achievement was
associated with better IS and cardiopulmonary health.
1
The Childrens Hospital at Westmead, Sydney Australia, Institute of
Endocrinology and Diabetes, Westmead, Australia, 2University of Sydney,
Sydney, Australia, 3University of Ulm, Institute of Epidemiology and
Medical Biometry, Ulm, Germany, 4German Center for Diabetes Research
(DZD), Munich-Neuherberg, Germany, 5Jaeb Center for Health Research,
Florida, United States, 6Barbara Davis Center for Childhood Diabetes,
Aurora, United States, 7Children’s Hospital for Wales, Cardiff, United
Kingdom, 8Leeds Children’s Hospital, Leeds, United Kingdom, 9University
of Glasgow, Institute of Cardiovascular and Medical Sciences,, Glasgow,
United Kingdom, 10Medical University of Innsbruck, Department of
Pediatrics, Innsbruck, Austria, 11Medical University of Graz, Department
of Pediatrics, Graz, Austria, 12Women’s and Children’s Hospital, Adelaide,
Australia, 13John Hunter Children’s Hospital, Newcastle, Australia,
14
Telethon Kids Insititute, Perth, Australia
O28
Prevalence of subclinical entheseal involvement in
children and adolescents with type 1 diabetes: a
case-control study
A. Scaramuzza1, A. Batticciotto2, M. Ferrari1, P. Sarzi Puttini2
University of Milano, Department of Pediatrics, Milano, Italy, 2ASST
Fatebenefratelli Sacco, Luigi Sacco Hospital, Reumathology, Milano, Italy
1
Objectives: At the best of our knowledge, no data about enthesis
ultrasonographic evaluation in young patients with type 1 diabetes(T1D) have been reported. The prevalence of subclinical entheseal
involvement in children and adolescents with T1D was studied using
a high frequency ultrasound probe.
Methods: We evaluated 23 children and adolescents (12 M), with
T1D, ages 9-18 years (meanSD, 13.92.5 years), disease duration
1-10 years, without any clinical sign or symptom of musculoskeletal
involvement. A control group consisting of 28, sex (12 M) and agematched (14.22.8 years), was also evaluated. Both patients and controls underwent an ultrasound examination (ESAOTE MyLAB 70 6-18
MHz linear array transducer). Brachial triceps, femoral quadriceps,
Achilles, plantar fascia, and proximal and distal patellar entheses were
all scored using the 0-136 Madrid Sonographic Enthesis Index
(MASEI).
Results: None of the patients had a MASEI score suggesting early
spondyloarthritis involvement but their average score was significantly
higher than controls (4.65 4.4 vs 3.04 1.9, p=0.009). No difference has been observed about enthesis with power Doppler score ≥2
or with dishomogeneous echo structure in both patients with T1D
and controls. Patients with T1D showed significantly more calcification than controls (43.5% vs 8.7%; p=0.0046). In patients with T1D a
significant correlation between the total MASEI score and diabetes
duration was observed (p=0.004), while no correlation was observed
between the total MASEI score and age (p=0.85) or HbA1c (p=0.15).
Conclusions: In a recent review, the hypothesis that in T1D patients
the excess of advanced glycation end products may be the cause of
tendon damages has been suggested. In our study we observed a
higher total MASEI score and calcifications in patients with T1D than
in controls. This finding is new in patients with T1D and needs to be
confirmed in larger group and during follow-up.
Objectives: Celiac disease (CD) affects ~5% of youth with type 1 diabetes (T1D). We examined international differences in CD prevalence
and clinical characteristics of patients with T1D+CD vs T1D only.
Methods: Data sources: DPV (Germany/Austria), T1DX (US), NPDA
(England/Wales) and ADDN (Australia). The analysis included youth
age < 18 yrs with a visit between Apr 2013 and Mar 2014. Linear
and logistic regression were used to assess the relationship between
T1D+CD vs T1D and A1C, therapy and growth, adjusting for sex,
age, ethnicity and T1D duration.
Results: Biopsy-confirmed CD was present in 1835 youth, diagnosed
at median age 8 yrs [IQR 5.0-11.0], with CD diagnosed before T1D in
5.5%. Comparing T1D+CD vs T1D, patients were younger at T1D
diagnosis: 5.4 yrs [2.9-8.7] vs 7.0 [4.0-10.2], fewer were male (41 vs
53%), non-white (15 vs 18%) or overweight/obese (34 vs 37%), all p<
0.01. Height SDS was lower (mean 0.291.2 vs 0.481.2, adjusted
p< 0.001). Stratified by ethnicity, A1C was comparable in T1D+CD vs
T1D: white 8.3 vs 8.3%; non-white 8.3 vs 8.5% and CSII use was similar: white: 43 vs 39%, non-white: 33 vs 33% (all p>0.05). Characteristics are shown in the table.
Conclusions: Differences in CD rates and T1D duration at CD diagnosis may reflect international variation in screening/diagnostic practices, and/or CD risk. Although fewer patients with CD are nonwhite, the association between CD and A1C or diabetes therapy
reassuringly does not appear to be related to ethnicity.
[Characteristics of youth overall and by registry]
O29
Celiac disease in 52,721 youth with type
1 diabetes: ethnicity is not associated with
glycaemic control nor therapy
E. Paul, D. Rottembourg, B. Moreau
O30
Celiac disease screening in asymptomatic type
1 diabetes mellitus patients across North America
and Europe
Université de Sherbrooke, Sherbrooke, Canada
Overall
DPV
T1DX
NPDA
ADDN
Number
52,721
24,611
7,536
17,152
3,422
Age at visit
13.2 [10.0-15.7]
12.8 [9.4-15.4]
13.0 [10.0-15.0]
14.1 [11.0-16.1]
12.9 [9.6-15.3]
Age at T1D diagnosis
7.0 [4.0-10.2]
7.3 [4.2 - 10.6]
6.0 [3.0-9.0]
7.0 [3.8-10.1]
6.9 [4.0-10.1]
Duration at visit
4.9 [2.6-7.9]
3.8 [1.5-7.0]
6.0 [3.0 - 8.0]
5.7 [3.6-8.5]
4.3 [1.9-7.5]
Non-white (%)
18.2
20.4
20.9
12.2
31.7
CSII (%)
37.0
43.0
60.5
17.7
40.1
CD (%)
3.5
3.2
1.9
3.8
7.7
Age <5 yrs at CD diagnosis (%)
23.0
23.3
17.2
-
26.3
CD within 2 yrs after T1D diagnosis (%)
54.2
55.5
27.4
-
69.1
22
Objective: Medical associations recommend screening for celiac disease (CD) in at-risk groups, as type 1 diabetes mellitus (T1DM). There
is a lack of consensus among guidelines on who and how to screen.
We aim to evaluate current practices and factors influencing and limiting the screening of CD in asymptomatic T1DM patients across
North America and Europe.
Methods: A web-based survey was sent to paediatric endocrinologists and paediatricians with an expertise in T1DM in Canada, United
States and Europe. Physicians were contacted through the following
associations: Pediatric Endocrine Society (PES), International Society
for Pediatric and Adolescent Diabetes (ISPAD), Canadian Pediatric
Endocrine Group (CPEG) and European Society of Pediatric Endocrinology (ESPE).
Results: A total of 381 participants responded to our survey. Two
hundred and twenty nine (60.1%) were from the United States,
90 (23.6%) from Europe, 48 (12.6%) from Canada and 14 (3.7%) from
others countries. Almost 21% of Canadians claimed never screen
asymptomatic T1DM patients for CD, compared to 0.4% of
Americans
(p< 0.001) and 0.0% of Europeans (p< 0.001). When asked about
the possible consequences of not treating asymptomatic CD patients,
22.2% of Canadians reported no possible consequence compared to
5.7% of Americans (p< 0.001) and 5.6% of Europeans (p=0.01). A proportion of 37.5% of Canadians don’t agree that screening for CD in
asymptomatic patients with T1DM can reduce their morbidity, compared to 12.0% of Americans (p< 0.001) and 14.4% of Europeans
(p=0.06). A proportion of 56.3% of Canadians think that the recommendations from their endocrine associations are unclear regarding
screening for CD in asymptomatic patients with T1DM, compared to
34.5% of Americans (p=0.01) and 19.8% of Europeans (p< 0.001).
Conclusion: We noted a clear difference in practices, mostly
between Canadians and others responders. A unification of guidelines
would be needed.
O31
Inflammatory bowel disease in children and
adolescents with type 1 diabetes: a multicenter
analysis from the German-Austrian DPV database
H. Jasser-Nitsche1, S. Bechtold -Dalla Pozza2, E. Binder3,
B. Heidtmann4, Y.H. Lee-Barkley5, K. Raile6, R.W. Holl7
University of Graz, Department of Pediatrics, Graz, Austria, 2Dr. von
Hauner Children`s Hospital, Ludwig-Maximilians University, Department
of Pediatrics, Munich, Germany, 3Medical University of Innsbruck,
Department of Pediatrics, Innsbruck, Austria, 4Wilhelmstift Catholic
Children´s Hospital, Hamburg, Germany, 5Heart and Diabetes Center,
Bad Oeynhausen, Germany, 6Charité - Universitätsmedizin Berlin,
Department of Pediatrics, Berlin, Germany, 7University of Ulm, Institute
of Epidemiology and Medical Biometry, Ulm, Germany
1
Objectives: The association between type 1 diabetes (T1D) and
other autoimmune comorbidities such as celiac disease and thyroiditis
is well known. Therefore, we investigated clinical characteristics of
the autoimmune overlap of T1D and inflammatory bowel disease
(IBD). Does the course of T1D differ in patients suffering from both
diseases?
Methods: Data of 65.147 young patients with T1D below the age of
18 years (mean age 14 3.86 years, mean diabetes duration 5.41 4.2 years) of 379 centres in Germany and Austria participating in the
DPV initiative (Prospective Diabetes Follow-up) were analysed.
We used multiple regression models to analyse differences in metabolic control, acute complications, insulin dose and steroid intake in
ORAL SESSIONS
patients with T1D and IBD compared to those with T1D only. Severe
hypoglycaemia was defined as requirement for need of outside help.
Results: Out of 65.147 children and adolescents, 63 children were
diagnosed with IBD: 33 with ulcerative colitis, 26 with Crohn´s disease, 4 with undetermined colitis.
Mean BMI-SDS in patients with T1D and IBD was −0.153 0.115
whereas in patients with T1D only BMI-SDS was 0.273 0.004 (p =
0.0002). However, patients with T1D and IBD had a significantly
higher use of steroids (0.223 0.053 versus 0.009 0.0003, p <
0.0001) and a significantly higher rate of severe hypoglycaemia
(0.328 0.073 versus 0.158 0.002, p = 0.001). No differences
were found in HbA1c levels and insulin dose, neither differences in
rates of ketoacidosis.
Conclusions: Although children and adolescents with T1D and IBD
take steroids more often, they suffer from severe hypoglycaemia
more frequently and have a lower BMI. This may be due to malabsorption caused by chronic intestinal inflammation.
O32
Liver stiffness by transient elastography as a noninvasive tool for detection of hepatopathy-induced
fibrosis in pediatric patients with type 1 diabetes
Z. Elkabbany1, N. Elbarbary1, E. Ismail2, N. Mohamed2, D. Ragab2,
Y. Ezzat1, S. Maurice1, N. Hashem1
1
Faculty of Medicine, Ain Shams University, Department of Pediatrics,
Cairo, Egypt, 2Faculty of Medicine, Ain Shams University, Department of
Clinical Pathology, Cairo, Egypt
Aim: To identify the effect induced by hepatopathies of different
etiologies among children and adolescents with T1DM using transient
elastography (TE) and its relation to glycemic control.
Methods: One hundred patients with T1DM (at least 5 years disease
duration) were studied stressing on liver function tests, fasting lipid
profile, HbA1c, hepatitis C virus (HCV)-RNA using PCR, serum immunoglobulins, autoimmune antibodies; Anti-nuclear antibody (ANA),
Anti-smooth muscle Antibody (ASMA), and Anti-Liver Kidney microsomal antibody (anti-LKM) using indirect immunofluorescence methods. Pelvi-abdominal ultrasound was performed and TE was done for
patients with elevated ALT, HCV, positive autoimmune antibody and/
or abnormal ultrasound findings. Liver biopsy was done when indicated after parental consent.
Results: 31% of patients were found to have one or more abnormalities; clinical hepatomegaly in 8%, elevated ALT in 10%, HCV in 6%,
autoimmune hepatitis (AIH) in 11% (10 were positive for ASMA and
2 were positive for ANA while anti-LKM antibodies were negative)
and abnormal hepatic ultrasound in 20% (5 AIH, 2 HCV, 1 Mauriac
Syndrome, 9 non-alcoholic fatty liver disease and 3 non-alcoholic
steatohepatitis). Mean liver stiffness in those 31 patients was 7.0 2.1 kPa (range, 3.1- 11.8 kPa); 24 were Metavir F0-F1, 7 were F2-F3
while none were F4. Type 1 diabetic patients with abnormal ultrasound had significantly higher FBG, HbA1c and total cholesterol than
those with normal liver
(p< 0.05). Patients with AIH had higher HbA1c than those with
negative autoimmune antibodies (p=0.012). Liver stiffness was significantly higher in patients with abnormal ultrasound compared with
normal liver (p=0.039). Significant positive correlations were found
between liver stiffness and HbA1c and ALT.
Conclusions: Hepatic abnormalities are prevalent in young patients
with T1DM and related to poor metabolic control. TE provides a reliable method for detection of hepatopathy-induced fibrosis.
23
ORAL SESSIONS
Oral Session V: Diabetes Genetics, Immunology and Environmental
and Monogenic diabetes
O33
DIAGNODE: autoantigen (GAD-alum) given into
lymph-nodes together with oral vitamin D to
preserve beta cell function in Type 1 diabetes. A
pilot trial
J. Ludvigsson1, B. Tavira1, H. Barcenilla1, J. Wahlberg2, R. Casas1
1
Linköping University/Div of Pediatrics, Linköping, Sweden, 2Linköping
University/Div of Endocrinology, Linköping, Sweden
Residual beta cell function in Type 1 diabetes (T1D) is clinically very
important, but no intervention without too serious risks/adverse
events has so far been efficacious. GAD-alum sc has been promising
but not enough effective. Vitamin D might help to gain additional
efficacy. Furthermore, in allergy allergen administration into lymphnodes seems more effective than sc administrations. For the first time
this administration route is tried in an autoimmune disease, T1D.
Objectives: To evaluate the safety as well as clinical and immunological response of giving GAD-Alum (Diamyd) directly into lymph nodes
in combination with oral vitamin D (2 000 IE/day).
Patients and Methods: DIAGNODE-1 is a single-center open-label
pilot Phase I trial designed to enroll approximately 9 subjects
between 12-30 years of age, T1D duration < 6 months , positive for
GAD65- antibodies (GADA) and a fasting C-peptide ≥0.12 nmol/L.
They get Vitamin D 2000 U/d Day 0-120 and 4 μg GAD-alum into an
inguinal lymph-node Day 30, 60 and 90. So far 7 patients have been
recruited and 4 have been followed for 6 months . The immune
response has been evaluated by measurement of GADA, and the
effect of GAD65 stimulation on cytokines in cell supernatants, cell
proliferation and T cell phenotypes, and beta cell function has been
evaluated by Mixed Meal Tolerance Tests.
Results: The treatment has been feasible and well tolerated, without
any concern regarding safety during the first 6 months follow-up.
From baseline to 6 months the C-peptide AUC (nmol/l) decreased 2%
and 29 % respectively in two patients, and increased 32% and 6%
respectively in two patients, with a pronounced Th2-deviation of the
immune system.
Conclusion: A low dose GAD-alum given into lymph-node in recent
onset T1D is feasible, tolerable, seems to be safe, and gives a strong
Th2-deviation of the immune response which together with Vitamin
D might preserve beta cell function.
O34
Detection of a viral footprint in the pancreatic islets
of newly diagnosed T1D patients: results from the
DiViD study
L. Krogvold1,2, P. Leete3, M.A. Russell3, I. Gerling4, S.J. Richardsson3,
N.G. Morgan3, K. Dahl-Jørgensen1,2
1
University of Oslo, Faculty of medicine, Oslo, Norway, 2Oslo University
Hospital, Division of Paediatric and Adolescent Medicine, Oslo, Norway,
3
University of Exeter Medical School, Institute of Biomedical & Clinical
Science, Exeter, United Kingdom, 4University of Tennessee Health
Science Center, Division of Endocrinology, Memphis, United States
Objectives: The Diabetes Virus Detection (DiViD) study has suggested the presence of chronic enteroviral infection in pancreatic tissue collected from 6 of 6 live adult patients with newly diagnosed
T1D. The aim of the present study was to compare the gene and protein expression of selected virus-induced pathogen recognition receptors and interferon stimulated genes in DiViD islets vs age-matched
non-diabetic (ND) controls.
Methods: RNA was extracted from laser captured islets and Affymetrix Human Gene 2.0 ST arrays used to obtain expression profiles.
The presence and localisation of viral response proteins were examined by triple immunofluorescent labelling in 4um sections of pancreatic tissue.
Results: PKR expression did not differ between T1D and ND islets at
the level of total RNA but a subset of β-cells displayed markedly
increased PKR protein levels. These cells corresponded to those previously shown to contain the viral protein, VP1. RNA encoding
MDA5 was increased significantly in T1D islets. At the protein level,
Mda5 staining was seen in α- and certain β- cells in both T1D and
ND islets. In addition, an uncharacterized subset of islet cells
expressed intense MDA5 staining and these were more prevalent in
DiViD cases. STAT1 RNA was elevated in T1D islets vs ND and was
exclusively increased in β-cells at the protein level. Both classical and
non-classical HLA Class I molecules were also increased at the RNA
and protein levels in T1D islets. MxA RNA was upregulated in T1D vs
ND islets and was detected exclusively in T1D β-cells at the protein
level.
Conclusion: The increases in PKR, MxA, HLA-I and STAT1 seen in
β-cells in T1D provide clear evidence of the activation of IFN signalling pathways. As such, these data strengthen the hypothesis that
chronic enteroviral infection contributes to the development of islet
autoimmunity in T1D.
O35
Increased prevalence of type 1 diabetes among
patients with 18q deletion syndrome may be
associated with a deficit in T regulatory cells
A. Hogendorf1, R. Śmigiel2, M. Constantinou3, M. Borowiec3,
E. Budzynska3, J. Wierzba4, J. Fijak-Moskal5, M. Piotrowicz3,
A. Jakubiuk-Tomaszuk6, K. Wyka3, A. Szadkowska3, M. Zielinski4,
P. Trzonkowski4, W. Mlynarski3
1
Medical University of Lodz, Department of Pediatrics,Oncology,
Hematology and Diabetology, Lodz, Poland, 2Wroclaw Medical
University, Wrocław, Poland, 3Medical University of Lodz, Lodz, Poland,
4
Medical University of Gdansk, Gdansk, Poland, 5Jagiellonian University,
Cracow, Poland, 6Medical University of Bialystok, Bialystok, Poland
Objectives: Several patients with the chromosome 18q del syndrome
(MIM#601808) are reported to suffer from autoimmune disorders
and immunoglobulin deficiency (mainly IgA deficiency). The aim of
the study was to evaluate the prevalence of type 1 diabetes (T1DM)
among patients with 18q del syndrome of Caucasian origin.
Methods: Medical registries and social media were used to recruit
the patients. Microarray oligonucleotide comparative genomic hybridization (aCGH) (Agilent, USA) was used to confirm initial diagnosis.
Lymphocyte phenotyping for the assessment of CD127low/CD25/
CD4/CD3 T regulatory cells using a FACS CANTO II flow cytometer
(BDBioscience, USA) was performed. FoxP3 expression was confirmed using nuclear factor FoxP3 staining kit supplied by eBioscience
(USA).
Results: Twenty three patients aged 3-31 years (median 13 years)
were included into the study. 18q aberrations varied from small interstitial deletions of about 8 Mbp (18q22.3-q23) to large deletions of
about 55 Mbp encompassing 18q11.2-q23. Of the patients 3/23 had
early onset T1DM (diagnosed at 7 months, 3.5 and 4 years, respectively) with OR(95%CI)=40.9(9.5-175.8) comparing the prevalence of
type 1 diabetes among pediatric patients in the region of Lodz district
(142/100 000 individuals < 18 years). In 9 of 23 patients hypothyroidism/autoimmune thyroiditis was present. Immunological studies,
performed in 16 out of 23 patients, revealed complex serum immunoglobulin deficiency in 4/16 patients. In general, IgA deficiency was
detected in 3/16, IgE def in 2/16, IgM def in 4/16, IgG def in 4/16,
IgG1 def in 1/16, IgG3 def in 1/16 and IgG4 def in 6 out of
24
16 patients. Interestingly, all recruited patients had Treg deficiency
with low intracellular expression of crucial transcription factor FoxP3
in this subset (<15%).
Conclusions: Relatively high prevalence of type 1 diabetes among
patients with 18q deletion syndrome may be associated with a deficit
in T regulatory cells.
O36
The microbiome in children with islet
autoimmunity: bacteriome profiling and virome
sequencing in stool samples from Finnish DIPP
study
O. Cinek1, L. Kramna1, J. Lin2, S. Oikarinen3, J. Ilonen4, O. Simell5,
R. Veijola6, R. Autio7, H. Hyöty3
Charles University in Prague, Prague, Czech Republic, 2University of
Tampere, BioMediTech, Computational Biology, Tampere, Finland,
3
University of Tampere, School of Medicine, Department of Virology,
Tampere, Finland, 4University of Turku, Turku, Finland, 5Turku University
Central Hospital, Turku, Finland, 6University of Oulu and Oulu University
Hospital, Oulu, Finland, 7University of Tampere, School of Health
Sciences, Tampere, Finland
1
Objectives: We set out to explore the stool bacteriome profiles in
the context of early-onset islet autoimmunity, taking into account the
interactions with the virus component of the microbiome.
Methods: Stool samples were longitudinally collected from 18 infants
and toddlers with islet autoimmunity that started at the median age
of 17.4 months, and from 18 tightly matched controls from the Finnish Diabetes Prediction and Prevention (DIPP) birth cohort. Three
stool samples taken 3, 6 and 9 months before the first detection of
autoantibodies in serum of the case child were analysed by bacteriome profiling, and virome sequencing. The risk of islet autoimmunity
was evaluated in relation to bacteriome diversity, composition of the
bacteriome profiles at various taxonomic levels, correlations between
abundances of bacteriophages and bacteria, and prominent unknown
motifs in the virome.
Results: The abundance of five bacterial operational taxonomic units
(OTUs) was significantly decreased in children with islet autoimmunity as compared to controls, with the most prominent distortion
observable in OTUs belonging to Bacteroides vulgatus,
B. thetaiotaomicron (corrected P values < 0.001) and Bifidobacterium
bifidum (p=0.0014). The diversity, or the composition at taxonomic
levels of bacterial phyla, classes or genera, showed no differences
between cases and controls. One of the bacteriophage signals, the
CrAssphage, showed a tendency towards an association with islet
autoimmunity, and correlated with Bacteroides dorei and
B. thetaiotaomicron.
Conclusions: The results confirm previous findings that an imbalance
within the prevalent Bacteroides genus is associated with islet autoimmunity. The detected quantitative relation of the novel "orphan" bacteriophage CrAssphage with two prevalent species of the Bacteroides
genus serve as an example of the bacteriome-virome interactions
whose complex nature we are only beginning to appreciate.
O37
Early childhood infections precede development of
β-cell autoimmunity and T1D in children with HLAconferred disease risk
N. Mustonen1,2, H. Siljander1,2, A. Peet3, V. Tillmann3, T. Härkönen1,2,
J. Ilonen4, H. Hyöty5, M. Knip1,2, The DIABIMMUNE Study Group
1
University of Helsinki and Helsinki University Hospital, Children’s
Hospital, Helsinki, Finland, 2University of Helsinki, Research Programs
Unit, Diabetes and Obesity, Helsinki, Finland, 3University of Tartu and
Tartu University Hospital, Department of Pediatrics, Tartu, Estonia,
4
University of Turku, Immunogenetics Laboratory, Turku, Finland,
ORAL SESSIONS
5
University of Tampere, School of Medicine, Department of Virology,
Tampere, Finland
Objective: To assess the relationship between early childhood infections and islet autoimmunity in children with HLA-conferred risk for
type 1 diabetes (T1D).
Methods: Seven hundred ninety-seven children with HLA-conferred
susceptibility to T1D (51.4% males) from Finland (n=387), Estonia
(n=324) and Russian Karelia (n=86) were followed from birth up to
the age of 3 years. Children attended clinical visits at the age of 3, 6,
12, 18, 24, and 36 months. Serum samples for analyzing five T1Dassociated autoimmune markers (IAA, GADA, IA-2A, ZnT8A, and ICA)
were collected and health data, including data on past and ongoing
infections, were recorded during the visits.
Results: Children who seroconverted to autoantibody positivity during the follow-up (n=47, 5.9%) had their first infection at a younger
age than children with no signs of islet autoimmunity (median 4.0
vs. 5.0 months; p=0.007). They had also more infections during the
first year of life (3.5 vs. 3.0; p< 0.001). By May 2016, seven children
(0.9%; one from Estonia, one from Russia, and five from Finland) had
been diagnosed with T1D. Their median age at diagnosis was
3.7 years (range 2.4-6.4 years). Compared to their non-diabetic peers,
children who progressed to T1D were younger at their first infection
(2.2 vs. 4.9 months; p=0.004) and had more infections during the first
2 years of life (both years 6.0 vs. 3.0; p=0.001 and p=0.027, respectively). By the age of 3 years, children progressing to T1D had double
the cumulative number of infections when compared to their nonaffected peers (17.5 vs. 9.0; p=0.007). These findings were not
explained by the HLA genotype or the country of origin.
Conclusions: Early childhood infections may play an important role in
the pathogenesis of T1D. On the other hand, the current findings
may reflect early immunological aberrancies in children developing
T1D at a young age.
O38
Early successful hematopoietic cell transplantation
(HSCT) in a boy with IPEX syndrome caused by
novel c.721T>C FOXP3 mutation
B. Obermannova1, R. Formankova2, Z. Sumnik1, L. Dusatkova1,
S. Pruhova1, J. Kayserova3, P. Sedlacek2, J. Lebl1
1
2nd Faculty of Medicine of Charles University and the University
Hospital Motol, Department of Paediatrics, Prague, Czech Republic, 22nd
Faculty of Medicine of Charles University and the University Hospital
Motol, Department of Paediatric Hematology and Oncology, Prague,
Czech Republic, 32nd Faculty of Medicine of Charles University and the
University Hospital Motol, Department of Immunology, Prague, Czech
Republic
Objective: IPEX (MIM #304790) is rare and fatal, X-linked immune
dysregulatory disorder caused by mutation in transcription factor
FOXP3 that result in either quantitative or functional deficiencies of
Tregs causing autoimmune disease and allergic inflammation. HSCT is
the only curative therapy available for IPEX patients.
Case presentation: Presented boy was born at 38th GW with birth
weight 3380 g and birth length 50 cm. Three maternal brothers died
in early infancy due to malabsorption. At six weeks patient presented
with hyperglycaemia (38 mmol/L) and severe ketoacidosis at onset of
type 1 diabetes (T1D), GAD antibodies were highly positive (>120
kIU/L). Subsequently he developed atopic dermatitis and progressive
failure to thrive due to diarrhea. The total parenteral nutrition (TPN)
and intravenous insulin infusion was initiated. At the age of three
months he underwent HSCT from an unrelated HLA-matched donor.
The HSCT course was uncomplicated, the outcome was favorable:
gastrointestinal and skin symptoms fully resolved, the boy is fed
orally and thriving well. C-peptide remained undetectable (<3.33
pmol/L) and insulin administration is needed. At the current age of
six months, his T1D is well controlled by CSII (HbA1c 45 mmol/mol)
with daily insulin requirements of 0.63 IU/kg.
Methods and Results: Direct sequencing of FOXP3 gene revealed a
novel c.721T>C (S241P) mutation in the proband, his mother and
25
ORAL SESSIONS
sisters. A The quantity of Tregs in our patient was in normal range
(9.0%), but in immunosuppressive assay his Tregs failed to suppresses
proliferation of effector T cells if compared to healthy controls.
Conclusions: We describe a previously unreported c.721T>C (S241P)
mutation in FOXP3 gene. To our knowledge the patient is the youngest reported patient with IPEX who underwent successful HSCT. We
suggest that an early genetic diagnosis followed by early HSCT offers
the greatest potential to correct disease process and thereby minimize end-organ damage.
O39
Binational Swiss-Lithuanian study “genetic diabetes
in Lithuania”
I. Stankute1, R. Dobrovolskiene1, E. Danyte2, D. RazanskaiteVirbickiene1, D. Marciulionyte2, V. Schwitzgebel3,4, R. Verkauskiene2
1
Department of Endocrinology, Hospital of Lithuanian University of
Health Sciences Kauno Klinikos, Kaunas, Lithuania, 2Institute of
Endocrinology, Medical Academy, Lithuanian University of Health
Sciences, Kaunas, Lithuania, 3Department of Child and Adolescent,
University Hospital of Geneva, Geneva, Switzerland, 4Diabetes Center,
Faculty of Medicine, University of Geneva, Geneva, Switzerland
Objectives: To examine markers of β-cell autoimmunity in a cohort
of young (0-25 years) patients with type 1 diabetes (T1D). To perform genetic testing in islet autoantibody negative diabetes cohort.
Methods: Study subjects were investigated for autoimmune markers
of T1D (GAD65, IA-2, IAAs, ICAs), coexistence of other autoimmune
diseases (thyroid, celiac disease). Diabetes control was assessed by
levels of HbA1C, clinical examination, lipid profile, presence of diabetic complications. Patients with negative pancreatic antibodies (Ab’s)
were selected for genetic investigation. Genetic analysis was performed in Switzerland by high throughput sequencing from DNA
selected for all coding and splicing regions of 483 genes involved in
diabetes, glucose homeostasis or pancreas development, captured by
bait using Haloplex technology.
Results: Our cohort consisted of 1211 subjects covering all pediatric
diabetes patients (<18 years, n=861), and 70% of adult patients
younger than 25 years at diabetes diagnosis (n=350). All positive Ab’s
were found in 25.4%, 1 or 2 positive Ab’s in 66.5%, and all negative
Ab’s - in 8.1% of cases. 147 cases of non-autoimmune diabetes were
identified during the overall project. We included probands positive
for insulin autoantibodies, because Ab’s were tested after introduction of insulin therapy. 25.9% of genetic tests of 147 subjects (3% of
1211) revealed polymorphisms and mutations. 36.7% variants in
potential diabetes genes with high predicted pathogenicity (would
increase monogenic diabetes to 7.5% of the entire cohort). GCK
mutation was found in 13.6%, HNF1A in 4.8%, other known genes
(HNF4A, KLF11, INS, KCNJ11, ABCC8) in 7.5%, and negative in
37.4% of the entire cohort. 10% of the 147 subjects had actionable
changes and were subjected to a treatment change.
Conclusions: This binational project revealed high rate of positive
results. This led to optimization of treatment and further follow-up of
such patients.
O40
Glucokinase mutations in pediatric patients with
impaired fasting glucose
C. Aloi1, A. Salina1, F. Lugani2, N. Minuto3, R. Tallone3, C. Russo3,
M. Cassanello4, G. d’Annunzio3
1
Giannina Gaslini Institute, Pediatric Clinic, Laboratory of Diabetology,
Genoa, Italy, 2Giannina Gaslini Institute, Nephrology and Dialysis Unit,
Laboratory of Physiopathology of Uremia, Genoa, Italy, 3Giannina Gaslini
Institute, Pediatric Clinic, Regional Center for Diabetes, Genoa, Italy,
4
Giannina Gaslini Institute, Pediatric Clinic, Laboratory for the Study of
Inborn Errors of Metabolism, Genoa, Italy
Aims: We aimed to detect the Glucokinase frequency in two cohorts
describing clinical manifestations and identified variants. We also
intent to predict the effect of the novel mutations to correlate molecular defects and clinical manifestations.
Methods: Totally 100 unrelated Italian families with incidental hyperglycaemia were enrolled and subdivided in two cohort applying strict
and mild criteria of Maturity Onset Diabetes of the Young selection.
Genetic testing was performing by Sanger Sequencing GCK gene of
all participants.
Results: 53 Italian families with 41 different mutations affecting the
GCK gene and co-segregating with the clinical phenotype of
GCK/MODY were identified. All mutations were found in heterozygous state. In cohort 1 we detected GCK defects in 32/36 subjects
(88.9%) selected with full stringent MODY criteria of diagnosis while
in cohort 2 GCK defects were found in 21/64 subjects (32.8%) with
no fully stringent MODY criteria of diagnosis.
Conclusion: Our study enlarge the wide spectrum of GCK defects
adding 23 novel variants. The application of strict recruitment criteria
resulted in a higher GCK/MODY prevalence (88.9%) never previously
reported for the Italian population. In order to reduce the proportion
of missed cases it could be useful to perform genetic test even if one
or more clinical parameters for MODY clinical diagnosis are missing.
Computational analysis could be useful to understand the effect of
the change on protein functionality, especially when the novel identified variants is a missense change and/or parents’ DNA is not
available.
26
ORAL SESSIONS
Oral Session VI: Diabetes Care
O41
Long-term improvement and sustainability of HbA1
outcome in children and youth with type
1 diabetes: the diabeter experience
H. Veeze1, D. Mul1, M. Vries, de1, A.-S. Racault2, J. Castañeda3, S. de
Portu2, R. Kulkarni3, H.-J. Aanstoot1
1
Diabeter, Center for Pediatric and Adolescent Diabetes Care and
Research, Rotterdam, Netherlands, 2Medtronic International Trading Sàrl,
Diabetes, Tolochenaz, Switzerland, 3Medtronic Bakken Research Center,
Maastricht, Netherlands
Diabeter is a comprehensive care model that has established healthcare management for Type 1 diabetes (T1D) children and adolescents
characterized by a strong focus on personalized care and usage of
technology. Central in this approach is Vcare, a disease management
system that monitors >200 outcome parameters. Upon every upload
of glucosemeter or insulinpump data, Vcare generates personalized
treatment overviews and therapy advice ([email protected]). We hypothesized that this personalized approach results into better clinical outcome. Only 15-30% of pediatric T1D reach the ISPAD HbA1c target
of < 7.5% (59mmol/mol)(McKnight,Diabet.Med 32(8):1036).
Method: A retrospective analysis, with HbA1c as primary outcome
parameter was conducted in patients treated in the clinic
(2006-2015), comparing the period before/after introduction of
[email protected] (2012). HbA1c outcome was expressed as percentage
of patients reaching the ISPAD HbA1c target. Patient’s contacts
(face-to-face, phone, email) with or without [email protected] were collected and expressed as per patient per year.
Results: The addition of [email protected] to the Diabeter care model
resulted in 45-50% of patients reaching ISPAD target, despite the
increased number of patients treated. Results were independent of
treatment-modality.
[diabeter4]
Conclusion: The Diabeter model can improve and sustain over time
clinical outcome in pediatrics T1D. Providing automated personalized
advice by [email protected] can further improve HbA1c outcome.
O42
Home telemedicine increases the number of type
1 diabetes care visits attended by young adults
C. Berget1, K.A. Driscoll1, K. Campbell2, K. Ketchum1, C. Cain1,
J. Raymond1
1
University of Colorado Denver, Barbara Davis Center for Diabetes,
Aurora, United States, 2University of Colorado Denver, Aurora, United
States
Objectives: To determine adherence to essential components of
T1D care: visit attendance, device downloads and A1C measurement
in young adults with T1D enrolled in a home telemedicine trial
(CoYoT1).
Methods: Visits occurred every 3 months for 1 year with 3 home telemedicine visits and 1 in-person clinic visit. Prior to each visit, participants were instructed to download their T1D devices from home and
obtain A1C at a local laboratory.
Results: 45 young adults (Mage=19.81.6 years; 56% female) with
T1D (Mdiabetes duration=8.64.6 yrs.) participated. At least 72% of participants downloaded their T1D devices and >80% completed A1C
(Table 1). In the year prior to study enrollment, participants completed 2.51.2 in person T1D clinic visits. With access to home telemedicine, participants completed significantly more T1D clinic visits
(M=3.31.1;
t= −3.563; p< 0.001) compared to the number of T1D visits
attended in the prior year. The proportion of participants who completed ≥4 T1D visits/year, as recommended by ADA, significantly
improved from 22% to 67%; McNemar c2 p < 0.001.
Conclusions: Providing young adults with T1D care visits via home
telemedicine increases visit frequency. Additionally, data needed for
quality T1D care was successfully obtained for the majority of home
telemedicine visits. Offering home telemedicine for young adults may
be a successful way to increase clinical care engagement during this
transitional stage.
[Adherence to T1D Care Components via Telemedicine]
O43
New challenges in pediatric diabetes care:
frequency and medical treatment of type 1 diabetes
among current refugees in Germany and Austria
N. Prinz1,2, K. Konrad3,4, E. Hahn5, T. Danne6, L. Dreher-Preis7,
J. Grulich-Henn8, B. Rami-Merhar9, A. Icks2,10, N. Jorch11,
S. Lanzinger1,2, K. Mönkemöller12, R.W. Holl1,2
1
University Ulm, Institute of Epidemiology and Medical Biometry, ZIBMT,
Ulm, Germany, 2German Center for Diabetes Research (DZD), MunichNeuherberg, Germany, 3University of Cologne, Department of Pediatric
and Adolescent Medicine, Cologne, Germany, 4Elisabeth Hospital Essen,
Department of Pediatric and Adolescent Medicine, Essen, Germany,
5
Protestant Hospital Oberhausen, Clinic for Children and Adolescent,
Oberhausen, Germany, 6Hospital for Children and Adolescent ’Auf der
Bult’, Diabetes Centre for Children and Adolescents, Hannover, Germany,
7
University Medicine Mannheim, Clinic for Children and Adolescent
Medicine, Mannheim, Germany, 8University of Heidelberg, Children’s
Hospital, Heidelberg, Germany, 9Medical University Vienna, Department
of Pediatric and Adolescent Medicine, Vienna, Germany, 10Leibniz Center
for Diabetes Research, German Diabetes Center, Paul-Langerhans Group
for Health Services Research and Health Economics, Düsseldorf,
Germany, 11Protestant Hospital Bielefeld, Clinic for Pediatric and
Adolescent Medicine, Bielefeld, Germany, 12Hospitals of the City of
Cologne, Children’s Hospital, Cologne, Germany
Objectives: For German and Austrian pediatric diabetes teams a new
challenge is the care of refugees from Afghanistan, Syria, Iraq and
Iran. We studied type 1 diabetes (T1D) outcome of these patients
using real-life clinical care data from Germany/Austria.
Methods: 38104 T1D patients (<21y) from the multicenter diabetes
patient follow-up registry, DPV, were studied. Patients born in
Afghanistan, Syria, Iraq or Iran were classified as refugees. In refugees
the first year of care was studied, for native patients (child and parent
born in Germany/Austria) the most recent year. To compare groups,
multivariable regression adjusted for age, sex, diabetes duration was
used (SAS 9.4).
Results: 175 patients were born in Afghanistan, Syria, Iraq or Iran.
They were younger (median [IQR]: 12.6 [9.4-15.3] vs 15.3 [11.7-
27
ORAL SESSIONS
# Completed Visits
Visit 1 Total N=45
Visit 2 Total N=45
Visit 3(in person visit) Total N = 45
Visit 4 Total N = 45
45(100%)
39(87%)
35(78%)
32(71%)
# T1D Device Downloads
38(84%)
29(75%)
32(91%)
23(72%)
# A1Cs Completed
41(91%)
36(92%)
35(100%)
26(81%)
17.5] y, p< 0.001), more often male (62.9 vs 53.2%, p< 0.001), but
age at diabetes onset was comparable (8.5 [5.7-11.4] vs 8.6 [4.912.0] y) to native children. Table 1 summarizes medical care after
demographic adjustment. BMI-SDS (KiGGS) did not differ between
groups (0.210.07 vs 0.270.01).
[Medical care of refugees with T1D]
Conclusions: A relevant number of pediatric refugees from Syria,
Iraq, Iran and Afghanistan have diabetes. Compared to native children, refugees are faced with several challenges in diabetes therapy
and outcome: language barriers, different health beliefs or therapeutic concepts in the home country, or access barriers within the health
care system might be contributing factors.
O44
Factors affecting health-related quality of life and
adherence to diabetes care in paediatric patients
with type 1 diabetes mellitus in Spain: results from
the CHRYSTAL study
J.P. López-Siguero1, L.A. Vázquez2, J. Reviriego2, H. Sapin3,
M. Merino4, R. Villoro4, T. Dilla2, M. Perez-Nieves5
1
Hospital Universitario Carlos Haya, Málaga, Spain, 2Lilly Spain, Madrid,
Spain, 3Lilly France, Neuilly sur Seine, France, 4Instituto Max Weber,
Madrid, Spain, 5Eli Lilly and Company, Indianapolis, United States
Objectives: CHRYSTAL (Costs and Health Related qualitY of life
Study for Type 1 diAbetes meLlitus paediatric patients in Spain) was
an observational study conducted in 2014 in patients ages 1-17 years
with type 1 diabetes mellitus (T1DM). The objective of this analysis
was to evaluate the association between diabetes-specific healthrelated quality of life (HRQoL), adherence to diabetes care, demographics, and diabetes-related factors.
Methods: The study included 2 patient-reported outcomes (PROs):
the Diabetes Module of the Pediatric Quality of Life Inventory
(PedsQL) and the Self Care Inventory-Revised (SCI-R). The PedsQL
measures HRQoL and is composed of 28 items, assessing diabetes
symptoms, treatment barriers, treatment adherence, worry, and communication. The SCI-R measures adherence to diabetes care and is
T1D
native children
N
HbA1c, %
SMBG, per day
insulin pump, %
37,929
with Syrian, Iraqi,
Iranian, or Afghan
origin
175
pvalue
-
8.160.01
9.210.12
<0.001
5.250.01
4.040.15
<0.001
6.6
<0.001
<0.001
39.9
insulin dose,
IU/kg/d
0.860.002
0.980.02
hypoglycemic
coma, per
100 pat.year
2.80.1
5.71.7
0.022
composed of 15 items, assessing diet, glucose monitoring, medication
administration, exercise, low glucose level, and preventive/routine
aspects of self-care. A stepwise regression procedure was used to
evaluate the association between each PRO score and the main variables related to T1DM, including HbA1c levels, number of hypoglycaemic episodes, puberty status, and sociodemographic factors.
Results: A total of 275 patients participated in the study. The main
factors significantly affecting PedsQL total scores were the number
of severe hypoglycaemic events in the last 12 months (β= −3.997,
p=0.046) and age of the child (β= 0.471, p=0.031). Age was also associated with the SCI-R total score (β= −1.174, p< 0.001).
Conclusions: For children and adolescents with T1DM in Spain,
severe hypoglycemic events and lower age were significantly related
to lower overall self-reported HRQoL. Higher age was associated
with lower adherence to diabetes care. Health care providers should
consider these interactions as part of their regular practice of managing diabetes in order to address specific patients’ needs.
O45
Correlation between hypoglycemia, glycemic
variability and C-peptide preservation after
alefacept therapy in patients with type 1 diabetes:
analysis of data from the ITN T1DAL trial
A. Pinckney1, L. Keyes-Elstein1, C. Soppe2, G. Nepom3, M. Ehlers2
Rho, Inc., Federal Systems Division, Chapel Hill, United States, 2Immune
Tolerance Network, Clinical Trials Group, San Francisco, United States,
3
Benaroya Research Institute, Immune Tolerance Network, Seattle,
United States
1
Objective: In natural history studies, maintenance of higher levels of
C-peptide (C-pep) secretion correlates with a lower incidence of
major hypoglycemic events in patients with type 1 diabetes (T1D),
but it is unclear whether this is true for drug-induced C-pep
preservation.
Methods: We analyzed hypoglycemic events & glycemic control data
from the T1DAL study (alefacept in new-onset T1D) which demonstrated significant C-pep preservation at 1 & 2 years. We performed
a post hoc analysis using mixed models of the relationship between
the meal-stimulated 4-hour C-pep area under the curve (4-hr AUC) &
rates of major hypoglycemia, measures of glycemic control and variability, & an index of partial remission.
Results: Data from 49 participants (33 in the alefacept group, 16 in
the placebo group) were analyzed at baseline & 12 & 24 months. The
4-hr AUC at baseline & at 1 year was a significant predictor of the
number of hypoglycemic events during the ensuing 12-month interval
(p=0.030). There was a strong relationship between the 4-hr AUC &
glucometer SDs (p< 0.001), highest readings (p< 0.001), & lowest
readings (p=0.03), all measures of glycemic variability. There was a
strong inverse correlation between the 4-hr AUC & two measures of
glycemic control: HbA1c & average glucometer readings (both p<
0.001); & between the 4-hr AUC & IDAA1C values (p< 0.001), as well
as a strong correlation between IDAA1C values & glucometer SDs
(p< 0.001), suggesting that reduced glycemic variability is associated
with a trend toward partial remission.
28
Conclusions: Measures of glycemic variability & control, including
rates of hypoglycemia, are significantly correlated with preservation
of C-pep regardless of whether this is achieved by immune intervention with alefacept or natural variability in patients with new-onset
T1D. Preservation of endogenous insulin production by an immunomodulatory drug may confer clinical benefits similar to those seen in
patients with higher C-pep secretion.
O46
Change in prevalence of impaired awareness of
hypoglycemia in a population-based clinic cohort of
youth with type 1 diabetes
M.B. Abraham1,2, P. Gallego1, W. Brownlee3, G. Smith3, E. Davis1,2,3,
T. Jones1,2,3
1
Princess Margaret Hospital, Endocrinology and Diabetes, Perth,
Australia, 2School of Paediatrics and Child Health, The University of
Western Australia, Perth, Australia, 3Telethon Kids Insititute, Perth,
Australia
Objectives: Impaired awareness of hypoglycemia (IAH) is a serious
complication of insulin therapy associated with an increased risk for
severe hypoglycemia (SH). IAH prevalence has been documented in
youth with Type 1 diabetes (T1D) however improvement in management and reduced rates of SH raise the question as to whether there
has been a change in the prevalence of IAH. The aim of this study
was to determine the change in prevalence of IAH in a populationbased cohort of adolescents with T1D on contemporary therapy.
Methods: Children > 12 years of age with T1D documented their
responses to hypoglycemia based on the modified Clarke questionnaire. The prevalence of IAH was also analysed in a similar
population-based cohort using the same questionnaire in 2002. The
clinical details of the participants and the number of SH events in the
year preceding the survey were determined from the Western
Australian diabetes database.
Results: The modified Clarke questionnaire was administered to
413 children in 2002 and to 444 children in 2015 with similar baseline demographic characteristics. The prevalence of IAH was 33% in
2002 and 21% in 2015 (z = 3.703, p < 0.001). A lower HbA1c,
younger age at diagnosis and longer duration of diabetes correlated
with IAH in the 2002 cohort but not in the 2015 cohort. There was a
significant decline in the rates of SH in 2015 compared to 2002 (p <
0.001) despite a reduced HbA1c in 2015. IAH increased the risk of
SH 3 to 4 fold in both cohorts (IAH vs aware: 52 vs 16 events/100pt
years in 2002 and 8 vs 2 events/100pt years in 2015).
Conclusions: The study demonstrated a reduction in IAH across a
similar population using the same questionnaire in 2002 and 2015.
The associated risk profile for IAH has also changed. Although IAH
has reduced, IAH is still prevalent in a substantial minority of adolescents with T1D and is associated with an increased risk of
SH. Identification of these individuals is an important component of
T1D management.
O47
The SWEET Initiative: targeting harmonized
diabetes care through high quality data registry
from 48 centers worldwide
I. Kosteria1, A. Schwandt2,3, M. Witsch4, D. Hasnani5, C. Mazza6,
S. Besancon7, N. Fisch-Shvalb8, S. O’Riordan9, SWEET Study Group
1
National and Kapodistrian University of Athens, Agia Sofia Children’s
Hospital, Division of Endocrinology, Diabetes and Metabolism, First
Department of Pediatrics, Athens, Greece, 2Institute of Epidemiology and
Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany, 3German
Center for Diabetes Research (DZD), Munich-Neuherberg, Germany,
4
Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg, 5DIA
Care-Diabetes Care Center, Ahmedabad, India, 6Hospital J.P. Garrahan,
Department of Diabetes and Clinical Nutrition, Buenos Aires, Argentina,
7
Santé Diabète, Mali Office, Bamako, Mali, 8Schneider Children’s Medical
ORAL SESSIONS
Center of Israel, Petah Tikva, Israel, 9Cork University Hospital,
Department of Paediatrics and Child Health, Cork, Ireland
Objective: SWEET (“Better control in Pediatric and Adolescent diabetes Working to CrEat CEnTers of Reference (CoR)”) is a non-profit
entity endorsed by ISPAD aiming to create an extensive network of
certified CoRs for childhood diabetes in order to ensure high
quality care.
Methods: Electronic documentation of at least 150 pediatric patients
with diabetes annually, with subsequent upload of anonymized data
to a common database is a main prerequisite. The SWEET dataset
consists of 37 clearly definable items that reflect adherence to
ISPAD’s guidelines. Data can be uploaded either through the DPV
software that is adapted for a multilingual group or in other electronic
formats. The results of data analysis are conveyed to members
through biannual benchmarking reports. In collaboration with NHS
Diabetes, peer review visits to applying centers are organized so as
to assess compliance with the SWEET quality criteria. Smaller or
partly compliant as yet centers can participate as collaborative
ones (CC).
Results: To date, 48 centers (CoRs & CCs) from 33 countries in
5 continents have contributed data for 28,667 patients. In 2015,
19.131 patients (51,6% males, median age 14,2 y, T1D: 96.0%, T2D:
1.1%, other forms: 2.9%) with 69,028 visits were recorded. Median
HbA1c was 7.8% with 39.1%, 41.4%, and 19.4% of patients having
HbA1c < 7.5%, 7.5-9% and >9%, respectively. One third of all centers
achieve a median HbA1c < 7.5%. Regarding treatment modality,
41,2% of all patients were pump users. Severe hypoglycemia and
DKA rates were low in all centers. Data completeness rates have significantly increased over time.
Conclusions: SWEET aims at an improved and more uniform care for
people with diabetes through comparing processes and outcomes
among participating members. Benchmarking has highlighted the
importance of complete and accurate data to achieve meaningful
interpretation. Annual meetings further enhance collaboration on scientific projects, exchange of experience and innovation.
O48
Characteristics of young adults with type 1 diabetes
(T1D) who attain HbA1c target in the global TEENs
study
B. Anderson1, L. Laffel2, D. Ozkaya3, T. Danne4, M. Phillip5,
R. Hanas6, C. Mazza7, S. Waldron8, R. Beck9, C. Mathieu10
1
Baylor College of Medicine, Houston, United States, 2Joslin Diabetes
Center, Boston, United States, 3Sanofi, Paris, France, 4Children’s Hospital
’Auf der Bult’, Hannover, Germany, 5Schneider Children’s Medical Center
of Israel, Petah Tikva, Israel, 6Gothenburg University, Gothenburg,
Sweden, 7Hospital de Pediatria J P Garrahan, Buenos Aires, Argentina,
8
National Children and Young People’s Diabetes Network, Leeds, United
Kingdom, 9Jaeb Center for Health Research, Tampa, United States,
10
University Hospital Leuven, Leuven, Belgium
Objectives: Increasing evidence documents that many young adults
with T1D are vulnerable to poor glycaemic control, mental health
problems, loss to medical follow up and acute complications. Little is
known about those young adults who reach an A1c of < 7% (ADA).
We aimed to identify demographic, treatment and family/psychosocial factors among a subgroup of the 1648 participants, 18-25 y/o in
the global TEENs study with A1c < 7%.
Methods: Data were collected from 219 centres, 20 countries. A1c
was measured uniformly using A1cNow™ (Bayer). Demographic, family and treatment factors were collected by interview, survey, and
record review. Participants completed 2 psychosocial measures—the
PedsQL™ 3.0 Diabetes Module and the PAID (Problem Areas in Diabetes). The cohort was split into 3 A1c groupings: < 7% [<53mmol/
mol] (N=299, 18.1%); 7-< 9 % [53-74 mmol/mol] (N=850, 51.6%); ≥
9 %.[>75 mmol/mol] (N=499, 30.3%). 299 young adults with A1c<
7% were compared with the other 2 A1c groups. Significant (p< .001)
predictive characteristics of the 299 young adults with A1c< 7% were
identified using multivariate logistic regression adjusted for region.
ORAL SESSIONS
Results: Young adults with A1c < 7% were more likely to have a university degree and to be working. Regarding treatment characteristics, they were more likely to use carbohydrate counting, exercise
more days per week, check BG more frequently per day, use pump
therapy, and miss fewer insulin doses per week. Young adults at target had less diabetes family conflict and reported lower diabetes
emotional burden and higher diabetes-related quality of life.
29
Conclusions: In the TEENs sample, young adults at target A1c< 7%
used contemporary diabetes management methods—approaches that
can potentially be used by those above target. Associations between
target A1c and lower family conflict, as well as better psychosocial
functioning, are likely bi-directional relationships.
This study was supported by Sanofi.
30
ORAL SESSIONS
Oral Session VII : DM2 & DM in Developing Countries
O49
Pharmacokinetic (PK) and pharmacodynamic (PD)
profile of the SGLT2 inhibitor empagliflozin (Empa)
in pediatric patients with type 2 diabetes (T2D)
L. Laffel1, A. Yver2, G. Simons3, J. Wu4, V. Nock3, S. Kaspers5,
J. Marquard5
1
Harvard Medical School, Joslin Diabetes Center, Boston, United States,
Boehringer Ingelheim, Reims, France, 3Boehringer Ingelheim Pharma
GmbH & Co. KG, Biberach an der Riss, Germany, 4Boehringer Ingelheim
Pharmaceuticals Inc., Ridgefield, United States, 5Boehringer Ingelheim
Pharma GmbH & Co. KG, Ingelheim, Germany
2
Objectives: The newest class of oral hypoglycemic agents, SGLT2
inhibitors, offers promise for treatment of pediatric patients with
T2D. Prior to pivotal safety and efficacy trials, data on pediatric
PK/PD are needed.
Methods: In a single dose study, 27 children and adolescents, aged
10-17 years, with T2D were randomly assigned to receive either
5 mg, 10 mg, or 25 mg of Empa. Eligibility criteria included HbA1c
≤10.5% (91 mmol/mol), treatment with diet and exercise and/or stable dose of metformin and/or stable basal or MDI insulin. Primary
endpoints included PK data (area under the curve [AUC], maximum
plasma concentration [Cmax], time to Cmax [tmax], and half-life [t1/2]).
Secondary PD endpoints included changes in urinary glucose excretion [UGE] and fasting plasma glucose [FPG] at 24 h postdose.
Results: Of the 39 patients screened for participation, 27 (67%
female, 44% White) were randomized and completed the study; mean
( SD) age was 14.12.0 years, body weight 96.723.5 kg, BMI
35.56.7 kg/m2, z-BMI 3.00.8, eGFR 165.825.8 ml/min/1.73m2,
HbA1c 7.01.2%, UGE 8.822.1 grams/24 h, and FPG 13956
mg/dL. For PK results, tmax occurred within 1-2 hours and t1/2 was
on average 7-8 hours; Cmax and AUC increased with higher doses.
For PD results, baseline and FPG adjusted mean increase in UGE was
53, 73, and 87 grams/24 h and baseline adjusted mean decrease in
FPG was 15.5, 16.6, and 20.4 mg/dL for the 5, 10, and 25 mg doses,
respectively. There were no severe adverse events and 1 investigator-reported drug-related event (dehydration).
Conclusions: Exposure (AUC and Cmax) and t1/2 were comparable in
pediatric and adult patients with T2D. There were dose-dependent
increases in UGE and comparable decreases in FPG. A single dose of
Empa in pediatric patients with T2D was well tolerated, with PK/PD
and safety results similar to adult studies.
O50
A phase IIb, randomised, double-blind, placebocontrolled study of the DPP-4 inhibitor linagliptin
(Lina) in pediatric patients with type
2 diabetes (T2D)
W. Tamborlane1, J. Weill2, M. Gordat3, Frappin3, W. Hettema4,
S. Retlich4, S. Kaspers5, J. Marquard5
Lina 1 mg/day
Lina 5 mg/day
Placebo
N
10
14
15
Age (years)
14.0 1.8
14.3 2.1
13.7 2.0
Weight (kg)
75.3 19.3
84.8 25.1
78.2 21.8
28.0 5.2
33.0 8.0
29.2 6.0
2
BMI (kg/m )
HbA1c (%)
FPG* (mg/dL)
8.22 0.93
160.5 53.6
*Fasting Plasma Glucose
7.87 0.98
150.8 48.0
7.60 0.92
149.0 39.6
1
Yale Pediatric Speciality Center, Yale Pediatric Endocrinology, New
Haven, United States, 2Hôpital Jeanne de Flandre, Lillle Cedex, France,
3
Boehringer Ingelheim France S.A.S, Reims, France, 4Boehringer
Ingelheim Pharma GmbH & Co. KG, Biberach an der Riss, Germany,
5
Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
Objectives: To study efficacy, safety, pharmacokinetics (PK) and
pharmacodynamics (PD) of Lina in youth with T2D.
Study design: Double-blind, randomised controlled parallel group
study comparing Lina 1 and 5 mg with placebo in patients with T2D
aged 10-17 years. Primary efficacy endpoint was change from baseline in HbA1c after 12 weeks of treatment and key PD endpoint was
DPP-4 inhibition at trough at steady-state.
Results: Baseline characteristics by treatment group are shown in
Table. Compared to placebo, there was a dose-dependent reduction
in mean HbA1c levels of 0.48% and 0.63% with Lina 1 mg and 5 mg,
respectively, associated with corresponding falls in mean FPG of 5.6
mg/dL and 34.2 mg/dL. The% of median DPP-4 inhibition was 38%
with Lina 1 mg and 79% with Lina 5 mg. Geometric mean trough
levels of Lina were 3.80 nmol/L and 7.42 nmol/L in the 1 mg and
5 mg groups. These values were slightly higher than in adult patients
and further PK analysis suggests that the higher exposure is mainly
caused by higher plasma DPP-4 concentrations in the study population. There were no drug-related adverse events during treatment
with either dose of Lina.
Conclusions: Lina was well tolerated and induced dose-dependent
DPP-4 inhibitions that were accompanied by corresponding reductions in HbA1c and FPG in youth with T2D. The results are consistent with the clinical efficacy and safety profile that has been reported
for Lina in adult patients with T2D, favoring Lina 5 mg over 1 mg.
[Baseline characteristics (mean SD)]
O51
Transfer from pediatric to adult care for U.S. youth
with type 2 diabetes: the SEARCH for diabetes in
youth study
S. Agarwal1,2, J.K. Raymond3, J.M. Lawrence4, C. Pihoker5, S. Isom6,
R.B. D’Agostino Jr.6, D. Dabelea7
1
University of Pennsylvania, Endocrinology, Diabetes and Metabolism,
Philadelphia, United States, 2Perelman School of Medicine, Philadelphia,
United States, 3Barbara Davis Center for Diabetes / Children’s Hospital
Colorado, Pediatric Endocrinology, Denver, United States, 4Kaiser
Permanente, Research and Evaluation, Southern California, United
States, 5Seattle Children’s Hospital, Pediatric Endocrinology, Seattle,
United States, 6Wake Forest School of Medicine, Biostatistical Sciences,
Winston-Salem, United States, 7University of Colorado, Pediatrics and
Epidemiology, Denver, United States
Objective: To describe factors associated with transfer from pediatric to adult care and poor glycemic control after transfer among youth
with type 2 diabetes (T2D).
Methods: Youth with T2D were included if they had a baseline
SEARCH visit in pediatric care at < 18 years and ≥1 SEARCH followup visit at 18-25 years. At each visit, HbA1c and BMI were measured;
sociodemographic and provider data (pediatric/adult/no care) were
self-reported. Predictors of transferring from pediatric care and association between transfer and poor glycemic control
(HbA1c ≥9%) at follow up were explored with multiple logistic
regression.
Results: 145 T2D youth (38.6% male, 75.2% minority, 88.6% obese)
were included. Most (n=115, 79%) reported transfer to adult care; a
substantial proportion (n=26, 22.6%) reported no care at follow
up. There were no major differences between those who reported
transfer to adult care vs. no care at follow up, with the exception of
insurance status (15.7 vs. 72.7% uninsured, p< 0.001). Increasing age
31
ORAL SESSIONS
[OR=1.3 per yr, p=0.02] and baseline HbA1c [OR=1.5 per 1%, p
=0.01] were each associated with increased odds of leaving pediatric
care at follow up, independent of sex, transfer age, and race/ethnicity. Conversely, leaving pediatric care was associated with a 6.8
higher odds (p=0.001) of poor glycemic control at follow up, independent of baseline HbA1c, sex, transfer age, race/ethnicity, and
whether participants reported transfer to adult care vs. no care at
follow up.
Conclusions: Most youth with T2D transfer from pediatric to adult
care between 18-25 years; however some report no care at this
point. Worsening glycemic control in childhood is associated with
increased likelihood of leaving pediatric care, and leaving pediatric
care is associated with poor glycemic control in young adulthood
regardless of baseline control. Our findings highlight a need for better
preparation and support surrounding transition from pediatric to
adult care for youth with T2D.
O52
"Flatbush diabetes": ketosis prone type 2 diabetes
presenting with hyperglycaemic hyperosmolar
state, ketoacidosis and severe hypernatraemia
S. Kiff1, E. Bayman1, K. Noyes1, H. Miles1, L. Bath1
1
Royal Hospital for Sick Children, Edinburgh, United Kingdom
Introduction: Type 2 diabetes (T2D) affects 1.5% of UK children with
diabetes. The case of a child presenting with severe diabetic ketoacidosis (DKA) and hyperglycaemic hyperosmolar state (HHS) at first
presentation of T2D is described.
Case description: A 12-year-old Afro-Caribbean boy presented with
collapse, preceded by polyuria, polydipsia, enuresis and aggression.
He had been drinking>3L of sports drinks daily but had vomited
for 24h.
Examination signs: Kussmaul breathing; tachycardia; 4 sec capillary
refill; GCS 11. He was obese with acanthosis nigricans.
Investigations showed severe hyperglycaemia and hypernatraemia
(glucose 95 mmol/L, ketones 6.4 mmol/L, HbA1c 122 mmol/mol, corrected sodium 179 mmol/L). Blood gas confirmed severe DKA.
Management: Fluid resuscitation was commenced, followed by 8%
rehydration volume over 48h with 0.05 units/kg/h IV insulin. Ketonaemia resolved in 24h and the patient was in an 8L positive fluid
balance after 48h of rehydration.
Following this, isotonic fluid (0.9% NaCl) was gradually reduced to
0.45% NaCl when serum sodium failed to fall. When possible,
sodium-free oral fluids were introduced to titrate with IV fluids.
Sodium and fluid balance reviewed 4 hourly prevented rapid
sodium fall.
CT head at presentation showed no cerebral oedema. Agitation
and confusion improved only with correction of hypernatraemia at
day 8.
Progress: Due to signs of insulin resistance and known paternal
T2D, metformin was commenced in parallel with subcutaneous insulin. Anti-IA2 and anti-GAD antibodies were negative. Insulin was
stopped at week 10, when HbA1c was 45 mmol/mol.
Discussion: Children with T2D can present with both DKA and HHS,
posing additional management challenges.
Flatbush diabetes (ketosis-prone T2D) classically affects patients of
African ethnicity
Glucose-rich sports drinks contribute to extreme hyperglycaemia
and hypernatraemia, and may precipitate HHS.
Hypernatraemia must be gradually corrected to prevent cerebral
oedema.
O53
Comparison of treatment regimes in children with
type 2 diabetes and its effect on glycaemic control
R.F. Vasanwala1, C. Chua2, S.P.B. Ng3, P.H. Wee4
1
KK Women’s & Children’s Hospital, Paediatric Medicine, Endocrine
Service, Singapore, Singapore, 2Yong Loo Lin School of Medicine,
National University of Singapore, Paediatric Medicine, Endocrine Service,
Singapore, Singapore, 3KK Women’s & Children’s Hospital, Paediatric
ACP, Division of Medicine, Singapore, Singapore, 4KK Women’s &
Children’s Hospital, Paediatric Medicine, Singapore, Singapore
Objective: To compare change in HbA1c at 1-year among different
treatment groups of patients with T2D who were initiated on insulinonly, oral-only or combined insulin & oral therapy.
Methods: Retrospective review of data from diabetes registry of
patients diagnosed with T2D. Treatment is categorized into single
versus combination therapy, while single therapy group includes oralonly or insulin-only.The change in HbA1c within treatment groups
was analysed using SPSS version 19.0 & values reported as
meanSD.
Results: Out of 70 patients,18 were started on insulin-only, 30 on
oral-only & 22 on combination therapy. Mean HbA1c at diagnosis
was significantly lower in patients on single therapy than those on
combination therapy [9.473.18 vs.12.41.42%; p< 0.001], while
mean HbA1c was lower in oral-only than insulin only [7.912.06
vs. 12.22.95%; p< 0.001].Patients on combination therapy are
younger than those on single therapy (p=0.021). Mean weight at
diagnosis was significantly higher in those on oral-only vs. insulin only
[75.521.1 vs. 55.818.0 Kg ; p=0.004].There was no correlation
between race, gender or C-peptide level and choice of therapy.
Reduction in HbA1c at 1-year was seen across all treatment groups
(Graph 1), but was more in combination than single therapy and more
in insulin-only than oral-only group.
[Graph 1:Compariosn of mean change in HbA1c ]
Conclusion: All types of treatment regimens help to achieve glycaemic control in T2D but combination & insulin-only therapy is more
effective than oral-only.
O54
A new approach to compare between different
screening tests for type 2 diabetes and prediabetes
in overweight and obese children
M. Abdellatif1, A. El-Hawary1, H. El-Khaleegy2, M. Sakr2
Mansoura University Children’s Hospital, Mansoura, Egypt, 2Al-Azhar
University in Damietta Faculty of Medicine, Damietta, Egypt
1
Objectives: In children, studies appear to show that A1C has lower
sensitivity when compared to fasting plasma glucose (FPG) or oral
glucose tolerance test (OGTT) as “gold standard”. However, FPG and
OGTT have themselves never been validated in children. The analysis
in these studies is confounded, as the tests under study are themselves being used as the ’gold standard’. When defining one test arbitrarily as the gold standard, any other test, by definition, will not
measure up.
We compared the three tests not to a ’gold standard’, but to a final
diagnosis reached through combining the results of more than
one test.
Methods: Fifty four children aged 5-15 years with BMI ≥85th percentile were recruited into the study. For all participants, FPG, 2h-PG
on the 75-g oral glucose tolerance test (OGTT) and A1C were
performed.
32
ORAL SESSIONS
defined as serum Mg < 1.8 mg/dL and P < 2.4 mg/dL. Hyperuricemia
was defined as serum uric acid > 7 mg/dL.
Results: The prevalence of central obesity was 6.8% (24/354). None
of the children had hyperuricemia or low P levels. HypoMg was identified in 21.7% (57/263). There was a significant association between
WC (z-score) and Mg (r-015), uric acid (r0.28), P(r-0.30), HOMA-IR
(r0.49), Triglycerides (r0.24), and HDL-C (r0.24). However, calcium,
sodium, and potassium were not significantly associated with WC. As
z-WC quartiles increased Mg and P levels significantly decreased,
whereas uric acid levels increased. Multiple linear regression analysis
showed that z-WC was associated significantly and directly with uric
acid (B0.31), triglycerides (B0.004), and HOMA-IR (B0.35); and
inversely with Mg (B-0.83) and phosphorus (B-0.25), adjusted for
confounding variables (R2 0.34).
Conclusion: Our results indicate that central obesity was significantly
and inversely associated with Mg and P and directly with uric acid in
indigenous school children. This underlines the importance of early
WC screening of children and early intervention. The interventional
methods include healthy lifestyle education and supplementation of
micronutrients. Therefore, supplementation with Mg and/or P could
decrease the likelihood of central obesity and future T2DM in this
community.
O56
Activity of the antioxidant enzyme paraoxonase in
indigenous versus urban Argentinean children
If two different tests are both above the diagnostic threshold, this
confirms the diagnosis. On the other hand, if a patient has discordant
results on two different tests, then the test result that is above the
diagnostic cut point should be repeated. The diagnosis is made on
the basis of the confirmed test.
Sensitivity and specificity were calculated for the 3 tests. The k
coefficient was calculated as a measure of agreement.
Results: One male obese child had T2DM, 36 showed normal glucose tolerance, while 17 children had pre-diabetes.
A1C was the most sensitive test (86.67%) followed by FPG
(62.5%). Both FPG and 2h-PG had equal specificities (97.3%) while
A1C had a lower specificity of 84.21%.
Fair agreement existed between FPG and both 2h-PG (k=0.215;
95% CI −0.086 to 0.516) and A1C (k=0.330; 95% CI 0.069 to 0.591)
diagnoses. While, there was poor agreement between A1C and 2hPG diagnoses (k=0.179; 95% CI −0.052 to 0.410).
Conclusions: A1C could be a valid screening test for prediabetes in
overweight and obese children and further studies are needed.
O55
Association between waist circumference and
magnesium, phosphorus and uric acid in indigenous
Argentinean children
V. Hirschler1, M. Esteban2, G. Maccallini3, C. Molinari1, L. Castano4,
San Antonio de los Cobres Study Group
1
University of Buenos Aires, Buenos Aires, Argentina, 2Hospital
Universitario Cruces, BioCruces, UPV-EHU, Ciberdem, Barakaldo, Spain,
3
Hidalgo Laboratories, Buenos Aires, Argentina, 4Hospital Universitario
Cruces, BioCruces, UPV-EHU, Ciberdem, Ciberer, Barakaldo, Spain
Background: Studies in adults show that central obesity increases
the likelihood of Type 2 diabetes (T2DM).
Objective: To determine the association between waist circumference (WC) and non-traditional risk factors such as magnesium, phosphorus, and uric acid in indigenous children living at high altitudes.
Methods: A total of 354 (166 M) indigenous school children, aged
9.6 2.3 years, were enrolled in a cross-sectional study in November
2011. Central obesity was defined as WC ≥ 90th percentile according
to age and sex. Low magnesium (Mg) and phosphorus (P) levels were
V. Hirschler1, M. Maximiliano2, K. Oestreicher1, C. Molinari1,
W. Tezlaff2, E. Botta2, L. Boero2, F. Brites2, San Antonio de los
Cobres Study Group
1
Universidad de Buenos Aires, Buenos Aires, Argentina, 2Universidad de
Buenos Aires, Laboratory of Lipids and Atherosclerosis, Department of
Clinical Biochemistry, School of Pharmacy and Biochemistry, CONICET,
Buenos Aires, Argentina
Background: We have previously found that indigenous children
from San Antonio de los Cobres (SAC) had lower HDL levels than
Buenos Aires (BA) urban children. Among the different antiatherogenic functions exerted by HDL, its antioxidant capacity is mainly
attributed to the enzyme paraoxonase 1 (PON1), which is synthesized
by the liver and circulates in plasma bound to HDL. Serum PON1
activity was found to be reduced in a number of pathological conditions including cardiovascular disease and type 2 diabetes.
Objective: To compare PON1 activity in indigenous SAC versus
urban BA children.
Methods: A cross-sectional study compared 150 (67 males) SAC versus 93 (47 males) urban BA children (6-16 years) between October
and November 2015. Anthropometric data, lipid levels, and PON1
activity were measured in both groups.
Results: The prevalence of overweight/obesity was significantly
lower in SAC (26/150; 17.3%) than in BA (30/93; 32.6%). However,
the prevalence of low HDL was significantly higher in SAC (14/150;
9.5%) than in BA (4/93; 4.3%); and the prevalence of high triglycerides was significantly higher in SAC (28/150; 18.7%) than in BA
(4/93; 4.4%). Comparisons of BMI percentile (59 vs 66); triglycerides
(120 vs. 78 mg/dL), HDL-C (45 vs. 51 mg/dL) and Apo B ( 83 vs.
70 mg/dL) levels, as well as PON-1 activity
(170 vs 203 IU/L) showed significant differences in mean levels in
SAC compared with BA. In separate linear regression models,
adjusted for sex, age, and BMI, SAC children had 44 mg/dL higher
triglyceride
(p< 0.001), 6.6 mg/dL lower HDL (p< 0.001) and 14 mg/dL higher
Apo B (p< 0.001) levels, and 45 IU/L lower PON1 activity (p< 0.001)
compared with BA children.
Conclusion: This study shows that SAC children had an unfavourable
lipid profile and lower PON1 activity compared with BA children.
These findings suggest that this community may be at higher risk for
earlier cardiovascular disease and type 2 diabetes.
33
ORAL SESSIONS
Oral Session VIII - Nutrition and DM in Developing Countries
O57
Is the glycaemic response from fat in meals dose
dependent in chidren with T1DM? Interim analysis
of 11 patients
S.M. O’Connell1, N. O’Toole1, C. Cronin1, P. McElduff2, B. King3,
C.E. Smart3, A. Shafat4
1
Cork University Hospital, Paediatrics and Child Health, Cork, Ireland,
University of Newcastle, School of Medicine and Public Health,
Newcastle, Australia, 3John Hunter Children’s Hospital, Department of
Diabetes and Endocrinology, Newcastle, Australia, 4National University
of Ireland, Physiology, School of Medicine, Galway, Ireland
2
Background: Management of people with T1DM on intensive insulin
therapy (IIT) uses algorithms based on the meal carbohydrate (CHO)
content (MCC) to calculate prandial insulin dose. Typically, these calculations do not consider the meal content of fat or protein.
Objective: To determine if the postprandial blood glucose
(BG) response to varying fat content is dose dependent when standard insulin bolus is given based on MCC.
Methods: Randomised repeat testing of 11 patients with T1DM
>1 year duration, aged 8-18 years on ITT. A test meal was given on
6 consecutive nights in random order without insulin 4 hours after
the regular evening meal; 5 test meals varying in fat content (3, 13,
25, 38, 50g), but without CHO/protein, and one 20g CHO meal with
no fat/protein. A continuous glucose monitoring system was used to
assess BG levels (BGL) at 10 minute intervals for 8 hours afterwards.
The relationship between the fat loads in the meals and the mean
change in postprandial BGL were analysed.
Results: The graph illustrates the change in BGL from baseline
(Y axis) versus time in minutes (X axis), following test meal consumption (each meal = different colour).
[Mean post prandial BGL excursion over time]
Conclusions: In 11 patients studied to date, there was no significant
dose response to fat consumed without CHO in either the early or
late postprandial period indicating that fat does not cause the immediate increase in BGL seen with CHO. More data are needed from
this ongoing study to accurately determine the full impact.
O58
Impact of advanced carbohydrate counting method
on oxidative stress and metabolic control in
children and adolescents with type 1 diabetes
(DM1) on multiple daily injection (MDI) therapy
I. Partsalaki1, F. Lamari2, I. Leivada1, B.E. Spiliotis1
1
Division of Pediatric Endocrinology and Diabetes, Department of
Pediatrics, University of Patras School of Medicine, Patras, Greece,
2
Laboratory of Pharmacognosy & Chemistry of Natural Products,
Department of Pharmacy, University of Patras, Patras, Greece
Objectives: Advanced (third level) carbohydrate counting (CC) is a
key strategy in diabetes care, especially for people on intensive insulin regimens. With advanced CC, DM1 patients learn how to use
insulin-to-carbohydrate ratios, thus acquiring dietary flexibility and a
better quality of life. The aim of this study was to assess the effects
of the advanced CC method on metabolic control and oxidative stress
in children and adolescents with DM1.
Methods: Thirty-five DMI subjects (2 to 23 years old), who followed
a basic CC method for their dietary planning, received individualized
nutritional consultation sessions on advanced CC. Anthropometric
measurements, HbA1c, lipidemic profile, antioxidant defense mechanisms using the FRAP assay and malondialdehyde (MDA) as an index
of lipid peroxidation estimated by the TBARS method, were evaluated at baseline and one year after the nutritional counseling.
Results: At the beginning of the study, all participants were on a
basal-bolus insulin regimen using MDI and had never received
advanced CC guidance. At baseline, their body fat mass, estimated by
BIA, was significantly correlated with HbA1c (r=0.486, p=0.01) and
with the levels of MDA (r=0.432, p=0.05). One year after advanced
CC counseling, HbA1c decreased significantly by 0.59180.83%
(p≤0.001) and HDL increased by 3.588.5 mg/dl, (p=0.04). Also,
MDA decreased significantly from 4.272.58 to 2.552 μM, (p=0.02)
and FRAP increased, but without statistical significance, from
0.140.05 to 0.350.27 M, (p=0.072).
Conclusions: Advanced carbohydrate counting in children and adolescents with type 1 diabetes is a method that may help in the attainment of greater glycemic and metabolic control, as measured by
HbA1c, increased HDL and significantly decreased oxidative stress,
and may play a role in decreasing the risk of diabetic complications.
O59
Greater postprandial glucose excursions and
inadequate nutrient intake in youth with type
1 diabetes and coeliac disease
A. Pham-Short1,2, K.C. Donaghue1,2, G. Ambler1,2, S. Garnett1,2,
M.E. Craig1,2,3
1
The Childrens Hospital at Westmead, Institute of Endocrinology and
Diabetes, Sydney, Australia, 2University of Sydney, Discipline of
Paediatrics and Child Health, Sydney, Australia, 3University of New
South Wales, School of Women’s and Child Health, Sydney, Australia
Objective: To compare daily glycemic profiles and nutrient intake in
youth with type 1 diabetes (T1D) and coeliac disease (CD) vs
T1D only.
Methods: Case control study of 10 youth with T1D+CD and 7 with
T1D, who wore blinded continuous glucose monitoring systems
(CGMS) for 6 days, with 5-minutely BGLs downloaded at study end.
Main meal BGLs (pre-meal, peak, 2-hr post meal) and time to reach
peak BGLs were compared between T1D and T1D+CD using MannWhitney U tests. Participants consumed a gluten free cereal and milk
test meal for 3 days and kept weighed food diaries, which were analyzed for nutrient intake and compared to national dietary
recommendations.
Results: Overall, 222 main meals were identified from CGMS traces
(median 16, range 8-18 meals per patient). Youth with T1D+CD vs
T1D only had shorter time to peak BGL (77 vs 89 mins, p=0.03),
higher peak (9.3 vs 7.3mmol/L,-p=0.001) and higher 2-hr post prandial BGL (8.4 vs 7.0 mmol/L, p=0.01), despite similar pre-meal BGLs
(9.2 vs 8.6 mmol/L, p=0.28), insulin to carbohydrate ratios (11.1 vs
10.4, p=0.84) and insulin sensitivity factors (3.3 vs 2.7, p=0.54) and
34
HbA1c (7.5% vs 8.0% / 58 vs 64 mmol/mol, p=0.34). For the test
breakfast, the difference between post-meal BGL and peak BGL
post-meal was significantly correlated with longer CD duration (R =
0.53, p=0.01). Caloric and macronutrient intake did not differ
between T1D+CD vs T1D, however, collectively the majority had
inadequate dietary calcium (76%), folate (71%) and fiber (53%) intake,
with excessive saturated fat (12% total energy intake) and sodium
(>2,000mg/day) intake.
Conclusion: A gluten free diet is associated with greater glycemic
excursions in youth with T1D+CD. Youth with T1D did not meet
ISPAD guidelines for saturated fat, fiber and sodium dietary intake.
Clinical management should address both glycemic variability and dietary quality to increase calcium and fiber, and reduce saturated fat
and sodium intake.
O60
Carbohydrate counting from onset of diabetes
reduced insulin requirements but increased weight
in children and adolescents
E. Jelleryd1,2, E. Örtkvist3, A. Janson3, P. Rydén2
1
Astrid Lindgren Children’s Hospital, Karolinska University Hospital,
Department of Clinical Nutrition, Pediatric Diabetes Clinic, Stockholm,
Sweden, 2Umeå University, Department of Food and Nutrition, Umeå,
Sweden, 3Astrid Lindgren Children’s Hospital, Karolinska University
Hospital, Pediatric Diabetes Unit, Stockholm, Sweden
Objective: The aim was to evaluate if carbohydrate (CHO) counting
improved glycemic control and anthropometrics compared to conventional treatment, one and two years after onset of diabetes in children and adolescents. A secondary aim was to explore patients and
caregivers perception of insulin dosage to meals with focus on efficacy, time consumption and adherence.
Methods: 371 subjects were included and divided into two groups,
based on whether onset of diabetes occurred before or after the
introduction of CHO counting as standard treatment method in our
clinic. Data was collected retrospectively from the Swedish pediatric
quality registry (Swediabkids). HbA1c, body mass index standard
deviation score (BMI-sds) and total daily insulin were calculated at
three months, one and two years. Occurrence of severe hypoglycemia was also measured. A web-based questionnaire provided information on perception of carbohydrate counting, answered by
78 subjects.
Results: CHO counting reduced insulin requirements (p< 0.001) and
eliminated differences in insulin requirements between pump- and
pen users as well as between boys and girls. Glycemic control was
not improved by CHO counting one and two years after diabetes
onset (p=0.233, p=0.295). An adverse effect was increased body
mass index standard deviation score (BMI-sds) (p=0.044), especially
amongst girls (p=0.038). Patients found CHO counting effective and
time efficient. Learning CHO counting from onset increased
adherence.
Conclusion: CHO counting lowers insulin requirements with maintained glycemic control. Contradictory, greater weight gain was found
in the carbohydrate counting group, especially among girls. A plausible explanation is that CHO have taken focus off protein- and fat
intake in combination with a more liberal approach to energy dense
foods, causing excess energy intake. The strength of CHO counting
does not lie in its ability to lower HbA1c-values but as a helpful tool,
which patients are happy to use.
O61
Costs to governments of type 1 diabetes care in
youth in less-resourced countries - three scenarios
for different income levels
G.D. Ogle1,2, J. da Rocha Fernandes3, S. Besancon4, G. Ahmadov5,
K. Ramaiya6, T. Orchard7, A.C. Middlehurst1,2, L. Makaroff3
ORAL SESSIONS
1
International Diabetes Federation Life for a Child Program, Sydney,
Australia, 2Diabetes NSW, Sydney, Australia, 3International Diabetes
Federation, Brussels, Belgium, 4Sante Diabete, Bamako, Mali, 5Endocrine
Center, Baku, Azerbaijan, 6Tanzanian Diabetes Association, Dar es
Salaam, Tanzania, United Republic of, 7University of Pittsburgh,
Pittsburgh, United States
Objectives: Evidenced-based tools are needed to help persuade governments in less-resourced countries to provide adequate youth diabetes health care. We developed 3 scenarios for differing country
income levels, calculating the annual cost of care/child needed to
achieve a healthy life year, and comparing that to Gross Domestic
Product (GDP)/capita as per WHO’s CHOICE approach.
Methods: Scenario (S)1: low-income Least Developed Country (LDC),
e.g. Mali. Child/adolescent supplied with human insulin and syringes.
Self-monitoring blood glucose (SMBG) frequency: 2/day.
S2: low-income non-LDC country, e.g. Tanzania. Child/adolescent
supplied with human insulin and syringes. SMBG frequency: 3/day.
S3: upper-middle income country, e.g. Azerbaijan. Child/adolescent
supplied with analog insulin and pens. SMBG frequency: 4/day.
Costs of insulin, syringes/pens, SMBG, ketone strips, HbA1c, complications screening, outpatient and inpatient care were determined
from publications, known international costs, and local investigations.
A healthy life year was assumed for 10+ years with this care. The
cost was compared to GDP/capita.
Results: Projected estimated annual costs were S1: (US)$761, S2:
$1,067, S3: $1,980. Annual costs in Mali were $740 (105% GDP/capita), Tanzania $889 (93%), Azerbaijan $1,980 (26%). Expressed as a
% total cost, supplies were 48%, 48%, 60% in S1, S2, S3 respectively;
laboratory/complications 10%, 7%, 4%; and health service delivery
42%, 45%, 36%.
Conclusions: This is a straightforward approach to determining costs
of youth diabetes care that will be useful for advocacy to governments. Next, the research team will quantify the healthy life years
gained for these 3 scenarios, and conduct a cost-effectiveness analysis in line with WHO CHOICE, where the indicative level for a very
cost-effective intervention resulting in a healthy life year is < 100%
GDP/capita.
Standard youth diabetes care can be provided at a relatively low
cost, even in low-income countries.
O62
Type 1 diabetes care and outcomes in rural low
income settings in India using family support
strategies
A. Sarda1
1
Sarda Center for Diabetes and Self Care, Aurangabad, India
Objective: Patient outcomes are hard to achieve in rural settings
because of lack of education in the family, lack of financial resources
and unavailability of specialized care. This a study of 100 children
supported by Udaan, an NGO based in Aurangabad, India to identify
low-cost strategies that can improve patient outcomes within these
constraints, bringing them at par with those observed in developed
countries.
Methods: 100 Udaan supported children with Type 1 diabetes were
studied. 30 children were below 10, 34 were between 10-14, and
36 were between 15-20 years of age. Average income of a family
was about 100 USD / month. Families were provided conventional
insulin, Glucometer and 50 strips a month to minimize the cost of
care. The average education level of mothers was below 9th grade
with 15% being illiterate. In place of traditional written material,
weekly interactive learning programs were provided to parents
and/or children. Each family attended an average of 15 sessions a
year. To address the lack of access to specialized care (there is no
pediatric endocrinologist in the region and the nearest doctor is
about 50 km away), Udaan ran 24 hour helplines for diabetes support, which each family used approximately 22 times a year.
Results: Average HbA1c level for the 100 children was 8.37%, at par
with values observed in developed countries. Of the 100, 9 children
35
ORAL SESSIONS
achieved scores below 7%, 24 between 7-8%, 38 between 8-9% and
29 children had HbA1c levels between 9-10%.
Conclusion: 100 children with Type 1 diabetes from rural, low
income, low literacy families with no access to specialized care were
able to achieve average HbA1c levels of 8.37%, at par with those
observed in less resourced-constrained settings. They achieved this
cost-effectively, using conventional insulin and less than 50 glucometer strips a month, overcoming access and literacy constraints
through 24 hour helplines and localized education support provided
by Udaan, an NGO for children with diabetes.
O63
Diabetes support groups in Ghana, 3 years of
diabetes youth care
N. Barnes1, E. Asante Bediako2
1
University of Cape Coast School of Medical Sciences, Cape Coast,
Ghana, 2Effia Nwanta Regional Hospital, Sekondi, Ghana
Introduction: The prevalence of diabetes in adults in Ghana is estimated to be 3.35%. The prevalence of diabetes mellitus in Ghana
among the young is not known. Management of diabetes is multidisciplinary and also involves a lot of support for the young person and
the family as a whole.
Started in 2012, Diabetes Youth Care has the main aim of filling
the unmet social support of these young ones and their families.
Problem statement: There are few support groups for and young
people living with diabetes in Ghana.
Aim: To assess impact of support network Diabetes Youth Care on
young ones living with diabetes in Ghana.
Objective: To determine the influence of monthly support group
meetings.
Method: Assessment of the support network was done by analyzing
the attendance and behavior at the monthly, support group meetings
and the number of admissions due to acute complications.
Results: The support network initially began with 5 young ones
under the age of 30 and has grown to over 100 across the country.
The young ones have been empowered with the knowledge about
managing diabetes and are able to identify acute complications, manage them to prevent death.
Most of the young ones living with diabetes were in a better position to tell their friends and family about diabetes and also educate
them about immediate measures to take when they develop acute
complications.
A website created by the support network encourages the young
ones living with diabetes to share their real life stories to encourage
each other, educate and create awareness about diabetes in young
people. This has led to some of them becoming peer educators and
mentors to the younger ones with diabetes.
Conclusion: Support network groups are vital in the management of
diabetes in young people as they serve as a point of information and
education about diabetes. Diabetes Youth Care has been a positive
impact in the life of these young ones living with diabetes and that of
their families.
O64
Follow-up of successful community mobilisation
with women’s groups to assess impact on growth
of children aged two to four years in Bangladesh
K. Azad1,2, E. Fottrell3, N. Ahmed2, B. Nahar2, S.K. Shaha2,
A. Kuddus2, T. Nahar2, C. Fall4, C. Osmond4, S. Finer5, V. Govoni5,
A.K.A. Khan6, A. Costello3, G. Hitman5
1
BIRDEM and Ibrahim Medical College, Paediatrics, Dhaka, Bangladesh,
Diabetic Association of Bangladesh, Perinatal Care Project, Dhaka,
Bangladesh, 3UCL Institute for Global Health, University College London,
London, United Kingdom, 4University of Southampton, Faculty of
Medicine, Southampton, United Kingdom, 5Blizard Institute, Barts and
The London School of Medicine and Dentistry, London, United Kingdom,
6
Diabetic Association of Bangladesh, Dhaka, Bangladesh
2
Objectives: Community Mobilisation (CM) with women´s groups
(WG) practising participatory learning and action are a cost-effective
strategy to improve neonatal survival in low-resource settings, with a
reduction In neonatal mortality in Bangladesh by 38%. The long term
effect, if any, has yet to be established. We studied differences in
anthropometric outcomes at ages two to four years of children to
examine the impact.
Methods: In a cross-sectional survey, anthropometric measures
(height, weight, and abdominal, head, chest, mid upper arm circumferences, triceps and sub-scapular skinfold thickness) in children born to
women who had been directly exposed to CM were compared at
ages 2-4 years with a random sample of age-matched children, whose
mothers were not exposed to the intervention.. Maternal weight and
height and BMI were recorded. Data were analysed as z-scores and
results stratified by maternal BMI.
Results: 2587 children. were inducted. Children whose mothers were
underweight at the time of the survey, and were exposed to WGs
interventions had significantly larger z-scores for HC (z-score increase
of 0.22 (95% CI 0.08, 0.36), p=0.002), AC (0.23 (0.05, 0.42), p=0.013)
and MUAC (0.13 (0.00, 0.25), p=0.045) than children whose mothers
were not exposed to the intervention. Children with overweight
mothers, exposed to the interventions,had significantly smaller
weight-for-age (−0.23 (−0.43, −0.04), p=0.018) and weight-for-length
(−0.17 (−0.33, −0.00), p=0.047) z-scores compared to control children. Results for weight-for-length z-scores also showed a significant
differential effect depending on the child’s gender.
Conclusion: Beneficial growth effects on the offspring of the most
under-nourished mothers in particular, could have a lasting effect on
diabetes and lifelong cardio-metabolic susceptibility. These findings
offer a potential public health approach to reducing cardiometabolic
risk
through
a
population-level
intervention
in
early
developmental life.
DOI 10.1111/pedi.12451
POSTER TOURS
Poster Tour 1: Chronic Complications
P001
Diabetic eye complication screening of children in
Kent, England: a multi-centre retrospective audit
P. Christian1, A. Ranasinghe1, P. Williams1, B. Hutter, K. Henderson3
1
Medway NHS Foundation Trust, Paediatrics, Gillingham, United
Kingdom, 2Darent Valley Hospital (Dartford and Gravesham NHS Trust),
Kent, United Kingdom, 3East Kent Hospitals NHS Foundation Trust,
Paediatric Diabetes, Ashford, United Kingdom
Objectives: To audit diabetic eye complication screening (DECS) in
children across Kent, comparing prevalence of diabetic retinopathy
(DR) against age and duration of diagnosis. Failure to attend screening to be compared with HbA1c and DR prevalence.
Methods: Outcomes of annual DECS were collected for all diabetic
patients aged 12-19 yrs known to four hospitals managed by Medway NHS Foundation Trust (MFT) and East Kent Hospitals University
NHS Foundation Trust (EKHUFT). Data was collected from the eye
screening service database and from hospital databases.
Results: 1026 screening events were recorded: 901 reported no DR,
123 (12%) reported background retinopathy (BR) and 2 reported referable diabetic retinopathy (RDR), both maculopathy. Ophthalmology
review reported no retinopathy in the first RDR case and minor retinopathy in the second with no intervention required.
These screens represented 366 patients: 82 (22.4%) had any DR
on at least one screen. Of these 36 (45%) had no DR on subsequent
screening.
202 screens were carried out at 12 yrs of age: 13 (6.4%) showed
any DR. 10 (77%) of these had no DR on subsequent screening.
Those with any DR on screens at 12-13 yrs had been diagnosed for
longer than those with none (7.94 yrs vs 5.36 yrs, p < 0.001).
65 patients missed at least one annual screen; last known HbA1c
was higher in this group (mean 79.6 mmol/mol vs 69.2 mmol/mol,
p = 0.0003) and a greater proportion had DR on at least one screen
(36% vs 21%).
Conclusions: Children are commonly reported to have BR, but this
often resolves without intervention. Rates of BR at 12 yrs of age are
low and the majority of cases do not persist. Risk can be stratified
according to duration of diagnosis; this may justify less frequent
screening for lower risk patients.
Those who failed to attend screening had higher mean HbA1c and
increased DR prevalence; therefore prevalence of DR in those who
attend screening will be skewed to underestimate true population
prevalence.
P002
Autonomic neuropathy screening in children
and adolescents with type1 diabetes mellitus
D. Kallinikou1, C. Tsentidis1, M. Louraki1, A. Papathanasiou1,
C. Kanaka-Gantenbein2, K. Karavanaki1
1
2
University of Athens, 2nd Department of Pediatrics, Athens, Greece,
University of Athens, First Department of Paediatrics, Athens, Greece
Background: Diabetic neuropathy is among the least recognized
complications of diabetes, despite its significant negative impact on
36
© 2016 The Authors.
Pediatric Diabetes © 2016 John Wiley & Sons A/S
survival and quality of life. Characteristic neuronal alterations may
occur subclinically early in the course of the disease, even in childhood, with a prevalence ranging from 7.9 ~ 19%.
Objectives: Our objective was to study the prevalence of subclinical
autonomic and peripheral neuropathy in T1DM children and adolescents and its correlations with associated factors.
Materials and Methods: We evaluated 97 T1DM children and adolescents (mean SD age 12.9 2.8 years, T1DM duration:
5.14 3.5years) and 80 age and gender-matched controls (mean SD age 11.9 2.7 years). We examined pupillary dilatation (PD) in
darkness, an index of autonomic neuropathy, using a Polaroid pupillometer and vibration sensation threshold (VST), an index of peripheral neuropathy, using a Biothesiometer. Abnormal cut-off values
(>95% or < 5%) were calculated from control values distribution.
Results: PD impairment was more frequent in the T1DM group,
compared to controls (31.6% vs 3.3%, p < 0.001). Moreover, in the
T1DM group impaired VST were more frequent than in the controls
in the lower (left: 23.3% vs 6.7%, p < 0.001, right: 28.3% vs 4%,
p < 0.001) and upper limbs (left: 17.1% vs 2.67%, p < 0.001, right:
23.2% vs 2.6%, p < 0.001), respectively.
PD was associated with age (r = 0.16, p = 0.038), HbA1c: (r = 0.23,
p = 0.048) and diabetes duration (r = 0.20, p = 0.022). Moreover in
the whole group, older age (p < 0.001) and puberty were associated
with greater proportion of abnormal VSTs in the lower limbs in
pubertal vs prepubertal children (left: 17.7% vs 2.8%,p = 0.001, right:
19.4% vs 0.0%, p < 0.001).
Conclusion: Impaired indices of peripheral and autonomic neuropathy are present in a significant proportion of T1DM children and adolescents, although asymptomatic. Indices of diabetic neuropathy are
associated with age, diabetes duration, puberty and the quality of glycaemic control.
P003
Joint mobility, flexibility and glycemic control
in youths with type 1 diabetes mellitus
P. Francia1, B. Piccin2, M. Gulisano1, E. Casalini1, S. Toni2
School of Human Health Sciences, Florence, Italy, 2Diabetes UnitMeyer Children’s Hospital, Florence, Italy
1
Objectives: Diabetes mellitus can influence periarticular tissue and
other major risks of limited joint mobility. The aim of this study was
to investigate the presence of limited ankle joint mobility (AJM) and
flexibility in young patients with type 1 diabetes mellitus (T1DM) and
to verify its relationship with patients’ historical values of glycosylated hemoglobin (HbA1c).
Methods: Foot plantar and dorsal flexion was evaluated using an inclinometer while flexibility was evaluated by the sit and reach test in
35 young patients with T1DM, (22/13:M/F), mean age 14.3 3.7 yrs;
diabetes duration 7.2 3.9 yrs, BMI 20.2 3.5 (kg/m2), and in 53 young
healthy subjects, (31/22:M/F), mean age 13.9 3.5 yrs, BMI 19.4 3.3
(kg/m2). AJM and flexibility were compared to patients’ HbA1c values of
the previous two years (baseline, and the 8 previous quarters).
Results: The patients’ ankle ROM was significantly lower than that in
controls (140.0 17.1 vs 121.4 21 ; p < 0.001). Both plantar
wileyonlinelibrary.com/journal/pedi
Pediatric Diabetes October 2016; 17 (Suppl. 24): 36–164
37
POSTER TOURS
flexion (35.3 6.5 vs 28.2 7.3 ; p < 0.001) and dorsal flexion
(104.7 12.8 vs 93.2 16.2 ; p < 0.001) were higher in control
group than in the patient groups. Patients’ AJM and the only dorsal
flexion underlined a growing inverse correlation to HbA1c that
becomes significant only on the basis of the values from 2 years
before (r = −0.40; r = −0.41; p < 0.05). Patients’ flexibility was not
correlated with HbA1c values of the period considered (previous
2 years) but it was directly associated with the total AJM (r = 0.40;
p < 0.05) and plantar flexion
(r = 0.50; p < 0.01). In healthy control subjects, flexibility was only
correlated with the total AJM.
Conclusions: The most interesting result of this pilot study is the
growing inverse relationship between the patient’s AJM and the
HbA1c values as they become progressively farther from the joint
mobility evaluation date. The overall data, also indicate a typical negative effect of diabetes on ankle plantar flexion.
P004
Levels of connective tissue growth factor as an
early marker of microvascular complications in type
1 diabetes mellitus
M. El Samahy1, A. Adly1, E. Ismail2
1
Ain Shams University, Pediatrics, Cairo, Egypt, 2Ain Shams University,
Clinical Pathology, Cairo, Egypt
Background: The risk for micro- and macrovascular complications is
high in young patients with childhood-onset type 1 diabetes. Growth
factors have been suggested to play a role in the development and
progression of diabetic nephropathy.
Aim: To explore level of connective tissue growth factor (CTGF) in
children and adolescents with type 1 diabetic patients and its relation
to inflammation, glycemic control, microvascular complications and
carotid intima media thickness (CIMT).
Methods: Sixty children and adolescents with type 1 diabetes were
divided into 2 groups according to the presence of micro-vascular
complications and compared with 30 age- and sex-matched healthy
controls. High sensitivity C-reactive protein (hs-CRP), HbA1c, urinary
albumin creatinine ratio (UACR), CTGF and CIMT were assessed.
Results: CTGF levels were significantly elevated in all diabetic patients
whether patients with micro-vascular complications (85.26 23.06
ng/ml) or those without complications (50.64 11.47 ng/ml) compared with healthy controls (16.4 7.3 ng/ml) with the highest levels
found in patients with complications (p < 0.001). CIMT was significantly increased in patients with and without micro-vascular complications compared with controls (p < 0.001). CTGF levels and CIMT were
significantly increased in relation to nephropathy (microalbuminuria),
peripheral neuropathy or retinopathy. Multiple regression linear analysis showed that HbA1c, UACR and CIMT were independently related
to CTGF. The cutoff value of CTGF at >65 ng/ml could differentiate
patients with and without micro-vascular complications with a sensitivity of 100% and specificity of 93.3%.
Conclusions: CTGF may be considered as an early marker of microvascular complications and subclinical atherosclerosis that could identify normoalbuminuric patients at high risk for diabetic renal disease
later in life.
P005
Adiposity and lipid intake, in addition to HbA1c
levels, increase the cardiovascular risk in children
and adolescents with type 1 diabetes
C. Maffeis1, A. Morandi1, E. Fornari1, A. Sabbion1, F. Tomasselli1,
C. Piona1, M. Marigliano1
1
Pediatric Diabetes and Metabolic Disorders Unit - University of Verona,
Verona, Italy
Objectives: To test the hypothesis that diet composition and adiposity could independently contribute to increase the cardiovascular risk
(CVR) of children/adolescents with type 1 diabetes (T1D), independently from confounders, in a sample of children and adolescents.
Methods: 180 children and adolescents with T1D (age range:
5–18 yrs) were enrolled. Diet (3-day weighed dietary record), physical
(height, weight, WC, BIA) and biochemical (HbA1c, lipid profile) parameters were measured. Energy intake (EI)/predicted basal metabolic
rate (pBMR) was used for excluding food intake under-reporters. A
multiple regression model, using non-HDL cholesterol as the dependent variable and HbA1c, FM%, lipid intake (%EI), and gender as independent ones was also calculated.
Results: Non-HDL-cholesterol was significantly associated with adiposity (FM; r = 0.27, P < 0.001), body fat distribution (WhtR,
r = 0.16, P < 0.05), lipid (%EI; r = 0.25, P < 0.05) and carbohydrate
(%EI; r = −0.24, P < 0.05) intake, and blood glucose control (HbA1c;
r = 0.24, P < 0.05). No significant correlation was found between
non-HDL-cholesterol and age, duration of diabetes, energy, protein
and carbohydrate intake, blood pressure, insulin requirements,
EI/pBMR and biochemical parameters other than HbA1c. Multiple
regression analysis showed that adiposity (FM), blood glucose control
(HbA1c) and lipid intake independently contributed to explain the
inter-individual
variability
of
the
non-HDL
cholesterol
(R2 = 0.164, p < 0.05).
Conclusions: Obesity, diet and HbA1c have an independent effect
on the non-HDL cholesterol, a gross index of CVR, in children and
adolescents with T1D. Therefore, intervention for reducing the CVR
in T1D patients should be focused not only on glycometabolic control
(HbA1c), but also on adiposity and lipid intake.
P007
Glycoalbumin (GA) / HbA1c ratio as a non-glycemic
predictor for complications
S. Amemiya1, T. Hoshino2, M. Mochizuki3, I. Musha1, J. Akatsuka1,
T. Kikuchi1, S. Sugihara4, the Japanese Study Group of Insulin
Therapy for Childhood and Adolescent Diabetes
1
Saitama Medical University, Pediatrics, Saitama, Japan, 2Institute of
Biopathological Medicine, Kanagawa, Japan, 3Yamanashi University,
Pediatrics, Chuo, Japan, 4Tokyo Women’s Medical University Medical
Center East, Pediatrics, Tokyo, Japan
Objectives: While HbA1c is established as a gold standard of glycemic control, we proposed GA/HbA1c ratio inversely highly related
with glycation gap for complications predictor1). We aimed to clarify
GA/HbA1c ratio as a non-glycation index using the most suitable
standardized HbA1c values.
Methods: We evaluated GA/HbA1c ratio as a non-glycation index
using NGSP (A1C) or IFCC (GHb) numbers as internationally harmonized standardized HbA1c values, compared with GA/HbA1c
ratio using KO500 (spA1C) number in Japan 2). Three standardized
numbers were obtained by mutual master equations. Clinical data
of simultaneously measured GA and HbA1c values in Japanese
pediatric T1D patients (n = 396) and their siblings (n = 65) were
analyzed.
Results: Correlations between GA/HbA1c ratios and HbA1c values
in patients were:
r = +0.3(p < 0.0001), r = −0.12(p =0.0173) and r = 0.001
(p =0.0983), using A1C, GHb and spA1C numbers respectively. Comparisons of means (SD) in GA/HbA1c ratios between patient and sibling groups were: 3.30(0.30) vs. 2.62(0.21), p < 0.0001, 6.76(0.60)
vs. 7.13(0.72), p < 0.0001 and 8.11(0.71) vs. 8.27(0.77), p not significant, using A1C, GHb and spA1C numbers respectively.
Conclusions: The spA1C number but neitherA1C nor GHb number
may be applied for the GA/HbA1c ratio as a non-glycation index,
depending on what is measured as HbA1c in each standardization.
The spA1C detects specific single Hb molecule glycated only at Nterminal valine of beta-chain. The A1C partly includes non-glycated
Hb molecules. The GHb measures all Hb molecules glycated at Nterminal valine but also glycated and modified at other sites. Thus we
propose the individual intrinsic GA/spA1C ratio predicting complications risk in Japanese pediatric T1D population. If the distribution of
38
GA/spA1C ratio in other population were obtained, risk factors could
be analyzed among populations, while glycation gap could not be
compared each other. Ref. 1) Endocr J 62:161, 2015, 2) J Diabetes
Invest 3:39,2012
P008
Do HLA-type, autoantibodies and C-peptide level at
diagnosis of type 1 diabetes correlate to the risk of
early microvascular complications?
J. Anderzén1,2, K. Åkesson3, A. Carlsson4, L. Hanberger5,
E. Örtqvist6,7, G. Forsander8, I. Kockum8, H. Elding Larsson9, Å.
Lernmark9, J. Ludvigsson10, C. Marcus11, S.A. Ivarsson9,
U. Samuelsson10
1
Ryhov County Hospital, Department of Paediatrics, Jönköping, Sweden,
Futurum - the Academy of Health and Care, Jönköping, Sweden,
3
Futurum - the Academy of Health and Care, Department of Paediatrics,
Jönköping, Sweden, 4Lund University, Department of Clinical Sciences,
Skåne University Hospital, Lund, Sweden, 5Linkøping University,
Department of Medicine and Health Sciences, Division of Nursing,
Linköping, Sweden, 6Department of Women’s and Children’s Health,
Karolinska Institutet, Stockholm, Sweden, 7Pediatric Diabetes Clinic,
Astrid Lindgren Children’s Hospital, Karolinska University Hospital,
Stockholm, Sweden, 8Department of Clinical Neurosciences, Karolinska
Institutet, Stockholm, Sweden, 9Department of Clinical Sciences, Lund
University/CRC, Skåne University Hospital SUS, Malmö, Sweden,
10
Linkøping University, Department of Paediatrics and Department of
Clinical and Experimental Medicine, Linköping, Sweden, 11Division of
Pediatrics, Department of Clinical Science, Intervention and Technology
Karolinska Institutet, Stockholm, Sweden
2
POSTER TOURS
Objectives: To study if HLA-type, autoantibodies (AAB) and cpeptide level at diagnosis correlate to microvascular complications in
young adults.
Methods: Data on 314 subjects diagnosed with T1D in Sweden
before 18 years of age was retrieved from the BDD (Better Diabetes
Diagnosis) study regarding HLA-type, AAB (GADA, IAA, IA2A and
ZNT8RA, −8WA, −8QA) and C-peptide. Data on microvascular complications was retrieved from the National Diabetes Registry (NDR).
Results: Lower C-peptide values at diagnosis and after 1 year were
found in patients with AAB. Patients negative for all AAB at diagnosis
had a mean C-peptide value of 1.21 1.1 compared to 0.36 0.28
in patients positive for one or several AAB, p < 0.001. The c-peptide
level at diagnosis and after 1 year did not differ significantly between
patients who developed microvascular complications or not. Only
GADA related to retinopathy; 37.5% vs 27.9% in GADA negative
patients, p = 0.06. Albuminuria showed an opposite pattern; 10% of
GADA positive patients had albuminuria compared to 15 % of the
GADA negative patients, p = 0.06. HLA was not related to retinopathy or albuminuria. A higher proportion of females was positive for
GADA; 71.9 % vs 57.4%, p < 0.01. Females more often had retinopathy; 40% vs 29.9%, p < 0.05. There was no gender difference regarding albuminuria; 12 % vs 12.5 %.
Conclusion: The higher c-peptide level in those without AAB at diagnosis can indicate a lower degree of inflammation, but does not seem
to protect against early microvascular complications. The risk of retinopathy is higher in those with GADA at diagnosis but there is no
indication that HLA-type, other AAB or the c-peptide level influence
the risk of early microvascular complications. The increased risk of
retinopathy in females may be due to the fact that more girls are
GADA positive. The GADA positive individuals, especially the
females, might be a group that needs to be carefully followed with
fundus photography.
39
POSTER TOURS
Poster Tour 2: Diabetes Care
P009
Total IgE levels are unexpectedly high in pediatric
and adolescent type 1 diabetes patients
D. Mul1, Q.J. ten Kate1, H.J. Veeze1, H.J. Aanstoot1
1
Diabeter, Center for Pediatric and Adolescent Diabetes Care and
Research, Rotterdam, Netherlands
According to the Th1/Th2 hypothesis it would be unlikely to have
allergy in type 1 diabetes (T1DM) patients. The frequent clinical
observation of high total immunoglobulin E (IgE) levels in many
T1DM patients prompted us to study the epidemiology of IgE levels
in our patient group.
Objective: We studied total IgE levels inT1DM patients together
with other markers of auto-immunity.
Methods: Retrospective patient file analysis from our electronic
patient management system. We evaluated the first total IgE measurement in the first decade after diagnosis in T1DM patients, who
were treated in our diabetescenter between 2006 and 2016. Other
types of diabetes were excluded. Distribution of IgE levels was
assessed per age group and correlated with other markers of autoimmunity. IgE-levels > 100 kU/L were considered to indicate atopy.
The upper limit of the total IgE assay was increased from 2000 to
5000 kU/L in the period of evaluation.
Results: n = 1388 patients (51.4% male), median age 12.1 years (IQR
7.61), median duration of T1DM 2.1 years (IQR 4.95). Distribution
per age group: see table 1. In the youngest age group the 95% confidence interval did not exceed 100 kU/L
Age group (yr)
0-5
5-10
10-15
15-20
20-25
Number of patients
136
345
502
297
69
Total IgE-level
(kU/L)(median
[IQR]
24.5
[67.0]
89.0
[208.5]
84.5
[247.5]
80.0
[213.0]
37.0
[127.5]
%patients with
IgE > 100 kU/L
21.3
47.0
45.0
46.1
33.3
1
We did not find a significant correlation of total IgE level with GAD
antibody level (n = 1129) nor with anti thyroid peroxidase (aTPO)
level (n = 1370).
Conclusions: In patients with T1DM, total IgE levels are high when
compared to reference values in most age groups. Nearly half of the
patients between 5 and 20 years showed IgE levels in the atopic
range. These data do not support the classical Th1/Th2 hypothesis
and the reason for the high levels needs further clarification.
P010
Impact of telemedicine on glycemic control and
family satisfaction in children and adolescents with
type 1 diabetes: effects 1 year after stopping
telemedicine support
P. Ros1, N. Lacamara1, E. Colino2, A. Ruiz3, L. Golmayo3,
I. Martinez-Badás3
1
Hospital Universitario Puerta de Hierro, Pediatric Endocrinology,
Madrid, Spain, 2Hospital San Rafael, Madrid, Spain, 3Hospital
Universitario Puerta de Hierro, Madrid, Spain
Age (years)
Gender (girls/boy
P011
Glycemic variability and metabolic control
measured by CGMS in a sample of type 1 diabetics
J. Oliveira1, S. Fernandes1, R. Santos Silva2, C. Costa2, C. CastroCorreia2, M. Fontoura2
[Distribution total IgE levels]
Group
Introduction: Telemedicine (TM) offers potential solutions to connect
providers and patients, especially those who are geographically distant.
Although TM represents a useful and cost-effective solution to the
strict follow-up required in pediatric diabetes type 1 (TD1) management, there are few applications of TM in the pediatric population.
Objective: To investigate family satisfaction and the impact on the
glycemic control of TM support during 1 year (telephone consultations, text messages, e-mails) and 1 more year of follow up after
interrupting the intervention, in pediatric patients with TD1
Patients and Methods: We included 32 patients in a program of TM
glycemic control from December 2011 to December 2012:
group 1 (≤1 year after diagnosis of TD1, n = 13; 7 girls and
6 boys) and
group 2 (>1 year after diagnosis, n = 19, 8 girls and 11 boys) (6 and
12, respectively, in Tanner stage III). All patients received TM support
for 1 year. Satisfaction scores were calculated by specific questionnaires
(ESCP Europe) submitted at the end of the 1 year period. HbA1c
(HPLC, Menarini, normal range 5.3 0.2%) was measured at 6 months
and 1 year after inclusion and 1 year after stopping TM support.
Results: TM support was generally well accepted by patients and
their families and glycemic control was adequate in both groups during the intervention and 1 year after its interruption. However we
found a significant increase in HbA1c levels between 6 months after
initiating TM and 1 year after stopping it in both groups
(p < 0.05)(Table 1).
Conclusions
1. TM support of patients with TD1 is well accepted by patients and
their families.
2. TM could be an alternative to in-person visits for adequate glycemic control, especially during the first six months of follow up.
Time after diagnosis (years
Integrated Pediatric Hospital, São João Hospital, Porto, Portugal, 2Unit
of Pediatric Endocrinology and Diabetes, Integrated Pediatric Hospital,
São João Hospital, Porto, Portugal
Introduction: The concept of glycemic variability has assumed an
increasing importance as it has been documented an association with
an increased risk of complications in patients with type 1 diabetes.
HbA1c, a parameter used in clinical practice to assess metabolic control, does not allow to evaluate glycemic variability. Continuous glucose monitoring systems (CGMS) has an important role in the
evaluation of this instability.
Methods: The data analyzed is obtained using a CGMS during 5 and
7 days in type 1 diabetic patients. The glycemic control is evaluated
using HbA1c, glucose average, AUC > 140 and < 70 mg/dL. Glycemic
variability is measured through SD and with the relation coefficient. It
was analyzed the number of asymptomatic hypoglycemia and the
percentage of time in hypoglycemia at night.
Results: Sample composed by 23 patients (average age - 11,9 years,
43.5% male), selected by clinical suspicion of glycemic instability,
18 patients in treatment with multiple insulin administrations and
5 patients in treatment with continuous insulin infusion system. The
results were: HbA1c - 8%, glycaemia - 195 mg/dL, SD - 75, coefficient
HbA1c (%)
HbA1c (%)
HbA1c (%)
HbA1c (%)
1 year after stopping
baseline
6 months
1 year
1
9.6 4.2
7/6
0.6 0.4
12.6 0.1
6.7 0.6
7.4 0.6
7.5 0.8
1
11.8 3.9
8/11
2.8 2.5
6.7 0.1
6.9 0.6
7.4 0.9
7.5 0.5
40
of variation - 0.38, asymptomatic hypoglycemia - 2.4, nocturnal hypoglycemia time - 10%, AUC < 140–66.37, AUC < 70–0.73. Comparing
patients with HbA1c ≤ 7,5% and HbA1c > 7,5%, The authors did not
find differences with statistical significance, regarding AUC > 140
or < 70, number of asymptomatic hypoglycemia, SD, coefficient of
variation and the percentage of nocturnal hypoglycemia.
Discussion: Our sample shows that the glycemic variability is very
important even in patients with HbA1c ≤ 7,5%. The AUC > 140 is
high but AUC < 70 seems closer to the desirable, although there is
an average of 2 asymptomatic hypoglycemia per patient and an average percentage of nocturnal hypoglycemia of 10%. Despite the small
sample, the authors observed a huge glycemic instability and this
evaluation provided important therapeutic settings.
P012
Unexplained hypoglycaemia in an adolescent with
type 1 diabetes - simple insulin overdose or
adnormal insulin binding?
E.M. Bayman1, S.E. Kiff1, D.S. Church2, R.K. Semple2, K.J. Noyes1,
C. Clarke3, L.E. Bath1
1
Royal Hospital for Sick Children, Department of Endocrinology and
Diabetes, Edinburgh, United Kingdom, 2University of Cambridge,
Metabolic Research Laboratories. Wellcome Trust-MRC Institute of
Metabolic Science, Cambridge, United Kingdom, 3Western General
Hospital, Clinical Biochemistry, Edinburgh, United Kingdom
Introduction: A 12 year old girl with type 1 diabetes treated with
insulin aspart via pump therapy presented with unexplained hypoglycaemia. This persisted after a change to basal bolus with aspart and
detemir. Plasma insulin concentration was 914 pmol/L following
hypoglycaemia on aspart alone, but 31,878 pmol/L following hypoglycaemia on basal bolus. Episodes were so frequent, the patient
ceased prescribed insulin for 72 hours, culminating in hospital admission for investigation. Excess exogenous insulin was suspected but
denied. During admission she was consistently hyperglycaemic and
insulin was re-started. Serial plasma insulin levels over a 3 month
period on basal bolus were 15,327-32,243 pmol/L, often without
hypoglycaemia and despite close supervision of injections. Studies
were undertaken to explain the excessive insulin levels found with
detemir.
Methods:
• Direct measurement of anti-insulin IgG (ImmunoCAP human specific method)
• Polyethylene glycol insulin studies to estimate free monomeric
insulin
• Gel filtration chromatography (GFC) studies to separate insulin
species according to size
Results:
• Anti-insulin IgG level undetectable, < 0.02 mg/L
• Insulin recovery < 3% post PEG precipitation
• GFC showed predominantly high molecular weight insulin. Addition ex-vivo of high concentration detemir to control plasma did
not replicate this
• Follow-up studies after 3 weeks of aspart monotherapy showed
insulin level of 966 pmol/L and no high molecular weight insulin
on GFC
Conclusion: 95-99% of detemir is bound to albumin, thus measured
plasma detemir will overestimate free insulin. However, this patient´s
levels were highly atypical. The results are consistent with insulin
binding by an antibody not detected by the human specific assay.
Immunosubtraction studies to support this theory are pending.
Insulin binding antibodies are rare but should be considered in
cases of labile glycaemic control where the clinical features and biochemistry are suggestive.
POSTER TOURS
P013
International HbA1c benchmarking in type
1 diabetes: Do we need to report between-clinic
variation in addition to national average values?
D. Charalampopoulos1, J.M. Hermann2,3, J. Svensson4,
T. Skrivarhaug5, D.M. Maahs6, K. Akesson7, J. Warner8, R.W. Holl2,3,
N. Birkebæk9, A.K. Drivvoll5, K. Miller10, A.-M. Svensson11,
T. Stephenson1, S. Hofer12, S. Fredheim4, S.J. Kummernes5,
N. Foster10, L. Hanberger13, R. Amin1, B. Rami-Merhar14,
A. Johansen15, K. Dahl-Jørgensen16, M. Clements17,18,19,
R. Hanas20,21
1
University College London, Institute of Child Health, London, United
Kingdom, 2Institute of Epidemiology and Medical Biometry, ZIBMT, Ulm
University, Ulm, Germany, 3German Center for Diabetes Research (DZD),
München-Neuherberg, Germany, 4Herlev University Hospital, CPHDirect, Pediatric Department, Herlev, Denmark, 5Norwegian Childhood
Diabetes Registry, Division of Paediatric and Adolescent Medicine, Oslo
University Hospital, Oslo, Norway, 6Barbara Davis Center for Childhood
Diabetes, Aurora, CO, United States, 7County Hospital Ryhov, Jönköping
Academy for Improvement of Health and Welfare, Jönköping University,
Department of Pediatrics, Jönköping, Sweden, 8Children’s Hospital for
Wales, Department of Paediatric Endocrinology and Diabetes, on behalf
of the National Paediatric Diabetes Audit (NPDA) and the Research and
Policy Division of the Royal College of Paediatrics and Child Health
(RCPCH), Cardiff, United Kingdom, 9Aarhus University Hospital,
Department of Pediatrics, Aarhus, Denmark, 10Jaeb Center for Health
Research, Tampa FL, United States, 11Centre of Registers in Region
Västra Götaland, Gothenburg, Sweden, 12Medical University of
Innsbruck, Department of Pediatrics 1, Innsbruck, Austria, 13Div. of
Nursing, Linköping University, Department of Medicine and Health
Sciences, Linköping, Sweden, 14Medical University Vienna, Department
of Paediatrics, Vienna, Austria, 15Copenhagen University, Department of
Growth and Reproduction, Copenhagen, Denmark, 16Division of
Paediatric and Adolescent Medicine, Oslo University Hospital and
Institute of Clinical Medicine, University of Oslo, Oslo, Norway,
17
Children’s Mercy Hospital, Kansas City, Missouri, United States,
18
University of Missouri - Kansas City, Kansas City, Missouri, United
States, 19University of Kansas Medical Center, Kansas City, KS, United
States, 20NU Hospital Group, Uddevalla, Sweden, 21Sahlgrenska
Academy, Institute of Clinical Sciences, University of Gothenburg,
Gothenburg, Sweden
Objectives: To compare national HbA1c means and measures of
between-clinic variation across eight countries.
Methods: Data were collected between 2013/14 from 63021
children < 18 years with type 1 diabetes across 527 clinics in Germany (n = 19732) and Austria (n = 1570) from the Prospective Diabetes Follow-up Registry, England (n = 20751) and Wales (n = 1281)
from the National Paediatric Diabetes Audit, USA (n = 10815) from
the T1D Exchange, Sweden (n = 4680) from the Swedish Pediatric
Diabetes Quality Registry, Denmark (n = 1877) from the Danish
National Diabetes Registry, and Norway (n = 2315) from the Norwegian Childhood Diabetes Registry. Completeness rates for HbA1c ranged from 77.2% to 99.8%. HbA1c means and measures of betweenclinic variation were compared across countries before and after
adjustment for case-mix (age, gender, diabetes duration, minority status). Multi-level models were used to calculate the % of total variance
in HbA1c which occurs between clinics (intra-class correlation-ICC) in
each country.
Results: The crude mean HbA1c ranged from 57 mmol/mol [7.4%] in
Sweden to 72 mmol/mol [8.8%] in Wales. Germany had the second
lowest mean HbA1c (61 mmol/mol [7.8%]) but showed the largest
between-clinic variation (Interquartile Range-IQR = 57-65 mmol/mol
[7.4-8.1%]). Norway and Sweden had the lowest between-clinic variation (IQR = 64-68 mmol/mol [8.0-8.3%] and 56-59 mmol/mol [7.37.6%]). When clinic characteristics in case-mix variables were compared, Germany showed the largest between-clinic variation in age
and diabetes duration and England in ethnic minority status. Casemix adjustment had a small impact on national averages. Adjusted
ICC ranged from 1.8% in Norway to 16.6% in Germany.
41
POSTER TOURS
Conclusion: Differences in HbA1c between countries are better
understood if national averages are interpreted together with measures of between-center variation. Exploring sources of this variation
should be a key priority for improving glycemic control in children
with type 1 diabetes.
P014
Impact of glycemic control and diabetic
complications or comorbidities on health related
quality of life (HRQoL) in pediatric patients with
type 1 diabetes mellitus (T1DM) and their
caregivers in Spain
L.A. Vázquez1, J. López-Bastida2,3, M. Perez-Nieves4, J. Oliva-Moreno5,
R. Villoro2, T. Dilla1, M. Merino2, H. Sapin4, I. Aranda2,5, J. Reviriego1,
J.P. López-Siguero6
1
Lilly Spain, Madrid, Spain, 2Hospital Universitario Carlos Haya, Málaga,
Spain, 3Instituto Max Weber, Madrid, Spain, 4Universidad de Castilla-La
Mancha, Ciudad Real, Spain, 5Eli Lilly and Company, Indianapolis, United
States
Objective: To assess HRQoL for paediatric patients with T1DM and
their caregivers, and evaluate how glycaemic control and diabetic
complications or comorbidities (DCC) affect HRQoL in this
population.
Methods: CHRYSTAL observational study was conducted in 2014 on
a representative sample of 275 patients aged 1–17 years diagnosed
with T1DM in Spain. Patient/caregiver pairs were stratified by
patient’s glycaemic control based on HbA1c level and by the presence or absence of DCC. The generic preference-weighted instrument EQ-5D was used to evaluate quality of life. EQ-5D measures
5 dimensions (mobility, self-care, daily activities, pain/discomfort, and
depression/anxiety). Responses were converted into utility scores
along a continuum extending from death (0.0) to full health (1.0).
Results: HRQoL measured by EQ-5D for overall population and stratified by glycaemic control and presence or absence of DCC are
shown in table 1. In the overall population, the most affected HRQoL
dimension in caregivers was depression/anxiety (34.8% of respondents reported some degree), followed by pain/discomfort (34.3%). In
children, the most affected dimension was pain/discomfort (18.2%
experienced “some” or “a lot”), followed by depression/anxiety (14.6%).
Conclusions: Glycaemic control and the presence of DCC may
impact HRQoL of paediatric patients with T1DM and their caregivers.
Health care professionals should consider these results in their interactions with T1D children and their caregivers.
Table 1: HRQoL measured by EQ-5D for overall population and
stratified by glycaemic control (HbA1c < 7.5% or ≥ 7.5%) and presence or absence of DCC.
Abbreviations: HRQoL = Health-related quality of life; EQ5D5L =
EuroQol 5 dimensions 5 levels; EQ5D3L = EuroQol 5 dimensions
3 levels; VAS = visual analogue scale; SD = standard deviation.
a- Range 0 to 1, higher scores indicate better quality of life.
b- Range 0 to 100. Information inside the VAS box was used
(instead of the VAS line on the scale), as it was considered more reliable (analysts had access only to the bottom page of the scale) and it
also had more valid cases. When information inside the box was
missing, information on the VAS line was used.
P015
Body mass at type 1 diabetes (T1D) onset - a
“player” in the remission phase in children
intensively treated
A. Chobot1, K. Szyda2, J. Stompór2, M. Sokołowska3, P. Adamczyk4,
P. Jarosz-Chobot2
1
Clinical Hospital No 1, Zabrze, Poland, 2School of Medicine in Katowice,
Medical University of Silesia, Katowice, Poland, 3Upper Silesian Center of
Child’s Health, Katowice, Poland, 4School of Medicine with the Division
of Dentistry in Zabrze, Medical University of Silesia, Katowice, Poland
Objectives: Analyze frequency of T1D remission (daily insulin
requirement (DIR) < 0.5U/kg/24 hrs and HbA1c < 7%) and assess its
relation to selected clinical parameters at diagnosis.
Methods: Study covered all children (98; 50♀ ; mean age 8.0 4.1
yrs) newly diagnosed (T1D) in the regional diabetes center (Katowice,
Poland) in 2013. We analyzed at T1DM onset: gender, age, age
groups (0-4/4-9/10-14/>15 yrs), weight, height, HbA1c, C-peptide,
blood pH, GAD, IAA, IA2, ICA antibodies and presence of other autoimmune diseases. All children received initially insulin intravenously
and continued directly with intensive insulin treatment targeting
nearly normoglycemia (with CHO counting). Patients were followed
up every 3 months: HbA1c, DIR. Statistica (StatSoft, Inc.) was used
for analysis, p < 0.05 considered as significant.
Results: At T1D onset mean weight and height were 0.24 0.99
and 0.88 1.31 SDS respectively. Mean HbA1c was 11.6 2.2%
and C-peptide 0.48 0.4 ng/ml; 34(35%) children had diabetes
ketoacidosis (DKA). 17(17%), 27(28%) and 54(55%) children had
respectively 1, 2 or ≥3 positive autoantibodies and 17(17%) had an
additional autoimmune disease.
60(61%) patients (33♀ ) entered remission that started 2.2 2.68
(0–10) mths after diagnosis. Its duration was 9.7 6.26 (2–31) mths.
Remitters had higher body mass than non-remitters (0.44 1.02 vs
−0.07 0.86 SDS, p = 0.011) and were less common to have another
autoimmune disease (10 vs 29%, p = 0.019). Other parameters did not
impact remission occurrence (tendency that children with DKA at onset
are less likely to enter remission than those without DKA, not significant: 45 vs 29%, p = 0.11). Duration of remission and time to its occurrence were not related to the analyzed parameters. Multivariate
analysis confirmed the results of the univariate analysis.
Conclusions: Remission occurred in more than half children with
newly diagnosed T1D. Weight seems to be a factor influencing remission occurrence in intensively treated children.
MNiSW grant IP2012 007672
P016
Improving the use of medical identification devices
(MID) in children with type 1 diabetes (T1DM)
N. Hecht Baldauff1, M. Vargas Trujillo2, M. Pozgaj Sepec3, J. Popovic1
1
Children’s Hospital of Pittsburgh University of Pittsburgh Medical
Center, Pittsburgh, United States, 2Rady Children’s Hospital University of
California San Diego, San Diego, United States, 3University Hospital
Centre Sestre Milosrdnice, Zagreb, Croatia
Background: Children with T1DM are at risk for acute diabetesrelated morbidity and mortality. The use of MIDs improves the
Primary Caregiver HRQoL
(EQ-5D-5 L)
Overall Mean (SD)
HbA1c <7.5% Mean (SD)
HbA1c ≥7.5% Mean (SD)
No DCC Mean (SD)
DCC Mean (SD)
UTILITY INDEX -a
0.92 (0.14)
0.92 (0.13)
0.91 (0.14)
0.92 (0.14)
0.90 (0.12)
VAS SCORE -b
81.68 (15.89)
83.62 (15.32)
78.90 (16.33)
82.78 (15.34)
77.66 (17.29)
Proxy of Child´s HRQoL
as Perceived by
Caregiver (EQ5D3L)
Overall Mean (SD)
HbA1c <7.5%
Mean (SD)
HbA1c ≥7.5%
Mean (SD)
No DCC
Mean (SD)
DCC Mean (SD)
UTILITY INDEX -a
0.94 (0.15)
0.94 (0.15)
0.93 (0.16)
0.95 (0.14)
0.90 (0.19)
VAS SCORE -b
86.13 (13.57)
88.03 (12.94)
83.34 (14.03)
86.84 (13.09)
83.59 (15.02)
42
chances of receiving prompt and adequate treatment for diabetes
related emergencies or during a catastrophic event. It has been
shown that compliance to MIDs in children with TIDM is low, but to
our knowledge, studies evaluating the barriers for compliance to
MIDs in this population have not been published in the English
literature.
Objective: We conducted a quality improvement study to
1) evaluate patient compliance to the use of MIDs and
2) to understand the barriers and limitations for its use in order to
focus efforts to improve patient adherence in the future.
Method: Patients and their families in a large Diabetes Center in the
US filled out a questionnaire
(Figure 1) during a routine diabetes clinic visit. The questions
assessed patients’ and families’ awareness of MIDs, compliance to its
use, and barriers to using it for those of them not using one.
POSTER TOURS
Results: A total of 516 families completed the questionnaire,
437 families (84.5%) reported awareness of MIDs and 41.7%
(n = 215) of patients were not using a MID. The main barriers identified were a lost or damaged MID and financial difficulties to purchasing MID, followed by patient refusal to wear an MID. One hundred
and sixty two families (31.4%) endorsed interest in learning about
MIDs or receiving resources to obtain one.
Conclusion: Compliance to the use of MIDs in the pediatric diabetic
population in our Diabetes Center is poor and lack of access due to
financial reasons seems to be a significant limitation for its use. Our
data is likely a reflection of the use of MIDs in other centers around
the country. We speculate that mandatory insurance coverage for
MIDs would improve compliance to its use, and thus, decrease diabetes related morbidity and mortality in acute or catastrophic situations.
Education on the importance of wearing a MID should be part of
ongoing diabetes education.
43
POSTER TOURS
Poster Tour 3: Diabetes Education
P017
A picture-based carbohydrate-counting resource for
Somalis
M. Sunni1, C. Brunzell1, J. Kyllo2, L. Purcell3, P. Plager1, A. Moran1
1
University of Minnesota, Minneapolis, United States, 2Children’s
Hospitals and Clinics of Minnesota, St Paul, United States, 3LorenPurcell.
com-Graphic Artist, Minneapolis, United States
Background: Carbohydrate counting is an essential routine task in
effectively managing type 1 diabetes (T1D). Carbohydrate-counting
references specific to the Somali diet are lacking and this has been
identified by families as a barrier to effective diabetes control.
Objective: To develop a picture-based carbohydrate-counting
resource for individuals with T1D in the Somali community.
Methods: The traditional Somali foods described in this project were
selected using a variety of methods. Serving sizes and carbohydrate
calculations were tabulated using the United States Department of
Agriculture National Nutrient Database for Standard Reference. Calculations of carbohydrate content of home-prepared foods were
made by measuring total yield and total carbohydrates of all ingredients in the recipe, divided by the number of servings and the serving
size to be consumed. When a recipe was available, the food item was
prepared and analyzed for more accurate carbohydrate estimation.
Results: Photos of prepared Somali foods were compiled into a PDF
file in 2 languages, English and Somali. While the introductions are
written in text, the focus was to make this resource primarily picturebased, where possible, to be useful to individuals with limited
literacy.
The resource will be shared free-of-charge via Open Access. We
will update the resource annually with new information.
Conclusion: There is a need to tailor educational materials to meet
the needs of Somali children with diabetes. We have created a
picture-based nutrition resource for carbohydrate-counting traditional
Somali foods, and have made this freely available online through
Open Access to individuals around the world.
P018
The development of an e-learning package to
support education staff with the management of
type 1 diabetes
M.G. Williams1, C.L. Acerini2, M.E. Carson3, J.E. Haerst4, H. Nelson5,
E. O’Hickey4, S. Singleton6, K. Wilson7
1
Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust, King’s
Lynn, United Kingdom, 2Cambridge University Hospitals NHS Foundation
Trust, Department of Paediatrics, Cambridge, United Kingdom, 3North
West of England Children and Young People’s Diabetes Network, Leeds,
United Kingdom, 4Oxford University Hospitals NHS Foundation Trust,
Oxford, United Kingdom, 5JDRF, London, United Kingdom, 6Blackpool
Teaching Hospitals NHS Foundation Trust, Blackpool, United Kingdom,
7
The East of England Children and Young Person’s Diabetes Network,
Cambridge, United Kingdom
Currently in the UK children and young people with diabetes receive
variable provision of care and support in educational settings. There
are concerns that this impacts on the young person’s glycaemic control, their quality of life, and their educational performance and outcome. Whilst most paediatric diabetes teams provide training for
school staff, it may take several days, even weeks, after diagnosis
before a diabetes educator is able to attend the school to provide
education and support.
The aims of this project were to develop a comprehensive,
consensus-based, e-learning package that would inform education
providers about diabetes and provide a framework for the best
practice management and support of young people with type
1 diabetes in schools. This package was not intended to replace the
visit from the specialist nurse but to complement this and allow the
young person to return to education at the earliest possible opportunity. This was achieved by convening a series of multi-agency
stakeholder workshops including clinicians, patients / families, teachers, and voluntary sector representatives, to discuss the content
and format that this package should take. These discussions were
then developed into two e-learning modules (basic and advanced)
by a core team of diabetes educators from 3 regional diabetes
networks.
The modules provide guidance to all key parties involved in the
day to day support of young people with diabetes, including expected
roles and responsibilities, and legal obligations. The basic module is
aimed at all staff to raise their general awareness of type 1 diabetes.
The advanced module is for those staff designated specific responsibilities for supporting the young person with type 1 and goes into
greater depth regarding the management and treatment of diabetes
in the school setting. These modules have been positively received
by education providers, and are endorsed by the National Children
and Young Person’s Diabetes Network.
P019
SPECTRUM - the worldwide first manufacturer
independent education program for continuous
glucose monitoring (CGM) for all age groups
M. Holder1, B. Gehr2, S. von Sengbusch3, R. Ziegler4, K. Lange5,
SPECTRUM Group of the AGPD and AGDT in the German Diabetes
Association (DDG)
1
Klinikum Stuttgart, Olgahospital, Pediatric Diabetology, Stuttgart,
Germany, 2Fachklinik Bad Heilbrunn, Bad Heilbrunn, Germany, 3Klinik
für Kinder- und Jugendmedizin, UKSH Campus Lübeck, Lübeck, Germany,
4
Pediatric Diabetes Center Münster, Münster, Germany, 5Hannover
Medical School, Medical Psychology, Hannover, Germany
Continuous glucose monitoring (CGM) is used by an increasing number of children, adolescents and adults with type-1 diabetes in Germany, however the total number is still small. Limited uptake of CGM
in Germany includes economic and behavioural barriers, but also the
lack of a manufacturer independent structured education program for
all age groups.
Based on intensive experiences in education for decades we therefore developed such a program called SPECTRUM (“Structured
patient education and treatment program for self-reliant continuous
glucose monitoring”). It combines technical understanding with
appropriate interpretations of monitoring results. It is available in
3 versions: one for adults and two adapted for pediatric patients (parents with their children and adolescents).
In several modules (each is intended to last 90 min with detailed
curricula) all aspects of CGM use will be discussed interactively with
the users. Module 0 (introduction) informs the patients and /or their
parents about positive and possible negative experiences in long-term
CGM use to provide them with a realistic view of the benefits of this
technology beforehand. The main modules 1 to 5 cover basic knowledge about CGM, alarm-settings, glucose trend arrows, CGM usage
in everyday life and CGM software. The patients and/or their parents
get trained how to assess and download CGM data, improve CGM
use and implement it in their daily life.
Spectrum provides patients, parents and their diabetes-teams with
the opportunity to optimize CGM use in an independent and effective way. Important conditions of this new education program are
independency of manufacturers, product-neutrality and qualified,
structured information also for young people with type-1- diabetes
and their families. An evaluation of SPECTRUM will be done within
the framework of a clinical trial.
44
POSTER TOURS
P020
Factors associated with glycemic control in
children, adolescents, and young adults diagnosed
with type 1 diabetes (T1D) under 8 years of age:
the global TEENs study
L. Laffel1, B. Anderson2, D. Ozkaya3, T. Danne4, M. Phillip5,
R. Hanas6, C. Mazza7, S. Waldron8, R. Beck9, C. Mathieu10
Joslin Diabetes Center, Boston, United States, 2Baylor College of
Medicine and Texas Children’s Hospital, Houston, United States, 3Sanofi,
Paris, France, 4Children’s Hospital ’Auf der Bult’, Hannover, Germany,
5
Schneider Children’s Medical Center of Israel, Petah Tikva, Israel,
6
Gothenburg University, Gothenburg, Sweden, 7Hospital de Pediatria J P
Garrahan, Buenos Aires, Argentina, 8National Children and Young
People’s Diabetes Network, Leeds, United Kingdom, 9Jaeb Center for
Health Research, Tampa, United States, 10University Hospitals Leuven,
Leuven, Belgium
1
Objectives: Early age at T1D onset is associated with fulminant beta
cell loss, leading to future challenges with glycemic control. The
TEENs study offers a means to assess factors related to target A1c
attainment in 2503 children, adolescent and young adults diagnosed
with T1D under 8 y/o.
Methods: Participants received care in 219 centers in 20 countries;
data were collected by interview, record review and survey. A1c was
measured uniformly using A1cNow™ (Bayer). A1c was categorized:
at target (<7.5%), needs improvement (7.5-8.9%) and at-risk (≥9%).
Factors associated with A1c, adjusted for global region and age,
included demographics, management and psychosocial issues.
Results: Participants (51% male) had a mean age of 13.6 4.2 y
(range 7–25), T1D duration of 9 5 y (range 1–24) and A1c of
8.5 1.7%; 29% attained A1c target, 30% had at-risk A1c. While
age, T1D duration, sex distribution and BMI were similar across A1c
groups, demographic/family factors, management characteristics,
DKA occurrence and psychosocial issues differed significantly in the
A1c groups, with high risk or unfavorable attributes associated with
at-risk A1c (Table).
Conclusions: In this global T1D sample diagnosed < 8 y/o, >2/3 did
not achieve A1c < 7.5%. Those with at-risk A1c ≥9% had many
unmodifiable demographic/family characteristics, suggesting a need
for more education and support. Opportunities exist to improve A1c
by targeting modifiable management factors; in turn, psychosocial
issues may improve.
Study was supported by Sanofi.
P021
Challenges in paediatric diabetic care - the effect
of implementing an outpatient based new patient
education programme
C. Avann1, L. Drummond1, M. Kershaw1, R. Krone1
1
Birmingham Children’s Hospital, Diabetes, Birmingham, United Kingdom
Objectives: To assess the effect of an outpatient based new education programme for newly diagnosed patients with type 1 diabetes
on their HbA1c in the first year following diagnosis. Poor HbA1c in
the first year following diagnosis of type 1 diabetes is a predictor of
poor metabolic control and early development of complications.
Achieving good glycaemic control however requires compliant, welleducated patients. In October 2013, we introduced an outpatient
based ’Newly Diagnosed Patient Education Programme’ in which a
total of 20 sessions are delivered by the multidisciplinary team.
Methods: All patients newly diagnosed with type 1 diabetes
between October 2013-October 2014, who completed the new education programme were analysed and compared to a pre-intervention
group diagnosed January-December 2010. Data obtained included
HbA1c during the first year post diagnosis, patient demographics and
psychosocial factors.
Results: 24 patients (8 males, 16 females) were included in the study
group compared to 17 (6 males, 11 females) in the pre-intervention
group. HbA1c at diagnosis was 11.4 % for the study group compared
to 10.2% in the pre-intervention group. Whilst at 6–8 weeks similar
HbA1c levels were achieved (8.1% vs. 8.0%), HbA1c at 12 months
measured 8.1% vs. 7.6%, but a similar percentage of patients in both
groups achieved an Hba1c < 7.5% (55% vs. 53%).
Discussion: Psychosocial factors varied greatly between groups, with
the study group having higher numbers of social risk factors (split
Target A1c (<7.5%,
<53 mmol/mol) (n = 734; 29%)
A1c Needs Improvement
(7.5-8.9%) (n = 1024; 41%)
At-risk A1c (≥9%,
≥75 mmol/mol) (n = 745; 30%)
85%
82%
75%
48%
41%
37%
19%
21%
34%
Insulin dose U/kg (Mean SD)
0.9 0.3
1.0 0.3
1.1 0.4
Frequency of daily BG checks (Mean SD)
5.2 2.4
4.7 2.2
3.6 1.9
37%
34%
21%
Insulin pump Rx (%)
47%
46%
35%
Carb. counting as diet management (%)
65%
65%
58%
90%
81%
70%
3%
4%
10%
36%
45%
55%
33%
38%
46%
75 13
71 13
67 14
A1c group* (N = 2503)
Demographic/Family Factors
Living with 2 parents (%)
Parent education: University (%)
Financial problems due to T1D (%)
Diabetes Management
Exercise ≥30 minutes, 3–7 days/week (%)
Rarely missing insulin (<1 time/week) (%)
DKA in last 3 months (%)
Psychosocial Issues
Family conflict with checking BGs (%)
Family conflict with insulin Rx (%)
Diabetes QoL (Mean SD)
1
* All comparisons significant, p < 0.003
[Factors associated with glycemic control in youth]
45
POSTER TOURS
families 9 vs. 3, domestic violence 3 vs. 0, ongoing psychology support 8 vs. 2, clinical depression 2 vs. 0), impacting on diabetes management. It is encouraging that despite this, the percentage of
patients achieving HbA1c levels < 7.5% one year after diagnosis is
similar between groups.
Conclusion: Current data highlights that the service is providing care
to a socially challenging population which will need further consideration and tailoring. Long term outcomes are awaited.
P022
Goals of diabetes education: a National UK
Structured Self-Management Education Programme
H. Thornton1, F. Campbell2, F. Hanson2, V. Seagrave1
1
St Helens & Knowsley Teaching Hospitals NHS Trust, Paediatric
Department, Liverpool, United Kingdom, 2Leeds Teaching Hospitals NHS
Trust, Paediatric Department, Leeds, United Kingdom
Objective: Goals of Diabetes Education is a structured education
programme that was originally developed in 1996 in Denmark. It was
translated and first published in the UK in 2012 to fulfil the requirements of the Paediatric Diabetes Best Practice Tariff. This original
structured educational framework has been updated and enhanced
following the recent publication of NICE Guidance 18:- Diabetes (type
1 and type 2) in children and young people: diagnosis and management
(NICE 2015).
All Paediatric Diabetes Units (PDU) are required to implement a
personalised, structured education programme with the aim that all
Children & Young People (C&YP) with diabetes should receive consistent, age appropriate diabetes self-management education.
Method: A team of healthcare professionals (HCPs), supported by an
educational grant from Novo Nordisk, updated the resources for
6–18 year olds based on social learning theory. PDU team members
have received training on the use of the resources that include a written HCP guide with age related competencies, hand-outs for patients
and parents and individual record sheets to track progress. An electronic version is also available to download and includes ability to
add local hospital logo.
Results: The updated Goals of Diabetes Education Structured education programme was published in March 2016 and is endorsed by the
National C&YP Diabetes Network. Over 482 copies have been distributed to PDU’s across United Kingdom.
Conclusion: Goals of Diabetes Education is a structured education
programme that has been designed to enhance the knowledge, confidence and skills of all C&YP with Type 1 diabetes and contribute to
their physical, social and emotional wellbeing. The uptake and use of
this programme will be monitored via the C&YP’s National Diabetes
Network the Diabetes Quality Improvement Information System and
the annual National Paediatric Diabetes Audit.
P023
Number of daily blood glucose measurements is the
most influential parameter associated with good
metabolic control in children and adolescents with
type 1 diabetes
G. Maltoni1, M. Zioutas1, M. Mantuano1, A. Pession1, S. Zucchini1
1
S.Orsola-Malpighi Hospital, Department of Woman, Child and
Urological Diseases, Bologna, Italy
As only some children with type 1 diabetes (T1D) achieve target
HbA1c levels, we tried to retrospectively study parameters associated
either with good or bad metabolic control. Inclusion criteria: age
3–20 years, disease duration >2 yrs, at least 3 visits in the last year.
We examined data about age, ethnic group, parental state, disease
duration, diabetes management (CSII or MDI, daily blood glucose
measurements and boluses, CHO counting), acute complications (nocturnal hypoglycemia -NH- in the last month, severe hypoglycemia
-SH- or DKA in the last 3 yrs).
Results: 270 subjects were analyzed and divided in group A (n. 75,
HbA1c < 7.5%) and B (n. 32, HbA1c > 9%). Older age (p = 0.002),
disease duration (p = 0.035), being son of immigrants (p = 0.001) or
separated parents (p = 0.0001) were associated with group B. Group
B subjects had more NH (p = 0.0003), SH (p = 0.005) and DKA
(p = 0.011). Significant differences were in daily BG measurements
(p = 0.0001), daily boluses (p = 0.0005), CHO counting (p = 0.005).
HbA1c increased significantly (p = 0.001) moving from 0–2 BG measurements (10 1.3%), to 3–4 (8.2 1.6%), 5–9 (7.3 0.8%). CHO
counters (49 vs 58) had a better HbA1c (7.4 1.1 vs 8.4 1.6%;
p = 0.0002), measured BG more frequently (p = 0.0001), injected
more boluses (p = 0.0001) and showed less SH (p = 0.02). Subjects
on MDI (n.76) vs CSII (n.31) were not significantly distributed in the
2 groups. Multiple logistic regression identified n. of BG measurements as the most influential parameter (p = 0.005). Including the
variable separated or immigrants parents, the strongest influence was
of the former (p = 0.0007), followed by the latter (p = 0.009).
Conclusions: A higher number of BG measurements seems to be
mostly associated with a good metabolic control, followed by use of
CHO counting (probably reflecting a better compliance to a correct
intensive management). Using a pump per se is not a guarantee for
good metabolic control. Patients with separated parents or of immigrant origin are at higher risk.
P024
When pediatric patients with type 1 diabetes can
get carbohydrate counting skills?
M. Hirose1, Y. Hotta1, K. Hashimura1, Y. Kashihara1, T. Hashimoto1,
T. Higashide1, T. Kawamura1
1
Osaka City University Graduate School, Pediatrics, Osaka, Japan
Carbohydrate counting is the essential way of insulin dose adjustment for treatment of type 1 diabetes. It is unclear that when young
patients can get carbohydrate counting skills.
We conducted a questionnaire survey about carbohydrate counting
education to patients with type 1 diabetes and their parents, which
contains 10 questions as follows; age, onset age, insulin regimen
(MDI or insulin pump), who was educated carbohydrate counting
skills at the onset, age patients started carbohydrate counting, age
that patients can estimate carbohydrate amount, age that patients
can calculate their insulin dose by carbohydrate counting etc…
172 patients returned questionnaire. Mean age was 18.2 8.7
years old. Mean onset age was 8.5 6.7 years old. 55.5% of patients
use insulin pump. 43% of patients were initially educated carbohydrate counting skills for both patients and their parents, 28% were
educated only patients, and 29% were educated only parents.
92 patients started to estimate carbohydrate amount from 7 to
15 years old. The age that patient could calculate their insulin dose
with insulin to carbohydrate ratio and insulin sensitivity focused on
from 10 to 15 years old (n = 78). The duration that patients can
obtain carbohydrate counting skill (carbohydrate amount estimation
and insulin dose calculation) was within 1 years (n = 70). In the group
that patients and their parents received carbohydrate counting at the
onset, many patients could completely obtain carbohydrate counting
skills from 11 to 12 years old. In the group that only parents received
carbohydrate counting, patients also learned carbohydrate counting
skills around 11 years old.
We conclude that we should start to educate carbohydrate counting skills to pediatric patients around 11 years old, and most of them
can obtain the skills within 1 to 2 years.
46
POSTER TOURS
Poster Tour 4: Diabetes in Developing Countries
P025
Improving diabetes care in developing countries:
suggestions for ISPAD and IDF
H. Aly
School of Medicine - AIn Shams University, Department of Pediatircs,
Cairo, Egypt
Diabetes Care in developing countries has always been hindered by
limited resources. Egypt is a lower middle income country according
to latest world bank classification. Charity fund raising is enormous in
Egypt. Egypt hosted one ISPAD postgraduate course and several conferences of the Egyptian society of pediatric endocrinology and diabetes in association with the ISPAD.
Objective: To assess if providing adequate funding to a university
diabetes clinic in Egypt and the ISPAD course and conferences held
did improve diabetes care offered?
Methods: Questionnaires were used to assess process and outcome
of DM care years after providing all needed insulin and supplies for
all patients and providing doctors with detailed ISPAD-based
guidelines.
Results: more than 90% of doctors were unaware of ISPAD poster
of early DM symptoms and its´ value to prevent DKA, 80% of doctors answered that type 1 DM must present in DKA, and 56.7% of
doctors answered it should be treated with premixed insulins. Baseline mean HbA1c before any funding or education was 9.12 1.99%
and turned years later after implementing changes to be
9.12 1.7%, the change in frequency of severe hypoglycemia/
patient-years and of recurrent DKA were non significant despite the
shift to using analogues by almost 50% of patients . All patients were
on a fixed insulin regimen with frequent pitfalls in insulin dose/ timing
ordering by 88% of doctors. Another study by Ogle GD, Middlehurst
AC and Silink M assessing DM care in developing countries gave DM
care in our clinic a score between 40–59 on a scale of 100.
Conclusions: poor doctor education rather than lack of resources is
the main barrier against improving DM care in developing countries.
Postgraduate courses and collaborative conferences do not seem to
result in improved care. Perhaps integrating essential aspects of care
into schools of medicine curricula is needed, integrating online exams
as part of these courses as in West Africa courses may be useful.
P026
Cohort analysis for glycemic control and
microvascular complications of resource
constrained type 1 diabetics under regular follow
up: interim analysis at 2 year (CARE 1 study)
R. Shukla1, B. Ganguli1, D. Yagnik2, S. Shukla1, A. Joshi1,
N. Wadhwa3, CARE 1
1
Centre for Diabetes and Endocrine Diseases, Kanpur, India, 2Yagnik
Diabetes Care Center, Kanpur, India, 3AUW Global, Mumbai, India
Objectives: To examine the glycemic trends of type 1 diabetics treated under a resource constrained setting with conventional insulin
and correlate with microvascular complications of diabetic retinopathy and nephropathy
Methodology: All children, diagnosed in a geographically defined
area around Kanpur, were identified using Kanpur Diabetes Registry
Project. Patterns of HbA1c values were observed over a 2 year time
point with regular monitoring of HbA1c with periodicity of 2 months
to 4 months, as part of continuing 5 year population based study
which evaluates impact of glycemic control early in disease and age
at onset on the occurrence of incipient diabetic nephropathy and
background retinopathy
Results: CARE 1 is the interim analysis of the follow up trends for
the glycemic control at 2 years, diagnosed as T1DM between
2011–12 followed until 2012–13. These patients are under active
5 year follow up (CARE study). Data was analysed retrospectively for
glycemic control pattern of 65 patients (36 M, 29 F), mean age
17 years SD 4.2, max 21.6 yrs and min 4 yrs (95% CI 15.94, 18.07
p < 0.0001). Mean duration of diabetes 8.53 years SD 3.6 years,
min 1 year and max 18 years (95% CI 7.6, 9.4 p < 0.0001). Duration
of diabetes was comparable between males and females (p = 0.66
NS). None of the patients at the first visit had diabetic retinopathy,
which would be again investigated in 2016 to assess changes in the
retina and microalbuminuria. 18 (27.6%) patients at the first visit were
detected to have microalbuminuria and 2 patients were detected with
clinical albuminuria. HbA1c trends demonstrate a decrease from visit
1 Vs Visit 4 (mean 10.46 % Vs 9.5%), with 6 (10%) of patients with
Hba1c < 7 at the fourth visit.
Conclusions: The management of T1DM under resource constrained
population is challenging. The glycemic control in the population
detected early with the complications have to be customised with an
intense follow up with regular patient education intervention.
P027
Socio-demographic profile of children with type
1 diabetes mellitus in a newly-created children
diabetes clinic in a semi-urban Cameroonian setting
J.C. Njabou Katte1,2, M. Dehayem3, E. Sobngwi4
1
Bafoussam Regional Hospital, Children Diabetes Clinic, Bafoussam,
Cameroon, 2University of Yaounde 1, Biotechnology Center, Yaounde,
Cameroon, 3Yaounde Central Hospital, Endocrinology and Metabolic
Disease Unit. Children Diabetes Clinic, Yaounde, Cameroon, 4University
of Yaounde 1, Internal Medicine and Specialities, Yaounde, Cameroon
Objectives: Type 1 diabetes mellitus represents about 5-10% of all
cases of diabetes worldwide. Its incidence in Africa is growing due to
improvement in diagnosis. Our main objective was to assess the
socio-demographic profile of children diagnosed and followed up at a
newly created diabetes clinic.
Methods: We carried out a descriptive cross-sectional study.
Results: A total of 28 children with T1DM were seen with 15 (53.6%)
being female. The majority (71.4%) aged between 15–20 years.
Twenty-one (75%) had secondary education and 68% resided in the village. Only 42.8% live with their biological parents. Fifteen (53.7%) had
had T1DM for at least 2 years and 19 (67%) thought T1DM is caused
by excessive sugar intake. The most common recognized symptom of
diabetes was weight loss reported by 8 (28.6%). The majority 57.4%
were diagnosed in the hospital following a severe illness. More than
half, 20, have a glucose meter for self-monitoring of blood glucose
(SMBG) and same number possess a urine dipstick for ketone analysis.
Conclusions: The social profile of children with type 1 diabetes can
help to better adapt treatment options. The diagnosis of type 1 diabetes mellitus should be taught and encourage in primary healthcare
centers followed by an adapted education platform to aid the children to better manage their diabetes.
P028
High prevalence of vitamin D deficiency among
adolescents with type 1 diabetes in Indonesia and
its association with diabetic retinopathy and
nephropathy
F. Soesanti, B. Tridjaja, A. Pulungan
Universitas Indonesia, Child Health Department, Paediatric
Endocrinology, Jakarta, Indonesia
Objectives: To assess the vitamin D profile in adolescents with
T1DM and its association with diabetic retinopathy and nephropathy.
47
POSTER TOURS
Methods: We conducted a cross sectional study involving T1DM
adolescents aged 11–21 years old with duration of illness ≥ 1 year.
Factors associated with vitamin D level were assessed using questionnaire. Blood sample was collected for 25(OH)D serum level and
HbA1c measurement. Albumin/creatinine ratio was measured using
urine sample. Fundal photography was performed to assess retinopathy. Serum 25(OH)D ≥ 30 ng/ml was considered sufficient,
21–29 ng/ml was considered insufficient, while ≤ 20 ng/ml was considered deficient.
Results: Forty nine subjects (34 female and 15 male) were recruited.
Median duration of illness was five years (1–16 years). Median of
HbA1c level was 9.5% (6.3%-18%). Mean of 25(OH)D level was
12.6 5.4 ng/mL. None of the subject had sufficient 25(OH)D level,
12.2% had insufficient 25(OH)D level and 87.8% was having 25(OH)D
deficiency. Duration of sun exposure was associated with 25(OH)D
level (prevalence ratio of 13.3; 95% CI = 1.8-96, p = 0.019); while
type of clothing, sunblock, body mass index, milk and juice intake
were not associated with 25(OH)D level. Diabetic retinopathy was
found in 4 subjects (8.2%), microalbuminuria in 14 subjects (28.5%),
and nephropathy in 8 subjects (16.3%); all of which had 25(OH)D deficiency. There were no significant association between vitamin D level
with diabetic retinopathy, microalbuminuria, or diabetic nephropathy.
Conclusions: The prevalence of vitamin D deficiency among adolescents with type 1 DM is high, despite of Indonesia´s title as a sunrich country. There was no association between vitamin D level with
diabetic retinopathy, microalbuminuria, or diabetic nephropathy.
P030
Clinical profile of diabetes among children and
adolescents at a paediatric endocrine clinic in
Ghana
E. Ameyaw1
1
Komfo Anokye Teaching Hospital, Child Health, Kumasi, Ghana
Background: Limited information is available on presentation characteristics and types of youth-onset diabetes in West Africa, with no
publications from Ghana. This study determined the clinical features
of children and adolescents presenting with diabetes at Komfo Anokye Teaching Hospital (KATH) in Kumasi, a tertiary referral centre for
northern Ghana.
Methods: Retrospective review of clinical features of all children and
adolescents with new-onset diabetes seen at KATH paediatric endocrine clinic from Jan. 2012-Jan. 2014.
Results: 47 subjects presented with diabetes. 43 (91.5%) were diagnosed by clinical features and family history as type 1 (T1D), and
4 (8.5%) type 2 (T2D).
For T1D subjects, age range at diagnosis was 0.9-19.9 year (y),
peak age of onset 12–13 y, and 2.3% were < 5 y, 25.6% 5- < 10 y,
58.1% 10- < 15 y and 14.0% 15- < 20 y. 69.8% were female. Common clinical features were polyuria (100%), polydipsia (97.7%), and
weight loss (67.4%). Mean BMI was −0.55, range −3.21-2.11. 65.1%
presented in diabetic ketoacidosis (DKA). Seven had infections at
onset (skin, abscess, leg ulcer). Mean SD blood glucose was
20.1 3.9 mmol/L and HbA1c 12.1 1.8% (109 20 mmol/mol).
Two have since died - one from osteosarcoma and one from a recurrent episode of DKA.
T2D cases were 75% female, age of onset age 13–19 y. All commenced treatment with metformin, with one also on insulin. One had
substantial visual loss at diagnosis, cause not yet determined.
13.4% did not have home refrigeration, using clay pot evaporative
cooling for insulin storage.
Conclusion: In this Ghanaian series, T1D has a female preponderance
consistent with a low-incidence country, with high rates of DKA.
T2D also occurs. Typology based on clinical features alone is difficult
- atypical forms such as malnutrition-related diabetes may be occurring. Community and health professional awareness is warranted
given high DKA rates - it is likely that some with T1D are dying misdiagnosed with another condition.
P031
Knowledge assessment of type 2 Diabetes in
Pakistan
A. Fatima
Fatima Jinnah Medical University, MBBS, Lahore, Pakistan
Objective: We aim to access the baseline disease related knowledge
in patients with type 2 diabetes about their disease, its risk factors,
signs/symptoms, related complications and suitable diet. We also aim
to find if there is an association between gender, duration of disease & age at diagnosis of diabetes and the above dependent
variables.
Methods: A 20-item interview-based structured knowledge questionnaire was used to collect information in Sir Ganga Ram Hospital.
A total of 100, diabetic patients, mean age 55.2 (11.4 S.D.) years, ranging from 35–80 years, were interviewed.
Results: Statistically significant association was found between age
at diagnosis aJ1d better understanding of risk factors, (OR = 1.20,
P = 0.012 with 95% CI 0.85- 0.98). Statistically significant association was found between gender and better understanding of word
"diabetes" or "sugar" OR = 1.15, P = 0.051 with 95% Confidence
interval 0.96-1.29). Statistically significant associations were found
between gender and patients´ better understanding of disease
signs/symptoms (OR = 1.35, P = 0.005 with 95% CI 0.40-0.56). No
significant associations were found between gender, duration of diabetes, age at diagnosis and patients´ better understanding of disease
related.
Conclusion: Priority needs to be given by WHO education programmes for the development of diabetes education program in rural
areas to give patients a better knowledge of their disease, to prevent
premature morbidity and mortality associated with diabetes.
P032
Thyroid dysfunction, celiac disease, economic
impoverishment and childhood type 1 diabetes
[T1DM] in India
R. Manjunath1,2, S. Malhotra1,2,3, S. Srikanta1,4, V.A. Rao5, L. Reddy2,
T. Kamala5, K.L. Chetana2, B.D. Thyagaraj5, A. Hegde5, R. Ashok1,
C.S. Muralidhara Krishna5, K. Rajiv5, T. Deepak2, A. Sharda6, Diabetes
Collaborative Study Group: Samatvam Jnana Sanjeevini
1
Jnana Sanjeevini Medical Center and Diabetes Hospital, Diabetes,
Community Health, Bangalore, India, 2Samatvam Endocrinology Diabetes
Center, Endocrinology Diabetes, Bangalore, India, 3Disha Dosti Free
Diabetes Clinic for the Poor, Diabetes, Community Health, Bengaluru,
India, 4Samatvam Endocrinology Diabetes Center, Diabetes, Community
Health, Bangalore, India, 5Jnana Sanjeevini Medical Center and Diabetes
Hospital, Endocrinology Diabetes, Bangalore, India, 6Samatvam
Endocrinology Diabetes Center, Endocrinology Diabetes, Bengaluru, India
Objective: To analyze the challenges of diagnosing hypothyroidism
and celiac disease in economically underprivileged children with diabetes obtaining medical care at the DISHA Free Clinic, India.
International Guidelines: Autoimmune thyroid disease: All children
with T1DM; Serum TSH level + thyroperoxidase antibodies, at diagnosis and every 2 years thereafter. If Positive thyroid antibodies, thyroid symptoms or goiter: Serum TSH level + thyroperoxidase
antibodies, every 6–12 months.
Methods: DISHA: Since 1987, 3000 children provided free insulin,
syringes, health counseling, 24 h helplines. Since 2006, BG meters,
5–10 strips/month added. Basal bolus insulin 100%. Routine TSH
testing unaffordable; done only if symptoms/signs strongly positive.
DISHA + CDiC/LFAC: 2011-ongoing: [Changing Diabetes in Children and Life for a Child with Diabetes] 292 children receiving
“enhanced support” - 100 BG strips/ month, quarterly HbA1c,
annual urine albumin: creatinine ratio, TSH on enrolment and once in
1–2 years. Thyroid peroxidase antibodies and celiac disease screening
still unaffordable.
48
Results: Hypothyroidism:
Already diagnosed at enrollment to DISHA + CDiC/LFAC: 38 out
of 292 [13%]
Newly diagnosed at enrollment to DISHA + CDiC/LFAC: 26 out of
292 [9%] [Mean TSH 32 uU/ml; range: 4.5 - 150]
Total number of hypothyroid type 1 diabetes children: 64 out of
292 [22%]
“Growth decline” was associated with younger age [prepubertal],
better initial height and weight SDS and higher prevalence of newly
diagnosed hypothyroidism.
POSTER TOURS
Conclusions: There is high prevalence of hypothyroidism in T1DM
children in India, similar to west. In resource limited setting, growth
faltering in T1DM children is commonly related to undiagnosed and
untreated hypothyroidism and possibly celiac disease; malnutrition
and protein calorie deprivation are contributory. Aggressive poverty
alleviation and better health and longevity of children with diabetes
remain challenge and dream.
49
POSTER TOURS
Poster Tour 5: Diabetes Technology
P033
Insulin pump therapy in children: bolus dosing
accuracy of different insulin pumps
R. Ziegler1, P. Adolfsson2, U. Kamecke3, C. Haug3, G. Freckmann3
1
Diabetes Clinic for Children and Adolescents, Münster, Germany,
Endocrine and Diabetes Center, Halland Hospital Kungsbacka,
Kungsbacka, Sweden, 3Institut für Diabetes-Technologie Forschungs- und
Entwicklungsgesellschaft mbH an der Universität Ulm, Ulm, Germany
2
Objectives: Continuous subcutaneous insulin infusion is a common
therapy for children with type 1 diabetes. Boluses are applied to
cover meals and to correct elevated glucose values. In this study,
accuracy of the delivery of bolus doses used when treating children,
0.1U and 1U, was evaluated.
Methods: In an experimental setting following EN 60601-2-24, 4 different pumps with different insulin infusion sets (IIS) were evaluated
(Accu-Chek® Spirit Combo with Accu-Chek® FlexLink [1] and AccuChek® Rapid-D Link [2]; Accu-Chek® Insight with Accu-Chek® Insight
Flex [3] and Accu-Chek® Insight Rapid [4]; Paradigm® VeoTM with
MiniMed® MioTM [5], MiniMed® Sure-T® [6] and MiniMed® Quickset® [7]; mylifeTM OmniPod® with its IIS [8]). Pumps were installed
with the tip of the catheter in a water-filled, oil-covered beaker
placed on an electronic balance. After a run-in period, 25 successive
boluses were delivered and weighed individually. Each combination
of pump and IIS was tested 9 times with each bolus dose.
Results: The maximal error of the median bolus was 7% for 0.1U
(see Figure) and 2% for 1U.
For 0.1U the maximal deviation from target value was 64%,
whereas for 1U it was 42%. In addition there were considerable differences in the scattering of single boluses.
Objective: To determine if recent improvements in CGM performance have been associated with increased CGM use and to assess
the association between CGM use and Hemoglobin A1c (HbA1c)
among pediatric, adolescent and young adult participants in the T1D
Exchange clinic registry.
Methods: Registry data from 11,497 participants 1- < 26 years of
age with duration of T1D ≥1 year collected between May 1, 2015
and May 1, 2016 were compared with registry data collected on
15,362 participants between September 1, 2010 to August 1, 2012.
CGM use and most recent HbA1c at each data collection time point
were obtained from clinic medical records.
Results: The overall number of participants using CGM increased
from 530 (3%) in 2010–2012 to 1,802 (16%) in 2015–2016. The largest increase was observed among youth 1- < 6 years old (Figure). In
2010–2012, 41% of CGM users reported using a Dexcom device
compared with 78% among current CGM users. Mean HbA1c in
2010–2012 was 7.9% among CGM users compared with 8.6% in
non- users (P < 0.001) and among CGM users in 2015–2016 the
mean HbA1cc was 8.1% vs. 8.9% in non-users (P < 0.001).
Conclusions: CGM use has increased dramatically among youth and
young adults with T1D over the past few years likely due to
improved CGM performance. CGM users consistently have lower
mean HbA1c than non-users. However, HbA1c has worsened among
both CGM users and non-users which may be due in part to
increased duration of diabetes in most participants.
P036
The role of professional continuous glucose
monitoring in the management of type-1 diabetes
by Ipro2 device at National Institute of Child Health
Hospital, Karachi
[Bolus Accuracy 0.1 Unit]
Conclusions: The investigated insulin pumps delivered the smaller
bolus dose less accurately than the larger dose. Dosing accuracy
might be taken into account when selecting insulin pumps for the
treatment of children.
P034
Continuous glucose monitoring (CGM) use in type
1 diabetes: an update from the T1D exchange clinic
registry
K. Miller1, N. Foster1, D. DeSalvo2, L. DiMeglio3, L. Laffel4,
W. Tamborlane5, R. Beck1, for the T1D Exchange Clinic Registry
1
Jaeb Center for Health Research, Tampa, United States, 2Baylor College
of Medicine, Houston, United States, 3Indiana University School of
Medicine, Indianapolis, United States, 4Joslin Diabetes Center, Boston,
United States, 5Yale School of Medicine, New Haven, United States
M. Ibrahim
National Institute of Child Health, Endocrinology, Karachi, Pakistan
Introduction: Insulin dependent Type I Diabetes accounts for significant morbidity and mortality.Meanwhile, the value of achieving normoglycemia (or near-normoglycemia) is well-established. To that end,
many medical organizations have established aggressive targets for
glycemic control in individuals with Type-1, their HbA1c levels are
above target in the majority of patients. Continuous glucose monitoring (CGM) is a 6 days test done to evaluate diabetes control by iPro2.
Objective: To analyze the importance of Professional CGM in comparison with Self-monitoring BG meters for the management of type
1 diabetes.
Method: In this study, CGM of 5 pediatric patients with type 1 diabetes were studied by ipro2 device. This CGM test uses interstitial glucose measurements done every 5 min with a glucose-oxidaseimpregnated membrane. The CGM test by iPro2 evaluates glucose
control retrospectively with the glucose results being unknown to the
50
patient until the results are downloaded after the testing period. During this period of study, we compared highs and lows Blood sugar
level with Professional CGM and BG meters. The CGM test by iPro2
allows the practitioner and patient to evaluate the effect of diet,
physical activity, medications, and lifestyle events on glucose control
during the 6 days period.
Result: We analyzed the CGM reports of 5 patients with type 1 diabetes by ipro2 at NICH Hospital, CGMs revealed frequent and prolonged asymptomatic hypoglycemia (glucose < 60 mg/dl) and
hyperglycemia (glucose >250 mg/dl). It was concluded that use of the
CGM System may provide a means to optimize basal and bolus insulin replacement in patients with type 1 diabetes. Uncovering hyperglycemia and hypoglycemia with Professional CGM is relevant to
improvement in diabetes management.
Conclusion: Professional CGM is a valuable tool in the evaluation of diabetes control by detecting episodes of hypoglycemia and hyperglycemia.
P037
How frequent are the dermatological and technical
problems of continuous subcutaneous insulin
infusion (CSII) and continuous glucose
monitoring (CGM)?
M. Xatzipsalti, L. Mentesidou, A. Kourti, K. Patouni, D. Delis,
A. Vazeou
“P. & A.Kyriakou” Children’s Hospital, Diabetes Center, A’ Department of
Pediatrics, Athens, Greece
Objectives: To identify the frequency of dermatological and technical
problems related to the CSII and CGM use in children, adolescents
and young adults with type1 diabetes (T1D).
Methods: 58 consecutive subjects with T1D [23 males, mean age
12.8 (SD 6.9) years, median disease duration 6.4 (range 0.4-21.9)
years, median pump duration 3.6 years (range 0.05-14.7), mean
HbA1c 7.04 (SD 0.95)%], who were current or ex pump users, were
questioned by the medical staff on the existence of technical and
dermatological problems.
Results: The majority of children (96.5%) were satisfied with the
pump, 3 (5.1%) discontinued. Mean duration of catheter change was
3.2 days (range 2–5). Lipohypertrophy had 25% of subjects, lipoatrophy 1.7% and various local reactions to infusion set 55.1% [10.3%
white spots, 50% red spots, 16% red papules, 3.5% hyperpigmentation, 12% bruises, 31% pain at catheter insertion, 10.3% infection
requiring local antibiotics , 5.2% infection requiring systematic antibiotics]. Furthermore, 74.1% reported catheter malfunction at least
once during the last year (55.1% kinked catheter, 15.5% leaking,
72.4% catheter detachment). There was no difference between the
Medtronic and Roche pump in frequency of catheter obstruction or
detachment nor between aspart (39 subjects) and lispro(19) insulin
groups. Mild DKA was reported by 23.6% (7% needed hospitalization)
and 44.8% had pump malfunction (23.2% key board problems, 28.6%
with batteries, 16% with stop functioning, 14.5% with rewind, 32.1 %
with the clip, 3.7 % with the alarm). Reaction to the adhesive of the
catheter was reported by 31.6%. Sensor augmented pump was used
by 31% for a median duration of 0.56 years (range 0.21-5.32). Local
reactions to the sensor (pruritus and red spots) were reported by
27.7% and 66.6% had difficulties to take away the specks of glue.
Conclusions: Technical problems are frequent amongst users of CSII
and CGM, however, the majority of patients were satisfied with the
treatment.
P038
Impact of continuous glucose monitoring system on
therapy of cystic fibrosis related diabetes in
children and young adults
T. Milenkovic, S. Todorovic, K. Mitrovic, R. Vukovic
Institute for Mother and Child Healthcare of Serbia Dr Vukan Cupic,
Endocrinology, Belgrade, Serbia
POSTER TOURS
Objective: Cystic fibrosis related diabetes (CFRD) is one of the
most common complications of CF. CFRD has great impact on progressive deterioration of lung function, poor growth and increased
mortality. The need for early detection of disturbance in glucose
metabolism was recognized long ago. Current recommendations
include screening that begins at age of 10 by performing oral glucose tolerance test (OGTT) but it can`t reveal the initial glucose disturbances. Many centres are using continuous glucose monitoring
system (CGMS) to discover hyperglycaemia in real time, during normal activities. There is still no agreement on the application of this
method for diagnostic purposes, but it certainly contributes to earlier detection of hyperglycaemia and enables early initiation of insulin therapy. The aim of this study was to evaluate profile of
glycaemia in patients with CF followed up in a single centre. The
indications for CGMS were abnormalities during OGTT or hyperglycaemia detected during regular visits.
Method: Patients were recruited during 2015. Glucose meter and
strips were provided to all patients; 4 blood glucose measurements
(BGM) per day were required. CGMS was performed by iPro2 system
during 7 days. Patients were instructed to record all BGM and dietary
intake in the diary. None of them was on corticosteroid therapy.
Results: 10 patients were included, four males, with a mean age of
22.4 years (11.1-36.7). In all patients CGMS revealed peaks of glucose higher than 11 mmol/L, after meals even above 19 mmol/L.
Asymptomatic hypoglycaemia was noticed in 9 patients. In 4 patients
insulin treatment was introduced and all of them changed dietary
habits.
Conclusion: We observed abnormal glucose values in almost all
patients. According to this experience, it seems that CGMS allows
better insight of glucose impairment than OGTT in patients with CF
as well as early initiation of insulin therapy.
P039
Providing patient-friendly data improves insulin
pump adherence
K.A. Driscoll1, S.B. Johnson2, Y. Wang2, N. Wright2, L.C. Deeb2
1
University of Colorado, Barbara Davis Center, Aurora, United States,
Florida State University, College of Medicine, Tallahassee, United States
2
Objectives: Providing patient-friendly data improves insulin pump
adherence. Providing patient-friendly data improves insulin pump
adherence.
To determine if providing patient-friendly intervention reports
resulted in better insulin pump adherence than standard care.
Methods: Providing patient-friendly data improves insulin pump
adherence
76 adolescents (Mage = 14.2 2.3 years; 53% female) with T1D
(Mdiabetes duration = 6.8 3.6 yrs) using Medtronic insulin pumps
(Mpump duration = 4.4 3.2 years) and parents participated. All participants received re-education on use of insulin pumps and then were
randomized to Patient Feedback or Treatment as Usual. Patient Feedback involved written feedback describing what the patient was
doing well and areas needing improvement. Treatment as Usual
involved providing the Medtronic report to the physician. Insulin
pump adherence was monitored for 6 months.
Results: Participants with suboptimal adherence: 58% BGM
(n = 44; < 4 readings/day), 45% carb counting (n = 34; <
3 entries/day), 23% bolusing (n = 18; < 3 boluses/day). For optimally adherent participants, adherence in the Patient Feedback
group was similar to the Treatment as Usual group; average
adherence behaviors remained stable, or declined slightly. However, in this small sample size with ongoing data collection, for
suboptimally adherent participants who received Patient Feedback,
their adherence appears to improve compared to the Treatment
As Usual group (Table 1).
Conclusions: Providing patient-friendly data with recommendations
may benefit adolescents with suboptimal insulin pump adherence.
Data collection is ongoing and full intervention effects will be analyzed at study completion.
51
POSTER TOURS
Suboptimal Adherence
Treatment As Usual
Patient Feedback
Education Tx 1 Tx 2 Education Tx 1 Tx 2
Avg # BG Readings/Day 2.2
2.1
1.9
2.6
2.7
2.9
Avg # Carb Entries/Day
1.5
1.6
1.6
1.9
2.0
2.1
Avg # Boluses/Day
1.8
2.0
2.2
2.0
2.6
2.8
[Table 1. Insulin Pump Adherence at 3 Visits]
P040
Mean blood sugar variability versus HbA1c in
monitoring effective glycaemic control
B. Bassoy, G. Margabanthu
Kettering General Hospital, Kettering, United Kingdom
Objectives: The clinics use near patient HbA1c testing as well as
SMART meter downloads to analyze patient compliance and treatment results. The MDT has an oversight of the process to actively
facilitate the learning for patients and their families to review and
make changes to their insulin regime. Glycaemic Variability was compared using mean blood sugar values and HbA1c.
Methods: A prospective analysis was undertaken from Jan 2014 to
June 2014 to compare the A1c and average blood sugars alongside
the standard deviation to analyze the correlation with glycaemic control and variability. All downloads had a mean of 5.3 tests a day.
Results: Mean A1C for 100 downloads was 61.67 mmol/mol
(9.8 mmol/L) that was comparable to a mean blood sugar of
9.6 mmol/L with a mean standard deviation of 4.7. This correlation
changed when the data was stratified based on Standard deviation.
When the standard deviation was less than 2 the average A1C was
45.75 mmol/l(7.6 mmol/L) versus 5.525 mmol/L average mean blood
sugar. Standard deviation between 2–4 co- related to A1C of
53.9 mmol/mol (8.7 mmol/L) versus 7.9 mmol/L average mean blood
sugar. Surprisingly both were the same when the standard deviation
was more than 4 with a mean A1C of 63.4 mmol/mol (10 mmol/L)
and the mean average blood sugars (9.97 mmol/L) . Gap widened in
the opposite way when the Standard deviation was more than 6 with
a A1C of 73.89mmool/mol (11.6 mmol/L) versus average mean blood
sugar of 12.4 mmol/L.
There was 50% reduction of DKA and hypoglycemia admissions in
this period.
Conclusions: Simple SMART meters are effective predictors for diabetes monitoring with average mean blood sugars, which are very different to the near patient A1c and it bears a correlation between
standard deviation of 4–6 with increasing gaps both sides of the
spectrum.
Smart meter download review is a good way of analyzing blood
sugars targets, variability and control over a period of time with
empowerment of patients.
52
POSTER TOURS
Poster Tour 6: Diabetes Technology & New Insulins and
Pharmocologic Agents
P041
Initial experiences and learnings from the unique
“first country in the world - India” novel libre pro
continuous glucose monitoring [CGM] system: plea
for approval in pediatric diabetes
R. Manjunath1,2, V.A. Rao2,3, S. Srikanta3, L. Reddy4, A. Sharda4,
T. Deepak4, A. Hegde5, B.D. Thyagaraj2, B. Reshma4, R. Ashok2,
S. Madiazaghan4, K.L. Chetana4, U. Dayashankar6, U. Rangaraj5,
Diabetes Collaborative Study Group: Samatvam Jnana Sanjeevini
1
Samatvam Endocrinology Diabetes Center, Endocrinology, Bangalore,
India, 2Jnana Sanjeevini Medical Center and Diabetes Hospital,
Endocrinology Diabetes, Bangalore, India, 3Samatvam Endocrinology
Diabetes Center, Diabetes, Community Health, Bangalore, India,
4
Samatvam Endocrinology Diabetes Center, Endocrinology Diabetes,
Bangalore, India, 5Jnana Sanjeevini Medical Center and Diabetes
Hospital, Diabetes, Community Health, Bangalore, India, 6Jnana
Sanjeevini Medical Center and Diabetes Hospital, Endocrinology
Diabetes, Bengaluru, India
Objective: To present initial experiences / learnings from Libre Pro
CGM, currently exclusively launched in India [not available in any
other country in the world].
Methods: Abbott FreeStyle® Libre Pro Flash Glucose Monitoring
System appears to be transformative. Superiority: Highest accuracy,
most user friendly, tremendous ease of use, 14 day memory, nonrequirement of calibrations with finger stick glucose.
We adapted Professional [“Pro”] version, into Personal mode
[76 subjects; 262 sensor 14 day cycles; continuous/ intermittent use;
local, national and international- USA, Australia, Indonesia- subjects telemedicine - software downloads; parallel finger prick BG once daily
/ biweekly 7 point profiles - despite not recommended by
manufacturers].
Results: Experiences from young adults with type 1 diabetes: Currently Libre Pro is approved by Health Authority of India only for people
above 18 years of age.
Indications:
1. T1DM on pump/MDI;
2. Pregestational diabetes;
3. Prepregnancy counselling;
4. Educational/ motivational tool;
5.Challenging clinical scenarios [hypoglycemia unawareness, nocturnal hypoglycemia, dawn, renal / liver dysfunction, artificial reproduction technologies],
6. Special life situations [high altitude mountain climbing; underwater sports; recreational/ religious vacations].
Complications: malinsertion [1], bleeding during sensor insertion [2],
premature disconnection of sensor [4]; true sensor malfunction [Nil].
Benefits: HbA1c improvements, decreased hypoglycemia, improved/
flexible lifestyles, better accuracy at high altitudes, improved motivation and very high patient satisfaction/ happiness [no finger pricks!].
Conclusions: With further continued technology improvements and
decreasing costs, Libre "Professional", and more importantly "Personal" CGM, could foster “universal” and “affordable” CGM use [with
special benefits in Pediatric Diabetes].
P042
Euglycemic diabetic ketosis in an adolescent with
type 1 diabetes treated with insulin and
Dapaglifozin an SGLT2 inhibitor
R. Roman1,2, M. Pereyra1, C. Ramirez1,3
1
University of Antofagasta, Faculty of Medicine and Odontology,
Antofagasta, Chile, 2Antofagasta Regional Hospital, Pediatric
Endocrinology Unit, Antofagasta, Chile, 3Hospital Regional de
Antofagasta, Pediatrics, Antofagasta, Chile
We present an euglycemic diabetic ketosis in a female adolescent
with Type 1 Diabetes (T1D) who was on Dapaglifozin, an inhibitor of
the sodium-glucose cotransporter 2 (SGLT2). The patient was
17 years old, had T1D during 9 years, and was started on Dapaglifozin 10 mg/day with the aim to reduce her insulin dose, her weight
and her clinical hyperandrogenism. She took the drug during
11,5 months with no adverse events, basal insulin was decreased
from 40 to 17 U and she lost 8 kg reaching a BMI of 21,1 kg/m2 (
174 cm 64 kg). In addition her metabolic control was improved
(HbA1c 8,3 to 7,5%, mean blood glucose 175 to 161 mg/Dl and glucose variability blood glucose SD 85 to 77). She was on an insulin
pump and continuous glucose monitoring (CGM). The glucose sensor
was well calibrated and interstitial glucose readings were concordant
with capillary blood glucose. Suddenly she presented with nausea
and vomiting. The CGM showed stable glucose levels under 200 mg/
dl. Capillary blood glucose was 180 mg/dl, and the pump delivered a
correction insulin bolus. She had several vomits without hyperglycemia. Three hours later she was severely dehydrated and fainting. Capillary Betahydroxibutirate (ketones) was 4.6 nmol/l and blood glucose
224 mg/dl. She received IV physiological saline fluid, ondansetron,
oral carbohydrates and SC insulin boluses. Hydratation and general
condition improved soon, but despite several insulin doses, ketones
production continued during 24 hours. Interestingly the pump was
working well and the cannula was not changed, after the ketosis was
resolved, she continued using the same cannula with good metabolic
control and no ketones. We report an atypical case of euglycemic diabetic ketosis related to Dapaglifozin. In this case CGM confirmed that
ketones were present without hyperglycemia. This condition may be
life threating and must be suspected in the absence hyperglycemia.
P043
Paying the price for accessing insulin
M. Ewen1, D. Beran2, R. Laing3
1
Health Action International, Amsterdam, Netherlands, 2Geneva
University Hospitals and University of Geneva, Geneva, Switzerland,
3
Boston University, School of Public Health, Boston, United States
Objective: Approximately 50 million people globally have difficulties
accessing insulin. We assessed insulin prices as they are thought to
be a key barrier to accessing insulin.
Methodology: In mid-2015, insulin prices were collected from
national key informants, individuals and price databases. Government
procurement prices and patient prices (public and private sector)
were analysed by insulin type, presentation and brand. Prices were
standardized to 10 ml 100 IU/ml insulin in US dollars. Affordability
was expressed as the number of days’ wages needed by the lowest
paid unskilled government worker to buy 10 ml insulin.
Results: Median government procurement prices of analogues ($34)
were far higher than human insulins ($6). The same was seen for
patient prices in the public sector ($45 vs $8) and private sectors
($39 vs $17). Vials were generally lower priced than cartridges and
pens e.g. regular/isophane 30/70, private sector: $13 vial, $32 pen,
$20 cartridge. In both sectors, some large price variations were seen
across countries eg. glargine, private sector, ranged from $8 (India) to
$196 (Venezuela). Insulin was unaffordable for those on low wages
i.e. 2.5 vs 7.5 days’ wages for human insulin and analogues, respectively, in the public sector and 3.5 vs 9.5 days’ wages in the private
sector.
Conclusion: Poor insulin availability has been reported previously
forcing many people to access insulin in the private sector. Drivers of
higher costs to individuals and health systems include using
53
POSTER TOURS
Objectives: To describe the use of sensor-augmented-pump (SUP)
therapy with predictive low glucose suspension in type 1 diabetes
(T1D) children and their influence on metabolic control and hypoglycaemia episodes.
Methods: Description of our experience in SUP use from 2015 summer in T1D children controlled in our Pediatric Diabetes Unit (>250
children followed-up) at University Miguel Servet Children’s Hospital.
We have analysed prior and post- SUP data: HbA1c, percentage of
hypoglycaemia and severe hypoglycemia episodes, basal percentage
and bolus number.
Results: 14 T1D patients are paying for the SUP treatment in our
Unit. The indication for SUP was: 2 cases by unawereness hypoglycemia and severe hypoglycemia episodes. 1 case by permanent neonatal diabetes. 3 cases < 6 years old, 4 cases < 10 y, and 4 cases < 15
y. 57% were male. The average age was 8,95 years (range 3,7-13),
average of age at onset of T1D was 3,94 years (0,1-11). Duration of
diabetes average was 5,01 years (1–7,6). No cases had ketacidosis.
Previous treatment to SUP was 42% with pump. The average HbA1c
for the prior SUP treatment was 7,32%. And HbA1c after 3 months
with SUP treatment was 7,2%, and 7,2% at 6 months. % of hypoglycemia before SUP: 10,2. After SUP < 8% (even longer than 3 months,
statistically significative). The previous severe hypoglycemia cases
have not presented any hypoglycemia episodes after SUP. 46,85%
basal rate pre- SUP and 38,57% at 3 months and 39,75% at 6 months.
Bolus number/day (pre-SUP, at 3 and 6 months): 6,7, 7,8 and
8 bous/d (p < 0,05). 3 patients have decided to finish SUP. One out
of them was by recurrent site infections.
Conclusions: SUP improves metabolic control, even in pediatric children with good control, with less needs of basal rate. It is clear and
fair, the SUP treatment in patients with unawareness hypoglycemia
or severe hypoglycemia episodes is highly beneficial. Therefore, these
families should receive some subsidy by health public system.
analogues, and cartridges/pens. Efficient government procurement
practices can lead to reduced prices, which need to be passed on to
patients (where insulin is not free). Add-on charges, such as tariffs
and taxes, can further increase prices and should be removed. In
order to ensure that an affordable source of insulin is present, a
global compact with the insulin industry is necessary to guarantee
that human insulin in vials is not removed from the market.
P044
Glycemic variability estimated with time series
analyses is associated with subclinical
macrovascular damage
L. García Maset1, L. Blasco González1, R. Hernández Marco2,
F. Montes Suay3
1
Hospital de Sagunto, Pediatria, Valencia, Spain, 2Hospital Dr. Peset,
Pediatria, Valencia, Spain, 3Universidad de Valencia, Estadística e
Investigación Operativa, Valencia, Spain
Hypothesis: Glycemic Variability (GV) in children with type 1 diabetes
(DM1) is related to subclinical macrovascular complications.
Material and Methods: A transversal, observational study, Diabetes
Unit Hospital Sagunto. Cases-controls paired by age and sex. Exclusion criteria: under 6 years of age, less than 1 year disease progression time, microangiopathy. SPSS and R.
Variables
• GV: continuous monitoring of interstitial glucose. Classic indices:
EasyGV program (standard deviation-SD, Coefficient Variation-CV,
interquartile range-IQR, Mean Amplitude of the largest Glycemic
Excursion-MAGE, Continuous Overlapping Net Glycemic ActionCONGA). Parameters derived from time series analysis (alpha
coefficient of Detrended Fluctuation Analysis-α, minor axis-ma,
major axis-MA and eccentricity-E of the Poincaré Plot).
• HbA1c.
• Peripheral and central Arterial Blood Pressure (ABP), Pulse Wave
Velocity: 24 hours of outpatient monitoring with an oscillometer
(Mobil-O-Graph). Data were interpreted with the aid of time series
analyses.
• Carotid intima media thickness (cIMT)
Results: 41 subjects with DM1, median age 13.6 yrs, HbA1c 7.8%
P047
Unsupervised home use of day-and-night closedloop insulin delivery: a pooled analysis of
randomized controlled studies in adolescents with
type 1 diabetes
M. Tauschmann1,2, J.M. Allen1,2, M.E. Wilinska1,2, H. Thabit2,
C.L. Acerini1, D.B. Dunger1,2, R. Hovorka1,2
[Glycemic Variability]
Diabetic cIMT 442.9 μm, no significant differences with controls.
7 DM1 subjects with high ABP
(5 masked), 50% no-dippers. The parameters for arterial rigidity
were greater in diabetic patients than in controls. No association was
observed between GV and cIMT. α for glucose was associated with
variability in ABP and arterial rigidity, both estimated through time
series analyses: β negative for ma-meanABP (p = 0.005, R2 = 0.180)
and ma-central diastolicABP (p = 0.014, R2 = 0.256); β positive for
α-central systolicABP (p = 0.01, R2 = 0.256).
Conclusions: Increased arterial rigidity precedes increases in cIMT.
GV estimated with routine indices is not associated with vascular
damage, but when both are evaluated with time series analyses, an
association is observed.
1
University of Cambridge, Paediatrics, Cambridge, United Kingdom,
University of Cambridge, Wellcome Trust-MRC Institute of Metabolic
Science, Cambridge, United Kingdom
2
Objectives: To compare day-and-night hybrid closed-loop insulin
delivery and sensor-augmented pump therapy in adolescents with
type 1 diabetes by combining data collected during free-living home
studies without remote monitoring or supervision.
Methods: We evaluated two randomized crossover studies in 24 adolescents on insulin pump therapy (age 15.0 2.8years; HbA1c
68 8 mmol/mol [8.4 0.8%]; duration of diabetes 8.0 3.4years;
mean SD). In both studies, each subject underwent a period of
closed-loop insulin delivery and a period of sensor-augmented insulin
pump therapy of identical duration in random order. In each study,
interventions lasted 7 days or 21 days, respectively. During closedloop, a model predictive algorithm automatically directed insulin
delivery between meals and overnight; prandial boluses were administered by participants using a bolus calculator.
Results: The proportion of time that sensor glucose was in the target
range (3.9 to 10 mmol/l, primary endpoint) was greater during
closed-loop phase than with sensor-augmented pump therapy
(67.1 9.6% vs. 49.6 12.1%, mean SD, p < 0.001). The mean
glucose level was lower during closed-loop (8.7 1.0
vs. 10.3 1.6 mmol/l, p < 0.001), as was the time spent above target (29.2 10.4% vs. 47.2 13.8%, p < 0.001). The time spent with
P045
Our experience with sensor-augmented-pump
therapy for children
G.M. Lou Francés1, A. Jiménez Olmos1, V. Adan Lanceta1, M. Ferrer
Lozano1, M.R. Rubio Abella2
1
Miguel Servet Children’s Hospital, Paediatric Diabetes Unit, Zaragoza,
Spain, 2Miguel Servet Children’s Hospital, DUE Paediatric Diabetes Unit,
Zaragoza, Spain
SD (mg/dL)
CV (%)
IQR (mg/dL)
MAGE (mmoL/L)
CONGA (mmoL/L)
α
ma (mg/dL)
MA (mg/dL)
E
68.5
38.85
102
7.18
8.35
1.54
5.09
98.75
19.77
54
glucose levels below 3.9 mmol/l was low and comparable between
interventions (3.3 [1.6 to 5.2] vs 1.8 [0.6 to 5.1]%, median [IQR],
p = 0.12). Improved glucose control during closed-loop was related
to increased variability of basal insulin delivery (p < 0.001) and an
increase in total daily insulin (55.1 [41.9 to 66.5] vs. 53.8 [41.2 to
61.4]U/day; p = 0.040) compared to control intervention.
Conclusions: Free-living unsupervised home use of day-and-night
hybrid closed-loop over period of one to three weeks in adolescents
with type 1 diabetes is safe and feasible. Compared to sensoraugmented insulin pump therapy, closed-loop may improve glucose
control without increasing the risk of hypoglycemia.
P048
Effects of Trigonella foenum graecum and sodium
orthovanadate on antioxidant enzymes, membrane
bound ATPases and glucose transporter expression
in muscle, kidney and brain in female diabetic rats
P. Kumar, N. Baquer
Jawaharlal Nehru University, School of Life Sciences, New Delhi, India
Objectives: Oxidative stress in diabetic tissues is accompanied by
high level of free radicals and the simultaneously declined antioxidant
enzymes status leading to cell membrane damage. In the present
POSTER TOURS
study, the effect of sodium orthovanadate (SOV) and Trigonella foenum graecum seed powder administration has been studied on blood
glucose and insulin levels, membrane bound ATPases (Na+K+ATPase ,
Ca2+ATPase) , antioxidant enzymes (superoxide dismutase, glutathione S-transferases), DNA degradation, lipid peroxidation, and distribution of glucose transporter in liver, muscle and brain tissues of the
alloxan induced diabetic rats and to see whether the treatment with
SOV and Trigonella is capable of reversing these effects.
Methods: Diabetes was induced by administration of alloxan monohydrate (15 mg/100 g b.wt.) and female rats were treated with 2 IU
insulin, 0.6 mg/ml SOV, 5% Trigonella in the diet and a combination
of 0.2 mg/ml SOV with 5% Trigonella separately for 21 days.
Results: Diabetic rats showed hyperglycemia with almost four fold
high blood glucose levels. Hyperglycemia increases lipid peroxidation
and DNA degradation, causing decreased activities of membrane
bound ATPases , antioxidant enzymes and glucose transporter
expression with diabetes in the rat tissue. Rats treated with combined
dose of vanadate and Trigonella had glucose levels comparable to
controls, similar results were obtained with the activities of antioxidant enzymes, membrane bound ATPases, DNA degradation, lipid
peroxidation and glucose transporter in diabetic rats.
Conclusion: Our results showed that lower doses of vanadate
(0.2 mg/ml) could be used in combination with Trigonella to effectively counter diabetic alterations without any toxic side effects.
55
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Poster Tour 7: Psychosocial Issues
P049
Diabetogenic and cardiometabolic risk factors of
health-related quality of life among Taiwanese
overweight and obese adolescents
M.-C. Tsai1, C.-Y. Lin2, C.-T. Lee3
1
National Cheng Kung University Hospital, College of Medicine, National
Cheng Kung University, Department of Pediatrics, Tainan City, Taiwan,
Province of China, 2Hong Kong Polytechnic University, Department of
Rehabilitation Sciences, Faculty of Health and Social Sciences, Hong
Kong, China, 3National Cheng Kung University Hospital, College of
Medicine, National Cheng Kung University, Department of Family
Medicine, Tainan City, Taiwan, Province of China
Objectives: The objective of this study is to demonstrate the association between diabetogenic and cardiometabolic risk factors and
health-related quality of life (HRQOL) in a medically referred sample
of Taiwanese overweight and obese adolescents.
Methods: Adolescents age 11–19 years with body mass index > 85
th % of age- and sex-adjusted weight were recruited in a tertiary hospital. We conducted anthropometric measurements and biochemical
testing. Insulin sensitivity was represented by homeostasis model
assessment-insulin resistance and quantitative insulin sensitivity
check index. Body composition was measured by the dual-energy Xray absorptiometry. HRQOL was assessed by the Pediatric Quality of
Life Inventory (PedsQL). Student t test was used to compare the differences in the PedsQL scores between groups stratified by weight
status and cardiovascular risks. Multiple linear regression models
were further applied to identify predictive factors associated with
PedsQL.
Results: Overweight and obese adolescents (n = 60) reported lower
PedsQL scores as compared to that of non-obese participants. Further stratifying overweight/obese subjects by cardiometabolic risks,
we observed larger negative effects in those with at least one cardiometabolic risk factor. Both BMI z-score and serum levels of alanine
aminotransferase (ALT) were negatively correlated with overall and
subscale scores of PedsQL with correlation coefficients being from
−0.248 to −0.433. In multivariate linear models, ALT stood out as the
most salient factors associated with poor obesity-related HRQOL
with β = −0.31 (p < 0.01) and −0.39 (p < 0.001) for the overall score
and physical subscale of PedsQL, respectively.
Discussion: Taiwanese overweight and obese adolescents, particularly those having additional cardiometabolic risk factors, reported
lower HRQOL than did normal weight peers. Impaired liver functions
may predispose overweight/obese subjects to even worse HRQOL,
notably in their physical functioning.
P050
Lower executive functioning associated with
greater diabetes-specific risk-taking in adolescents
with type 1 diabetes
R. Wasserman, B. Anderson, D. Schwartz
Baylor College of Medicine and Texas Children’s Hospital, Houston,
United States
Objective: Diabetes-specific risk-taking is a novel concept defined as
a type of nonadherence in which youth make decisions about selfmanagement that put them at risk for poor health outcomes
(e.g., going 24 hours without insulin, drinking alcohol with no plan to
check blood glucose overnight). Executive function deficits such as
poor planning, problem-solving, and impulse-control have been associated with greater general risk-taking behavior (e.g., smoking, binge
drinking) and poorer diabetes management. In this pilot study, we
investigated whether poorer executive functioning was associated
with diabetes-specific risk-taking, regimen adherence, and general
risk-taking in youth with type 1 diabetes (T1D).
Methods: Thirty adolescents with T1D (age 15–19, 60% female, M
A1c = 8.7 1.4%, and 33% on insulin pumps) and his/her caregiver
participated. Youth completed a new questionnaire: the DiabetesSpecific Risk-Taking Inventory (DSRI, α = .92), in which they
reported how often they engaged in 34 behaviors that placed them
at risk for acute adverse events or poor glycemic control. Participants also completed general risk-taking items from the Risk-Taking
and Self-Harm Inventory for Adolescents (RTSHI-A). Parents
reported on their child’s executive functioning, using the Behavior
Rating Inventory of Executive Functioning (BRIEF), and general diabetes management with the Diabetes Management Questionnaire (DMQ).
Results: Results indicated a positive correlation between poor executive functioning (as measured with mean scores across all 86 items)
and diabetes-specific risk-taking (r = .46, p < .05). Associations with
general risk-taking and adherence were not statistically significant,
but were in the expected direction.
Conclusions: Executive functioning may play an important role in
understanding adolescent non-adherence and specifically risks that
teens take with their diabetes care.
P051
Illness Intrusiveness in parents and glycemic control
in youth with type 1 diabetes: intergenerational
processes
S. Prikken1, L. Oris1, I. Weets2, P. Moons1,3, K. Luyckx1
KU Leuven, Leuven, Belgium, 2Brussels Free University, Brussels,
Belgium, 3Gothenburg University, Gothenburh, Sweden
1
Objectives: Type 1 Diabetes (T1D) is a chronic condition imposing
strict treatment regimens, impacting both patients and their parents.
Despite an extensive diabetes literature on specific intergenerational
links, comprehensive models relating broader parental functioning to
patient functioning are scarce. The present study investigated an
intergenerational path model, in which parental functioning (illness
intrusiveness and depressive symptoms) was expected to relate to
patient functioning (depressive symptoms, treatment adherence, and
glycemic control) through parenting practices (overprotection and
psychological control).
Methods: Selected through the Belgian Diabetes Registry, 316 patient-mother dyads and 277 patient-father dyads completed questionnaires. All patients were diagnosed with T1D, were aged 14–25,
and were living with their parents. Patients indicated their depressive
symptoms and treatment adherence; treating physicians provided
patients’ HbA1c values. Parents reported on their experience of illness intrusiveness, their depressive symptoms, and the patient’s
treatment adherence. Parenting, as operationalized by the dimensions
of overprotection and psychological control, was assessed in both
parents and patients.
Results: Structural equation modelling favored our hypothesized path
model to an alternative, child-driven model. An adequate fit was
found for both patient-mother and patient-father dyads. Parental
functioning seemed to predict patient functioning with parenting
dimensions as intervening mechanisms. Parental illness intrusiveness
was associated with parental depressive symptoms, both predicting
overprotection and psychological control. Psychological control in
particular predicted patient depressive symptoms, treatment adherence, and glycemic control.
Conclusions: These findings underscore the relevance of including
parental functioning when assessing patient outcomes.
56
P052
Body emotional map: an innovative and useful tool
to improve parents´ adaptation to the diagnosis of
type 1 diabetes of their child
B. Predieri1, A. Nicolucci2, M.C. Alessandrelli3, M. Pagnini3,
B. Pintaudi4, F. Zani1, A. Iannilli3, L. Ferrito3, G. Lucisano2, L. Iughetti1,
V. Cherubini3
1
University of Modena and Reggio Emilia, Department of Medical and
Surgical Sciences for Mothers, Children and Adults, Modena, Italy,
2
CORESEARCH, Center for Outcomes Research and Clinical
Epidemiology, Pescara, Italy, 3Azienda Ospedaliero-Universitaria
Ospedali Riuniti, S.O.D. Diabetologia Pediatrica, Ancona, Italy, 4Niguarda
Cà Granda Hospital, Diabetes Unit, Milano, Italy
Objectives: The diagnosis of type 1 diabetes mellitus (T1DM) in a
child is a traumatic event for parents. The path of a good adaptation
to the child´s disease is a purpose of the therapeutic education to
attain and keep a good quality of life. Aim of this study was to demonstrate the effectiveness of the new tool Body Emotional Map
(BEM) in helping parents to overcome the trauma of T1DM diagnosis
and to achieve the best adaptation.
Methods: Sixty-two parents (29 mothers, 33 fathers) of 36 children
with T1DM (age = 11.3 3.3 yrs; T1DM duration >1 yr; HbA1c =
57 11 mmol/mol) were recruited in a 3-days educational group
intervention study. The re-examine of the traumatic event of the
T1DM diagnosis through the BEM path included spatial and time-line
anchorage, retrace of the future, emotional awareness, interactive
discussion. Relaxing technique, diaphragmatic breathing, and guided
visualization were used by 1 psychologist, 1 counselor and 1 pediatric
diabetologist. Self-report questionnaires [Diabetes Related Distress
(DRD), Parent Stress Index Short Form scale (PSI-SF), Fear of Hypoglycemia Survey (FHS), Parent Health Locus of Control Scale
(PHLOC), and Health Survey Short Form-36 (SF-36)] were filled by
parents at baseline, 1 month (M1), and 3 months (M3) after the
intervention.
Results: Respect to baseline, at time M3 we found a significant score
reduction of the “difficult child” subscale of the PSI-SF in both parents (p < 0.05), of the DRD in mothers (59.0 2.6 vs. 52.4 2.7 vs.,
p = 0.03), and of the “parental distress” subscale of the PSI-SF in
fathers (24.9 1.5 vs. 21.8 1.5, p = 0.04) . Moreover, the social
functioning score of the SF-36 was significantly improved in fathers
at time M1 (81.3 3.2 vs. 88.3 3.2, p = 0.03).
Conclusions: In T1DM we must always to consider the emotional
reaction occurring when the diagnosis is given both in children and
parents. BEM path seems to reduce stress and to improve social
functioning of parents of children and adolescents with T1DM.
P053
Parent-reported perceptions of educational
opportunities to alleviate burden associated with
the management of type 1 diabetes (T1D) in
children < 8 years old
P. Commissariat1, A. Whitehouse1, K. Miller2, M. Hilliard3,
M. Mantravadi4, M. Van Name5, D. DeSalvo3, W. Tamborlane5,
B. Anderson3, L. Laffel1, L. DiMeglio4
Joslin Diabetes Center, Boston, United States, 2Jaeb Center for Health
Research, Tampa, United States, 3Baylor College of Medicine, Houston,
United States, 4Indiana University School of Medicine, Indianapolis,
United States, 5Yale School of Medicine, New Haven, United States
1
Objective: Management of T1D in youth < 8 years old places substantial stress upon parents. We interviewed parents of children < 8
in an effort to identify educational opportunities to relieve their perceived burdens of care.
Methods: Semi-structured qualitative interviews were conducted
with parents (81% mothers) of 79 children with T1D, aged
1 to < 8 years old, from 4 diverse sites. All youth (77% White) had
T1D for ≥6 months; mean age was 5.2 1.5 years, T1D duration
POSTER TOURS
2.4 1.3 years, A1c 7.9 0.9%, 66% pump-treated. Interview transcripts were coded and evaluated using content analysis to derive
central themes.
Results: Parents of young children with T1D were constantly aware
of their obligation to care for their child’s diabetes at home and their
responsibility to educate others involved in their child’s care. Parents
identified 3 major areas in which education would reduce their perceived burdens of care, worry, and stress while increasing their confidence in diabetes management: 1) further knowledge of potential
acute and chronic complications of T1D; 2) education from healthcare providers related to the benefits and burdens of advanced diabetes technologies (pump and CGM) specifically in young children; and
3) separate educational courses for other caregivers regarding overall
T1D care, insulin administration, and symptom recognition of hypoglycemia and hyperglycemia.
Conclusions: Given high parental stress of T1D care in early childhood, tailored education around developmentally relevant issues of
T1D care may be particularly appreciated by parents. Parent
requests for education should be supported, as education provides
parents with tools to reduce worry, increase confidence in their abilities, improve other caregivers’ abilities, and provide realistic expectations regarding pros and cons of technology as well as risks for
complications. Such educational efforts may reduce parental burden
while helping to optimize glycemic control in young children
with T1D.
P054
Mood and anxiety disorders in adolescents with
type 1 diabetes and their parents/caregivers: first
results from the baseline assessment of the
longitudinal diabetes LEAP study
L. Nguyen1, G. Nefs1,2, H.-J. Aanstoot2, P. Winterdijk2, F. Pouwer1
1
Tilburg University, Medical and Clinical Psychology, Tilburg,
Netherlands, 2Diabeter, Rotterdam, Netherlands
Objectives: The exact scope of mood and anxiety disorders in
adolescents with type 1 diabetes (T1D) is unknown as prior
research mainly focused on depression, used questionnaires and
overlooked parental emotional problems (EP). This study examines
1) the prevalence of these disorders in adolescents with T1D
using a diagnostic interview, 2) the relation between adolescent
and parental EP.
Methods: Adolescents (aged 12–18) with T1D were recruited in
2015–16 at Dutch paediatric clinics. Mood and anxiety disorders
were assessed with the Diagnostic Interview Schedule for ChildrenIV. In primary caregivers, depressive and anxiety symptoms were
assessed with the PHQ-9 and GAD-7 (cut-off ≥10). A Fisher’s Exact
test was conducted to assess the relation between parental and adolescent EP. Additional clinical data is being collected and will be available to present at the ISPAD conference.
Results: The sample consisted of 154 adolescents, of whom 51%
were boys (n = 78). Mean age was 14.5 years (SD = 1.83). Insulintherapy was mainly administered through continuous subcutaneous
infusion (79%). While 15% of the adolescents (n = 23) reported having experienced at least one mood or anxiety disorder in the past
year, only 35% of this group had consulted a health-care professional
for these problems. Anxiety disorders were more prevalent (14%)
than mood disorders (4%). In the primary caregivers, of whom 89%
were mothers, with a mean age of 46.2 years (SD = 4.58), clinically
relevant depressive symptoms were more prevalent than anxiety
symptoms (5% vs. 4%). Parental and adolescent EP were not significantly related (p > 0.99).
Conclusion: The first results of the Diabetes LEAP study suggest
mood and anxiety disorders in adolescents with T1D often go
untreated. In adolescents anxiety disorders were more common
than mood disorders. Parents, however, more often reported
depressive symptoms. Diabetes teams are advised to be aware of
parental EP even if the adolescent does not have an emotional
disorder.
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P055
Diabetes-specific emotional distress in parents of
teenagers with type 1 diabetes
and may be useful in routine, clinic-based assessments to guide
clinical interventions.
J. Weissberg-Benchell1, K. Rychlik2
P056
Executive problems in adolescents with type
1 diabetes are associated with poor metabolic
control and low physical activity
1
Lurie Children’s Hospital, Chicago, United States, 2Lurie Children’s
Hospital, Stanley Manne Research Center, Chicago, United States
Parent involvement in their teen’s diabetes regimen is associated
with optimal outcomes, but can also lead to increased diabetesspecific emotional distress. Our team created a suite of diabetes
distress measures. We report on the psychometric properties of
the P-PAID-T, a parent-report measure of their own diabetes distress.We utilized two distinct data sets. One with 256 parents of
teens, (M age 15.7, range 14–18, 60% female, 68% Caucasian, M
A1c = 9.1) enrolled in a depression-prevention RCT. The other
includes parents of 1026 teens, (M age 14.4, range 12–18, 90%
Caucasian, M A1c = 8.9) attending one of 42 diabetes camps.Principal component factor analysis with oblique rotation was performed. The RCT data resulted in a 24 item measure, Cronbach’s
α = .96. The one-factor solution accounted for 53% of the variance. The camp data resulted in a 23 item measure (same 2 items
deleted from RCT data plus one more), Cronbach’s α = .95. The
one-factor solution accounted for 47% of the variance.Scores from
the RCT significantly correlated with parent r = .65 and teen
r = .40 reports of family conflict; parent r = .56 and teen r = .27
reports of depression; and teen report of emotional distress r = .38
(all p’s < .001), evidencing criterion validity. Discriminant validity
was shown by negative correlations with diabetes strengths
r = −.33 and adherence r = −.30 (p’s < .001). A positive correlation
with A1c (r = .34, p < .001) suggests better control may occur at
the cost of higher parent distress. Scores from the Camp study
negatively correlated with parent r = −.50 and teen r = −.28
reports of self-care skills and teen report of strengths r = −.44,
(p’s < .001), offering more evidence of discriminant validity.This
psychometric assessment of the P-PAID-T, with over 1,200 parents
of teens, suggests it reliably and validly captures parents’ diabetesspecific emotional distress, is associated with key clinical outcomes,
C. Nylander1, Y. Tindberg1, J. Haas2, I. Swenne1, T. Torbjörnsdotter2,
K. Åkesson3, E. Örtqvist2, J. Gustafsson1, E. Fernell4
1
Uppsala University, Uppsala, Sweden, 2Karolinska Insitute, Stockholm,
Sweden, 3Futurum - Academy for Health and Care, Jönköping, Sweden,
4
University of Gothenburg, Gothenburg, Sweden
Management of diabetes is demanding and requires efficient cognitive skills, especially in the domain of executive functioning. However, the impact of impaired executive functions on diabetes control
has only been studied to a limited extent.
Objective: To investigate the association between executive dysfunctions and diabetes control in adolescents with type 1 diabetes.
Methods: 241/477 (51 %) of 12–18 year-old adolescents, with a diabetes duration of >2 years, in Stockholm. Uppsala and Jönköping,
Sweden, participated. Parents and adolescents completed questionnaires, including BRIEF, ADHD Rating Scale (ADHD-RS) and background factors. Diabetes related data was collected from the Swedish
Childhood Diabetes Registry, SWEDIABKIDS. Self-rated and parentrated executive functioning problems were analyzed with regard to
gender, HbA1c, frequency of outpatient visits and physical activity,
taking background factors into account.
Results: Executive functioning problems, according to BRIEF and/or
ADHD-RS, respectively, were associated with mean HbA1c > 70
mmol/mol, many outpatient visits and low physical activity for both
genders. Self-rated executive problems were more prevalent in girls,
while parents reported these problems to a larger extent in boys.
Conclusion: Patients with executive functioning problems need to be
recognized by the diabetes team. The diabetes care should be especially tailored to provide adequate support to these patients.
58
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Poster Tour 8: Latebreakers
P057
Activity of matrix metalloproteinase in
development of experimental diabetes
D. Tursunov
with C-peptide levels (r = 0.32; p = 0.07) hinting at let-7 g’s association with residual beta cell function.
Conclusions: Temporal dynamics of let-7 g showed an association
with residual beta cell function and its involvement in the progression
of type 1 diabetes.
Tashkent Medical Academy, Biochemistry, Tashkent, Uzbekistan
Topicality: Matrix metalloproteinases (MMPs) - group of structurally
related zinc dependent endopeptidases involved in the degradation
of the basement membrane and extracellular matrix. MMP modulate
the degradation of extracellular matrix by binding to specific receptors, the expression of which, in turn, is mediated by levels of several
pro-inflammatory cytokines, neuropeptides, integrins, growth factors,
and apoptosis inducers (Schnee JM, Hsueh WA, 2000; MurphyUllrich JE, 2001; Ross RS, Borg TK, 2001; Wang BW et al., 2008).
Objective: To investigate activity of metalloproteinases in the
dynamics of the development of alloxan diabetes.
Material and Methods: Alloxan diabetes in albino rats receiving
administration of alloxan in a dose of 13 mg per 100 g body weight
once. 1-, 4-, 7- and 14-day experiment in serum to determine the
activity of metalloproteinases-1 and −9 PCR method.
Results and discussion: As a result of the experiment it was found
that the development of alloxan diabetes first day of experiment significantly increases the activity of the enzymes, especially a sharp
increase in MMP-1 and MMP-9 is set to 7 and day 10 of the experiment. Increasing their activity was 2.1 and 2.6 times, respectively,
compared with control animals. This is due to the accumulation of
blood glycated endoproducts , i.e. complexes of organic substances
(mostly proteins) and carbohydrates.
Conclusion: Thus, it is proved that the development of alloxan diabetes increases the activity of metalloproteinase-1 and −9. The development of pharmaceuticals that inhibit the work of the enzyme - a
promising new way to protect the body´s cells in diabetes.
[Figure 1]
P059
Identification of a novel INS-gene missense variant
p.G71V in three generations with diabetes
S. Ahmed1, P. Christian1, A. Ranasinghe1
1
P058
Temporal dynamics of serum let-7 g expression
show its involvement in the decline of residual beta
cell function
K. Wyka1, M. Bartlomiejczyk2, B. Malachowska2,3, P. Pruszkowska1,
P. Wroblewski1, A. Szadkowska1, W. Mlynarski1, W. Fendler2
Medway Maritime Hospital NHS Foundation Trust, Kent, United
Kingdom
Case: A 12 year old non-obese girl was referred to our daibetes clinic
as T2 diabetes on Metformin via GP. There was no acanthosis nigricans or DKA on presentation. Several family members had diabetes,
they were non-obese, on oral hypoglycaemic agents with addition of
Insulin in 40´s. IA2 and GAD antibodies were negative, genetic testing for MODY was performed at Exeter lab.
1
Medical University of Lodz, Department of Pediatrics, Oncology,
Hematology and Diabetology, Lodz, Poland, 2Medical University of Lodz,
Department of Biostatistics and Translational Medicine, Lodz, Poland,
3
Medical University of Warsaw, Post-Graduate School of Molecular
Medicine, Warsaw, Poland
Objective: To evaluate whether the serum profile of microRNAs
changes is parallel with residual beta cell function or autoantibodies
in children with newly onset type 1 diabetes (T1DM).
Methods: A group of 30 children with T1DM had serum samples collected at four timepoints: at onset, after 12, 24 and between 48–72
months since onset of T1DM. In all samples levels of four autoantibodies and c-peptide (CP) were evaluated. A panel of six microRNAs
(miR-24, miR-21, miR-126, miR-146, miR-375 and let-7 g) selected
on the basis of a previous panel profiling experiment and current literature had their expression measured in the serum using a quantitative realtime-PCR (qPCR).
Results: Serum levels of ICA, ZnT8A and CP differed significantly
throughout the observation period with CP showing a significant
increase at the 1-year timepoint followed by a decline thereafter.
ZnT8A and ICA declined linearly over time, while GADA and IA2A
levels did not change significantly. Expression of beta-cell associated
miR-375 was below detection level in qPCR in all samples since the
1-year timepoint. Let-7 g expression pattern mirrored that of Cpeptide (fig 1). At the last timepoint, expression of let-7 g correlated
[Family tree]
Results: All known MODY genes were screened on the HiSeq 2500
targeted next generation sequencing platform using previously
described methods (Ellard 2013, Diabetologia) but no pathogenic
mutations were detected. A single heterozygous variant (p.G71V;
c.212G > T) was however identified in the INS gene. The glycine residue at codon 71 is moderately conserved across species and is
located within the region of the gene encoding c-peptide which is
59
POSTER TOURS
cleaved during insulin processing. This variant has also been reported
previously in control datasets with a minor allele frequency of < 1 in
10,000 (ExAc Browser). Family member testing identified the variant
in the probands affected mother and maternal grandmother however
testing of the probands maternal aunt and maternal great uncle,who
had both been diagnosed with diabetes, did not identify the variant.
Whilst the clinicial significance of this variant is currently uncertain,
the absence of co-segregation within this family suggests that it may
be a rare variant of no clinical significance.
Patient is currently doing well on Metformin with BMI 24.8 and
HbA1c 40 mmol/mol.
P060
Serum levels of lysophosphatidic acid are strongly
elevated in patients with HNF1B-MODY
B. Malachowska1,2, M. Ciborowski3, J. Janikiewicz4, K. Pietrowska3,
J. Madzio5, K. Antosik6, M. Bartlomiejczyk1, K. Wyka5, A. Kretowski3,
M. Borowiec6, A. Dobrzyn4, W. Mlynarski5, W. Fendler1
1
Medical University of Lodz, Department of Biostatistics and
Translational Medicine, Lodz, Poland, 2Medical University of Warsaw,
Post-Graduate School of Molecular Medicine, Warsaw, Poland, 3Medical
University of Bialystok, Clinical Research Center, Bialystok, Poland,
4
Nencki Institute of Experimental Biology, Polish Academy of Sciences,
Laboratory of Cell Signaling and Metabolic Disorders, Warsaw, Poland,
5
Medical University of Lodz, Department of Pediatrics, Oncology,
Hematology and Diabetology, Lodz, Poland, 6Medical University of Lodz,
Department of Clinical Genetics, Lodz, Poland
Objectives: Identification of altered serum metabolites among
HNF1B-MODY patients.
Methods: We recruited patients with HNF1B-MODY (N = 10),
HNF1A-MODY (N = 10), polycystic kidney disease: non-dialyzed and
dialyzed (N = 8 and N = 13 respectively) and healthy controls
(N = 12). Previously unthawed serum samples were fingerprinted by
LC/MS. Observed metabolic changes were validated by ELISA performed in a different set of serum samples (HNF1B-MODY (n = 9),
HNF1B-negative patients with diabetes and renal cysts (n = 6),
HNF1A-MODY (n = 11), GCK-MODY (n = 17), healthy controls (n = 17)).
Results: In order to obtain metabolites that best differentiate
HNF1B-MODY patients, we selected metabolic features detected in
80% of samples in each group, with adjusted p < 0.05 and with fold
change >3 or < 0.33 for comparison of HNF1B-MODY patients and
non-dialyzed ones. Eight identified metabolites had convergent fold
change for comparison of HNF1B-MODY versus all other groups.
Three of them were lysophosphatidic acid species (LPAs: 18:1, 18:2,
20:4) that proved to be the best biomarkers for HNF1B-MODY (Area
under ROC curve 1.00 (95%CI 0.91-1.00); 1.00 (95%CI 0.91-1.00);
0.923 (95%CI 0.795-0.983) respectively). On a new set of samples
we confirmed elevated levels of LPA among HNF1B-MODY patients
(p = 0.0063). The main enzyme producing serum LPA - autotaxin was down-regulated in HNF1A- vs HNF1B-MODY patients
(p = 0.0173) but did not differ between HNF1B-MODY and other
groups (all p values >0.84). The downregulation of autotaxin expression was evidenced on cellular level with HNF1B-silenced human
hepatocytes.
Conclusions: An important lipid mediatory compound - LPA was
found to be elevated in serum of patients with HNF1B-MODY. The
main extracellular pathway responsible for LPA production was not
up-regulated, indicating that other pathways were responsible for
increased serum concentration of LPA.
P061
Next-generation sequencing-based screening of
monogenic mutations in 43 Japanese children
clinically diagnosed with type 1B diabetes
K. Ushijima1, M. Fukami1, T. Ayabe1,2, M. Okuno1,3, S. Narumi1,
T. Ogata4, N. Kikuchi5, T. Kawamura6, T. Urakami3, I. Yokota7,
S. Amemiya8, S. Sugihara9, The Japanese Study Group of Insulin
Therapy for Childhood and Adolescent Diabetes
1
National Center for Child Health and Development, Department of
Molecular Endocrinology, Tokyo, Japan, 2Sanaikai General Hospital,
Department of Pediatrics, Misato, Japan, 3Nihon University School of
Medicine, Department of Pediatrics and Child Health, Tokyo, Japan,
4
Hamamatsu University School of Medicine, Department of Pediatrics,
Hamamatsu, Japan, 5Yokohama City Minato Red Cross Hospital,
Department of Pediatrics, Yokohama, Japan, 6Osaka City University
School of Medicine, Department of Pediatrics, Osaka, Japan, 7Shikoku
Medical Center for Children and Adults, Department of Pediatrics,
Division of Pediatric Endocrinology and Metabolism, Kagawa, Japan,
8
Saitama Medical University Faculty of Medicine, Department of
Pediatrics, Saitama, Japan, 9Tokyo Women’s Medical University Medical
Center East, Department of Pediatrics, Tokyo, Japan
Objectives: Type 1 diabetes (T1D) lacking diabetes-associated autoantibodies are termed as type 1B (T1BD). Monogenic diabetes such
as neonatal diabetes and maturity-onset diabetes of the young is
caused by genetic defects in the insulin secretion pathway. Because
clinical characteristics of those monogenic forms and T1BD are partially overlapping, children with monogenic diabetes could be clinically diagnosed with T1BD. The objectives of this study was to clarify
the prevalence and clinical consequences of monogenic mutations in
Japanese children clinically diagnosed with T1BD.
Methods: We studied 43 Japanese children from 42 families diagnosed with T1D at age between 0.5 and 16.0 years and had no
diabetes-associated autoantibodies. The participants were recruited
from 30 hospitals of the Japanese Study Group of Insulin Therapy for
Children and Adolescent Diabetes. We performed genetic analysis
using the HaloPlex target enrichment system (Agilent) and a nextgeneration sequencer HiSeq (Illumina) to screen mutations in 30 genes
known to cause monogenic diabetes.
Results: Four of 43 participants had heterozygous missense mutations in the insulin gene (INS). No mutations were observed in the
remaining 29 genes. The INS mutations (p.G75C, p.C96F and p.V42A)
were hitherto unreported. The p.C96F mutation-carrying children
were siblings, whose mother was also affected by T1D. No significant
differences were observed in body mass index-Z score between the
INS mutation carriers and non-carriers (−0.4 vs −0.9, p = 0.26). Age at
diagnosis was significantly younger in the INS mutation carriers than
that of non-carriers (2.7 vs 9.4 years, p = 0.025).
Conclusions: The results indicate that small proportion of T1BD children with onset age >0.5 years have monogenic mutations. Mutation
screening of those children is helpful not only to understand the
molecular pathogenesis but also to provide individualize management,
including genetic counseling.
P062
Late atypical IPEX syndrome diagnosis in a 26-year
male with neonatal diabetes
A.D.C. Riquetto1, L.A. Caetano1, L.S. Santana2, A.M. Lerário3,
M. Nery4, A.A.L. Jorge2, M.G. Teles1, Monogenic Diabetes GroupFMUSP
1
Clinics Hospital, School of Medicine, University of Sao Paulo (USP),
Genetic Endocrinology Unit/Laboratory of Molecular & Cellular
Endocrinology/LIM25, and Diabetes Unit, Sao Paulo, Brazil, 2School of
Medicine, University of Sao Paulo (USP), Genetic Endocrinology Unit and
Laboratory of Molecular & Cellular Endocrinology/LIM25, Sao Paulo,
Brazil, 3School of Medicine, University of Sao Paulo (USP), Laboratory of
Hormones and Molecular Genetics/LIM42, Adrenal Unit, Sao Paulo,
60
Brazil, 4Clinics Hospital, School of Medicine, University of Sao Paulo
(USP), Diabetes Unit, Sao Paulo, Brazil
Objective: Immune dysregulation, Poliendocrinopathy, Enteropahty,
X-linked syndrome (IPEX) is a rare and often lethal systemic autoimmunity that usually presents in first year of life. Our aim is to report a
26 year-male patient with late diagnosis of IPEX in which main clinical characteristic was insulin-dependent neonatal diabetes mellitus (NDM).
Case report: FHC was in our Monogenic Diabetes Outpatient Clinic
for first time at the age of 25 years(y). He had NDM diagnosis at
26 days of life. He presented diarrhea and cachexia for 3 months in
his first year and two severe episodes of cutaneous lesions due to
skin infections by varicella and herpes in first 2y. Until 10y, he had
recurrent acute medium otitis, six episodes of pneumonia, several
asthma attacks and oral lichen planus. He had lot of hospitalizations
during his six first years and no one thought about IPEX as a diagnostic hypothesis. Nowadays his clinical manifestations were restricted
POSTER TOURS
to diabetes. As he came to us in his third decade of life with only diabetes as current clinical manifestation, we hypothesized a mutation in
KCNJ11 and investigated by Sanger sequencing, with negative result.
We decided then perform genetic analysis by targeted massively parallel sequencing. We used a customized genomic panel with 26 NDM
genes. We identified a disease-causing previously described missense
variant in exon 11 of FOXP3 [c.G1190A/p.R397Q - NM_014009].
Conclusion: Mutations in FOXP3 are responsible for 4% of diagnosis
in male patients with permanent NDM. It should be suspected when
NDM is related to immune dysregulation and/or in presence of autoantibodies for pancreatic antigens. Our report reinforce the necessity
of attention to mild cases, otherwise they will be underdiagnosed.
We also present a case with a greater life expectancy comparing to
reported cases (mortality of 34% at medium age of 10y, with 3/134
reported cases with more than 20y). Finally, it shows the importance
of genetic test for NDM.
61
POSTER TOURS
Poster Tour 9: President’s Choice
P065
Insulin requirements and the factors contributing to
insulin dose adjustment during the first year of type
1 diabetes duration in children treated with
insulin pump
K. Piechowiak, K. Dżygało, K. Indulska, L. Groele, A. Ramotowska,
A. Szypowska
Medical University of Warsaw, Warsaw, Poland
Objectives: Continuous subcutaneous insulin infusion(CSII) is
initiated in many children from type 1 diabetes(T1D) onset. Guidelines on insulin dosage adjustment might help clinicians in therapy of
this patients.The aim of the study was to assess the insulin requirement and determine factors contributing to insulin dose adjustment
in the first year of T1D duration in children on CSII.
Methods: There were included 100 children(49 boys) with newly
diagnosed T1D treated with CSII. Mean age at diagnosis was
8.16 3.58(0.7-15.9) years, mean initial HbA1c was 12.04 2.49%;
mean initial BMI z-score −0.75 2.20. Following parameters were
analysed: c-peptide, HbA1c, total daily insulin dose(TDD; units/kg/
day), basal/TDD proportion(basal%) and BMI at onset, 3, 6, 9 and
12 months of follow-up.
Results: Daily insulin requirements remained low in the subsequent
months(0.37, 0.40, 0.47, 0.5units/kg; p < 0.0001). Basal insulin rate
was low(16.7, 18.7, 21.4, 23.5%;p = 0.0003). Patients had good diabetes control(HbA1c 6.2, 6.4, 6.6, 6.7%). We found correlation
between C-peptide level and age(r = 0.42 95%CI[0.23-0.57];
p < 0.0001). There was no correlation between age and TDD or basal
%. Correlations between levels of C-peptide and BMI were observed
during the entire period of follow-up(p < 0.05). At the onset were
found significant negative correlation between BMI and
TDD(p = 0.0001)
and
correlation
between
HbA1c
and
TDD(p = 0.0002), and basal%(p = 0.012). At diagnosis correlation
was found between C-peptide and TDD(p = 0.011), HbA1c
(p = 0.090), basal%(p = 0.036). There was correlation between Cpeptide and TDD(p = 0.001) and HbA1c(p = 0.029) after 3 months of
follow-up.
Conclusions: During the insulin pump programming in patients with
newly diagnosed diabetes, levels of BMI, HbA1c and C-peptide should
be considered. Lower insulin requirement is expected in children with
lower initial HbA1c and higher BMI and C-peptide level. In the first year
of diabetes duration, basal insulin rate is low(<25% of TDD).
P066
BMI change during the course of type 1 diabetes is
modified by the level of diabetes control - data
from the Swedish national quality register
SWEDIABKIDS
A. Pundziute Lyckå1, L. Hanberger2, S. Särnblad3, K. Åkesson4,
U. Samuelsson5
1
Södra Älvsborg Hospital Borås, Department of Pediatrics, Borås,
Sweden, 2Linköping University, Department of Medicine and Health
Sciences, Division of Nursing, Linköping, Sweden, 3Örebro University
Hospital, Department of Pediatrics, Örebro, Sweden, 4Jönköping
Hospital, Department of Pediatrics, Jönköping, Sweden, 5Linköping
University Hospital; Linköping University, Department of Pediatrics,
Linköping, Sweden
Objectives: Female gender, low BMI at onset of diabetes, long diabetes duration, pubertal diabetes onset and intensified insulin therapy
were previously associated with increased weight gain during the
course of Type 1 diabetes in paediatric patients. We aim at investigating the development of BMI-SDS and associated factors in a
nationwide data set from Sweden.
Methods: The study population consisted of all patients below
18 years of age with T1D registered in the Swedish national childhood diabetes register SWEDIABKIDS during 2000–2014. The Swedish population-based growth reference was used for calculating BMI
standard deviation score (SDS). Mean BMI-SDS and HbA1C was calculated for every patient for every year of diabetes duration, excluding the first 90 days after the diagnosis. Comparisons were made
between groups of 0–4, 5–9 and >9 years of diabetes duration and
HbA1C < 52; 52–69 and >69 mmol/mol (NGSP < 6,9; 6,9-8,5
and >8,5%).
Results: Data were available from 9710 patients (4397 girls). The
duration of diabetes ranged from 0 to 17 years. Mean HbA1C
increased with increasing diabetes duration: 59,1; 66,7 and 69,0
(p < 0,001), this was true for both sexes. For the girls mean BMI-SDS
increased with increasing diabetes duration: 0,60; 0,81 and 0.88
(p < 0,001). However for the boys mean BMI-SDS decreased with
long diabetes duration: 0,56; 0,56 and 0,38 (p < 0,001). We analysed
the effect of diabetes duration and metabolic control for mean BMISDS. For the girls mean BMI-SDS increased with increasing diabetes
duration in groups with HbA1C >52 mmol/mol (p < 0,001). For the
boys mean BMI-SDS decreased with long diabetes duration >9 years
within every level of HbA1C (p < 0,001).
Conclusion: BMI-SDS change with increasing diabetes duration is
modified by the level of diabetes control and differs between boys
and girls. The positive association of increasing BMI-SDS and diabetes duration is particularly pronounced in girls with less well controlled diabetes.
P067
Seasonality of birth and first diagnosis dates of
children and adolescents with type 1 diabetes
mellitus in a large diabetes center during the last
16 years
I.-A. Vasilakis, I. Kosteria, F. Tzifi, A. Voutetakis, G. Chrousos,
C. Kanaka-Gantenbein
Diabetes Center, Division of Endocrinology, Diabetes and Metabolism,
First Department of Pediatrics, National and Kapodistrian University of
Athens Medical School, Athens, Greece
Objectives: Previous studies supported seasonality regarding the
dates of birth and first diagnosis of children with type 1 diabetes mellitus (T1DM), with most patients being diagnosed in the fall and winter and born during the same seasons. This was confirmed,
concerning the date of first diagnosis, with data from our country
between 1978 and 2008. Our objective was to test whether such a
seasonality is still present in a large cohort of children followed in a
single diabetes center in the years 2000–2015 under Mediterranean
weather conditions.
Method: We retrospectively collected data of 622 children (n = 307
females, mean age 8.17 4 years - median: 8.39 years, range: 0.616 years), admitted in our Department with newly diagnosed T1DM
between 2000 and 2015. We investigated whether there was a seasonal preponderance according to dates of birth and diagnosis.
Results: According to date of diagnosis, significantly more T1DM
patients were diagnosed during winter (183 children, 29.4%) and fall
(163, 26.2%) compared to summer (127, 20.4%) (p < 0,05). According
to date of birth significantly more T1DM patients were born in the
fall (184 children, 29.6%) compared to spring or summer (143, 22.9%
each) (p < 0.01).
Conclusion: In our cohort of newly diagnosed T1DM children in the
last 16 years, there was a statistically significant seasonality according
to date of diagnosis with most newly diagnosed T1DM cases being
diagnosed in winter, like previously described in our country, being
also concordant with current data from west European populations.
According to date of birth of newly diagnosed cases, there was a
62
significant seasonal preponderance with most children born during
the fall, contrary to previous data reporting an increased number of
children with T1DM born during summer and spring.
P068
Ketoacidosis at diabetes onset in the last two
decades in Germany and Austria - a multicenter
analysis and binational comparison with 35,817
patients
K. Nagl1, A. Neu2, T.M. Kapellen3, B. Karges4,5, B. Rami-Merhar1,
J. Hermann5,6, J. Rosenbauer5,7, R.W. Holl5,6
1
Medical University Vienna, Department for Pediatrics and Adolescent
Medicine, Vienna, Austria, 2University Children’s Hospital Tübingen,
Tübingen, Germany, 3University of Leipzig, Women and Children’s
Centre, Leipzig, Germany, 4RWTH Aachen University, Division of
Endocrinology and Diabetes, Aachen, Germany, 5German Center for
Diabetes Research (DZD), Neuherberg-Munich, Germany, 6University of
Ulm, ZIMBT, Department of Epidemiology and Medical Biometry, Ulm,
Germany, 7Leibniz Centre for Diabetes Research at Heinrich-Heine
University Düsseldorf, Institute for Biometrics and Epidemiology, German
Diabetes Centre, Düsseldorf, Germany
Objectives: Late diagnosis of Type 1 Diabetes with occurrence of
diabetic ketoacidosis (DKA) continues to be a problem. An Austrian
population-based analysis found that 37.8% of children presented
with DKA at diagnosis. A large-scale poster-prevention program was
conducted in Austria in 2009 without significant effect on DKA frequency (1). The DKA rate at T1D onset (1995–2007) in the multicenter Diabetes Prospective Follow-up (DPV) registry including Austrian
and German pediatric patients was 21.1% (2), suggesting lower DKA
rates in Germany compared to neighboring Austria.
Methods: DKA occurrence at T1D onset was analyzed with DPV
data from 35,817 patients aged 0.5-20 years at diagnosis between
1995 and 2015 (age: 9 4 years, 54% male, 18% migration background). Occurrence of DKA (pH < 7.3)/ severe DKA (pH < 7.1) at
T1D onset in Austria and Germany was assessed by log binomial
regression adjusting for possible confounders (migration background,
gender, age, year of diagnosis). A two-sided p-value < 0.05 was considered significant.
Results: Overall, DKA/severe DKA rates did not change significantly
over time, with 18.9 0.2% of all patients manifesting T1D with
DKA and 5.5 0.1% with severe DKA. In the last decade 18%/6% of
German and 23%/6% of Austrian patients presented with DKA/severe DKA at onset. Adjusted for confounders there was no significant
difference between rates of DKA or severe DKA at T1D onset
between the two countries. Highest rate of DKA/severe DKA
occurred in children < 5 years (23%/7%), females (19%/6%) and
patients with migration background (23%/7%).
Conclusion: DKA rate at T1D onset does not differ significantly
between Austria and Germany after adjustment for demographic confounders. Overall, DKA rates did not change significantly over the last
two decades. A higher risk for DKA at T1D diagnosis was present in
girls, in children < 5 years of age and in patients with migration
background.
1) Fritsch M. J Pediatr 2013, 2) Neu A. Diabetes Care 2009.
P069
Association between insulin-like growth factor-I
(IGF-I) and IGF-binding protein-1(IGFBP-1) axis and
glucose intolerance in children
J.W. Hwang1, M.S. Kim1, D.-Y. Lee1
1
Chonbuk National University Medical School, Department of Pediatrics,
Jeonju, Korea, Republic of
Objectives: Increasing evidence suggests an important role of the
IGF-IGFBP axis in the maintenance of normal glucose and lipid
metabolism. This study aimed to investigate the association of
POSTER TOURS
insulin-like growth factor-I(IGF-I) and IGF-binding protein-1(IGFBP-1)
with glucose intolerance in children.
Methods: We included 80 children aged 10 to 16 years without
known diabetes and other chronic diseases. They were classified into
3 groups according to oral glucose tolerance test(normal glucose tolerance, NGT; impaired glucose tolerance, IGT; diabetes, DM). We
performed anthropometric measurement and laboratory tests including serum IGF-I and IGFBP-1.
Results:
1. Serum IGF-I levels were significantly higher in IGT group than
other 2 groups(P = 0.021), and serum IGFBP-1 levels were not different in 3 groups(P = 0.663). However, serum IGF-I/IGFBP-1
ratio were significantly different with highest level in
DM(P = 0.012).
2. Serum IGF-I was correlated with age, c-peptide, HOMA-IR and
IGFBP-1 in NGT. But these correlations were disrupted in glucose
intolerance group without any correlations(IGT + DM).
3. Serum IGFBP-1 was negatively correlated with age, BMI, serum cpeptide, IGF-I, HOMA-β and HOMA-IR in NGT, and only correlated with age and BMI in glucose intolerance group.
4. Serum IGF-I/IGFBP-1 ratio were significantly related with age,
BMI, serum c-peptide, IGF-I, IGFBP-1, HOMA-β and HOMA-IR in
NGT. However, in IGT + DM group, they were only correlated
with BMI, c-peptide, HOMA-β and IGFBP-1.
Conclusion: Serum IGF-I and IGF-I/IGFBP-1 ratio were significantly
elevated in children with glucose intolerance, and their relationships
with c-peptide, HOMA-β and HOMA-IR were altered to according to
glucose tolerance status. These findings suggest that disturbances of
IGF-1/IGFBP-1 axis may affect the development of glucose intolerance including diabetes in children.
P070
Risk of recurrent severe hypoglycemia or
hypoglycemic coma remains associated with a past
history of severe hypoglycemia even up to 4 years
in a large prospective contemporary pediatric
cohort: results from DPV initiative
D. Pacaud1,2,3, J. Hermann3,4, A. Herbst5, J. Rosenbauer4,6,7,
S. Müther8, R. Dürr9, B. Karges10, S. Lindauer11, K. Raile12,
M. Witsch13, T. Danne14, S. Pötzsch15, R.W. Holl3,4
1
University of Calgary, Paediatrics, Calgary, Canada, 2Alberta Children’s
Hospital, Pediatric Diabetes and Endocrinology, Calgary, Canada,
3
University of Ulm, Institute of Epidemiology and Medical Biometry,
ZIBMT, Ulm, Germany, 4German Center for Diabetes Research (DZD),
Munich-Neuherberg, Germany, 5Medical Clinic Leverkusen, Center for
Paediatrics, Leverkusen, Germany, 6Heinrich Heine University, Leibniz
Center for Diabetes Research, Düsseldorf, Germany, 7German Diabetes
Center, Institute for Biometrics and Epidemiology, Düsseldorf, Germany,
8
DRK Clinics Berlin Westend, Diabetes Center for Children and
Adolescent, Berlin, Germany, 9Rems-Murr-Clinics, Children and
Adolescent Medicine, Waiblingen, Germany, 10RWTH Aachen University,
German Center for Diabetes Research (DZD), Medical Faculty, Division
of Endocrinology and Diabetes, Aachen, Germany, 11Hospital
Barmherzige Schwestern Linz, Department for Children and Adolescent
Medicine, Linz, Austria, 12Charité Berlin, Department of Pediatric
Endocrinology and Diabetes, Berlin, Germany, 13Centre Hospitalier de
Luxembourg, Clinique pediatrie, Luxembourg, Luxembourg, 14Hospital for
Children and Adolescent ’Auf der Bult’, Diabetes Centre for Children and
Adolescents, Hannover, Germany, 15Helios Vogtland Clinic Plauen,
Department for Children and Adolescent Medicine, Plauen, Germany
Objectives: In a contemporary cohort of youth with type 1 diabetes
(T1DM), to examine interval between episodes as a risk factor for
recurrent severe hypoglycemia (SH) or hypoglycemic coma (HC).
Methods: Using the DPV Diabetes Prospective Follow-up in Germany and Austria, frequency and timing of recurrent SH (defined as
requiring assistance from another person) and HC (loss of consciousness or seizures) in youth with T1DM aged < 20 yr and at least 5 yr
of follow-up were analyzed (n = 14,177). Logistic regression models
63
POSTER TOURS
adjusting for age (<12, 12- < 18, ≥18 yr), duration (5–10, ≥ 10 yr)
and gender were used to examine the relationship between history
and timing of previous SH/SHC and risk of SH/HC in the current year
of observation (04/2015-03/2016).
Results: Subjects were: 51% male, median age at last observation
16.7 [Q1;Q3: 13.8;17.8] yr, duration of T1DM 8.2 [6.3;10.8] yr and
A1C 7.9 [7.2;8.8]%. During the 5 years of follow-up, 72% had no SH,
14 % one SH and 14% > 1 SH. The relative risk of SH in the current
year was highest with SH in the previous year (odd ratio (OR) 4.7
[CI 4.0-5.5]), but remained elevated even 4 years after an episode
(OR 2.0 [CI 1.5-2.7]). A similar pattern was observed when examining
the OR for HC. Table 1 presents the proportion of patients with
SH/HC in the current year according to time since last previous
episode.
History of
last
SH/HC in
yr −1
History of
last
SH/HC in
yr −2
History of
last
SH/HC in
yr −3
History of No past
last
history
SH/HC in of SH/HC
yr −4
SH in current 23%
yr
15%
8%
9%
4.6%
HC in
13%
current yr
8%
5%
5%
2%
dysfunction, cardiac defects, exocrine pancreatic dysfunction and
neutropenia can be associated. Outcome is poor. Most patients die in
childhood of flu-like episodes with fulminant hepatitis sometimes
combined with encephalopathy.
Case presentation: 8.5 (95% The patient presented at 2,5 months of
age with diabetes, liver failure and neutropenia. Initiation of insulin
pump therapy induced a good glycemic control and normalization of
liver function. Epiphyseal dysplasia and mental impairment were
absent. WRS was confirmed by the finding of a homozygous stop
mutation in EIF2AK3 (p.W681X). At 21 months, she was hospitalized
with fever, hepatitis, somnolence and hypotonia. Influenza A infection
was confirmed. Liver tests normalized after18 days yet she remained
hypotonic and developed ataxia. Brain MRI revealed cerebellitis. A
repeat MRI after five months showed cerebellar atrophy.
Discussion: 8.5 (95% This is the first case of WRS and severe neurological sequellae after proven Influenza A virus cerebellitis. Early
neurodegeneration has been described in WRS. Innate immune system pathways and connectome analysis suggest a role for EIF2AK3
in human host defense against viruses such as HSV, EBV and Influenza A. Functional testing is ongoing to confirm this hypothesis.
P072
Neonatal diabetes: story of collaboration
K.N. Humayun1, A. Hattersley2, E. Sian3
[Table 1]
Conclusions: This is the first prospective pediatric study evaluating
the impact and timing of a previous episode on the OR for future
severe hypoglycemia. Even 4 years after an episode of SH/HC, children and youth remain with a long term higher risk for SH/HC compared to children who never experienced SH/HC. Therefore,
clinicians should continue to regularly track this history at every visit
and, whenever possible, adjust therapy in order to avoid recurrences.
P071
Influenza A cerebellitis in Wolcott-Rallison
syndrome: more than bad luck?
B. Bosch1,2,3, M. Ciancanelli2, M. Leen4, F. Vermeulen5, P. Witters6,
J.-L. Casanova2,7,8, I. Meyts1,9, K. Casteels10,11
1
KU Leuven, Department of Microbiology and Immunology, Leuven,
Belgium, 2The Rockefeller University, St Giles Laboratory of Human
Genetics of Infectious Diseases, New York, United States, 3University
Hospital Leuven, Leuven, Belgium, 4KU Leuven, Experimental Laboratory
Immunology, Leuven, Belgium, 5University Hospital Leuven, Pediatric
Infectious Diseases, Leuven, Belgium, 6University Hospital Leuven,
Pediatric Gastroenterology, Leuven, Belgium, 7The Howard Hughes
Medical Institute, New York, United States, 8Necker Hospital for Sick
Children, the Laboratory of Human Genetics of Infectious Diseases, Paris,
France, 9University Hospital Leuven, Pediatric Immunology, Leuven,
Belgium, 10University Hospitals Leuven, Pediatric Diabetes, Leuven,
Belgium, 11KU Leuven, Department of Development and Regeneration,
Leuven, Belgium
Background: Wolcott-Rallison Syndrome (WRS) is a rare autosomal
recessive syndrome caused by mutations in EIF2AK3 (Eukaryotic
Translation Initiation Factor 2-alpha Kinase 3). WRS is characterized
by neonatal insulin-dependent diabetes, epiphyseal dysplasia and
growth retardation. Mental retardation, hepatic and kidney
1
Aga Khan University, Pediatrics and Child Health, Karachi, Pakistan,
University of Exeter Medical School, Department of Molecular Medicine,
Exeter, United Kingdom, 3University of Exeter Medical School,
Department of Molecular Genetics, Exeter, United Kingdom
2
Background: Neonatal diabetes is a rare form of monogenic diabetes
with onset in the first six months of life occurring in 1/100,000 to 1/
400,000 births. Both permanent and transient forms are described.
Objectives: We want to bring to focus how collaboration with a center of excellence in Diabetes Genes has been possible through the
ISPAD forum.
Methods: Four neonates presented to our center with diabetic
ketoacidosis between the years 2011 to 2015. Through the ISPAD
forum contact with Exeter Monogenic Diabetes team was established
and genetic testing was done for all these babies free of charge.
Results: Each of these 4 babies was found to have a different mutation. First one had a novel hemizygous missense variant, p.N388S in
the FOXP3 gene which causes IPEX syndrome. Second baby was
found to be homozygous for EIF2AK3 nonsense mutation, p.L1030X
which confirmed diagnosis of Wolcott Rallison syndrome. Unfortunately both of them succumbed to the associated complications of
their syndromes. Third baby was homozygous for an INS promoter
mutation, c.-332C > G and had recessively inherited neonatal diabetes due to mutations in the INS gene. He has the TNDM phenotype.
After the age of 3 months till now when he is 18 months old he has
no insulin requirement. Our fourth patient had his journey to the miracle when he was found to have the KCNJ11 missense mutation,
p.R201H. His neonatal diabetes due to a mutation in the Kir6.2 subunit of the K-ATP channel. Transfer to sulphonylurea therapy was
initiated and he is now three year old with glibenclimide controlling
his diabetes well.
Conclusion: Genetic diagnoses and management of these babies
with neonatal diabetes is an excellent example of multicenter collaboration between developed and developing countries happening
through ISPAD forum.
64
POSTER TOURS
Poster Tour 10: Chronic & Acute Complications
P073
Only one identified patient with persisting simple
retinopathy in childhood T1D - is screening
indicated in Denmark from the age of 12 years?
I.M. Overgaard Ingeholm1, B. Olsen2, K. Pilgaard3, M. Madsen4,
P. Kjærgaard5, S. Fredheim2, A. Johansen6, K. Kristiansen7,
N. Birkebæk7, J. Svensson2, J. Johannesen2
1
Herlev University Hospital, Herlev, Denmark, 2Herlev University
Hospital, Pediatric, Herlev, Denmark, 3Nordsjællands Hospital, Hillerød,
Denmark, 4Aalborg University Hospital, Aalborg, Denmark, 5Herning
Hospital, Herning, Denmark, 6Rigshospitalet, Growth and Reproduction,
Copenhagen, Denmark, 7Aarhus University Hospital, Aarhus, Denmark
Aim: From 1996 and forward the HbA1c has decreased amongst children and adolescents in Denmark. Therefore this preliminary study
aimed to test if screening for retinopathy is indicated in Denmark
from the age of 12 years as the current Danish guideline
recommends.
Methods: Data from the national diabetes register for children and
adolescents in Denmark, DanDiabKids was used to identify children
and adolescents that had been screened at age 12, 15, and 18 years
for retinopathy. Data was collected from 1996 to 2015.
Results: 17 out of 1994 patients (0.9%) had retinopathy changes at
the age of 12 years. Only 7 of the patients had changes in both eyes.
All of them had simple retinopathy changes at this age. By the age of
15 years 2% had retinopathy changes and 2.8% at the age of
18 years. Only one patient born in 1985 had persisting simple retinopathy from age 12 to 18 years. From 2001 and forward the data
completion of the screening varies between 60 and 78%. Higher
HbA1c was observed among individuals with retinopathy than
without.
Conclusion: Since the HbA1c has decreased in Denmark from 1996
and only one patient that was born in 1985 has had persistent simple
retinopathy, strict adherence to the ISPAD guidelines (screening
starting from age 10, or at onset of puberty if this is earlier, with 2–5
years diabetes duration) seems very resourceful with little gain for
the individual patient. We suggest that current guidelines should be
adjusted nationally and individually according to metabolic control.
P074
Skin-advanced glycation end products and arterial
stiffness in children with type 1 diabetes
S. Mahnin1, M. van Albada1, A. van Roon2, H. Westra3, A. Smit2,
W. Bakker-van Waarde1
1
Department of Pediatric Endocrinology, Beatrix Children’s Hospital,
University Medical Center Groningen, University of Groningen,
Groningen, Netherlands, 2Division of Vascular Medicine, University
Medical Center Groningen, University of Groningen, Groningen,
Netherlands, 3Department of Rheumatology and Clinical Immunology,
University Medical Center Groningen, University of Groningen,
Groningen, Netherlands
Objectives: Advanced glycation end products (AGEs) are considered
to contribute to micro- and macrovascular complications in patients
with type 1 diabetes (DM1). The aim of the present study was to
investigate if skin AGEs are associated with early signs of atherosclerosis, measured by arterial stiffness and correlate results with inflammatory biomarkers.
Methods: In a prospective cohort study, 81 T1D patients (age range,
3–21 years) and 65 control subjects (age range, 4–21 years) participated. Skin autofluorescence (SAF) was measured with an autofluorescence reader. Vascular compliance was measured by using the
carotid-to-femoral pulse wave velocity (PWV), in patients and control
subjects of eight years and older. Interleukin 6 (IL-6) and high
sensitivity C-reactive protein (hsCRP) were evaluated in T1D patients
and controls . Data were analyzed statistically by Mann–Whitney U
test, Spearman’s test and linear and multiple regression.
Results: Patients with T1D had an increased value of SAF, PWV and
hsCRP compared to control subjects (1.33 vs. 1.17 AU, P = 0.000;
5.54 vs. 5.14 m/s, P = 0.009; 0.46 vs. 0.33 mg/L, P = 0.000 respectively). IL-6 was not significantly different between both groups.
In patients with T1D SAF correlated with age, gender, HbA1c and
hsCRP. PWV correlated with age, SAF, diabetes duration, cardiovascular disease and hypercholesterolemia in the family medical history.
hsCRP was correlated with age, gender, height SDS, waist SDS, BMI
SDS, smoking, SAF, diabetes duration, micro-albuminuria, HbA1c and
hypertension. There were no correlations with
IL-6.
Conclusions: Children with DM1 have increased skin AGEs that are
associated with higher PWV values, and increased hsCRPs compared
to controls. Measurement of skin AGEs may contribute to the early
identification of children at increased risk for macrovascular
complications.
P075
Antecedents of diabetic ketoacidosis with new
onset type one diabetes from a regional paediatric
diabetes centre: Auckland, New Zealand 2010
to 2014
E. Gunn1, A. Gunn1, C. Jefferies1,2, B. Albert1,2
1
Starship Children’s Hospital, Auckland, New Zealand, 2University of
Auckland, Liggins Institute, Auckland, New Zealand
Background: There has been little change in the rates of diabetic
ketoacidosis (DKA) in newly diagnosed type 1 diabetes mellitus over
recent decades.
Objectives: To examine the hypothesis that the risk of diabetic
ketoacidosis (DKA) in children aged < 15 years with new onset
T1DM was related to delayed diagnosis in primary care.
Methods: Retrospective analysis of prospectively collected data from
a complete regional cohort for Auckland (New Zealand) from 2010
to 2014.
Results: 263 children presented with new onset T1DM, including
141 males, at a mean age of 9.1 0.2 years. 68 (25.8%) presented in
DKA. 217 (82%) children were referred from primary care, while
47 (18%) self-presented to local emergency departments. 81 (37.5%)
had delayed referral from primary care, often due to obtaining community blood tests. However, delayed referral was associated with a
reduced rate of DKA (14.8% vs. 30.4%; p < 0.05). Self-presentation
was more likely in children with a family history of T1DM (37.8% vs
6.9%, p < 0.0001) and in children in DKA (40% vs 24.5%, P = 0.043).
Conclusions: The great majority of children with new T1DM in the
Auckland region were first diagnosed in primary care. Overall, referral
from primary care was associated with a lower risk of DKA than with
self-presentation. Although delayed referral was common, it was
associated with reduced risk of DKA, likely because sicker children
were more likely to be referred for urgent assessment. These data
suggest that although clear referral guidelines for primary care clinicians may reduce delay in diagnosis of new T1DM, community education is critical to reduce the risk of DKA with new onset T1DM.
P076
Managing hypoglycemia during fasting in Ramadan
- scoping review of the evidence based
perspectives in type 1 diabetics (MYRIAD)
M. Siddiqui1, S. Kulkarni2, K. Shah3, S. Shaikh4, N. Wadhwa5,
T. Shah6, M. Chawla7, R. Kovil8
65
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1
Siddiqui Nursing Home, Thane, India, 2Diabetes, Heart and Child Care
Center, Navi Mumbai, India, 3Diabetes and Thyroid Care Centre,
Mumbai, India, 4Dr Shehla Shaikh Clinic, Mumbai, India, 5AUW Global,
Mumbai, India, 6Diabetes Care Clinic, Mumbai, India, 7Lina Diabetes
Care Centre, Mumbai, India, 8Dr Kovil’s Diabetes Care Centre, Mumbai,
India
Objectives: People with Type 1 Diabetes Mellitus (T1DM) are generally advised not to fast because of the risks of severe complications,
especially hypoglycemia; with enhanced risk for augmented ketogenesis. The novel approaches have been documented to help mitigate
the clinical risks of hypoglycemia especially during fasting.
Methods: We conducted a step wise literature mapping and a scoping review for the evidence based perspectives for identifying the
research question and the relevant studies, across the pubmed and
Cochrane library by using specific MeSH, boolean operators Type
1 diabetes AND Ramadan AND Hypoglycemia AND challenges NOT
type 2 Diabetes. We undertook interpretive synthesis to identify evolution of approaches that can enable people with T1DM to fast during Ramadan.
Results: T1DM fasting increases the risk of hypoglycaemia by 4.7
fold during Ramadan as compared before Ramadan (EPIDIAR). We
evaluated a total of four studies across 2005–2016 which evaluated
the hypoglycemia risk mitigation modalities. The cumulative no. of
patients analysed were 103 (mean 25.75 23.82, min 5, max 60 CI
−12.16, 63.66). Two studies each were published from Lebanon and
one each from UAE and the recent most (2016) from Egpyt, evaluated the benefits of the low glucose suspend feature of the Medtronic sensor-augmented insulin pump system (MiniMed 530G with
Enlite). The modalities to mitigate the risk of hypoglycaemia include,
insulin pumps, self-monitoring with regular follow up through a comprehensive care team approach model and modulation of the insulin
type and dosage during Suhur and Iftar.
Conclusions: The recent evidences demonstrate that an individualised management plan under medical supervision with multi pronged
approach can enable people with T1DM to fast safely. We propose a
new comprehensive care model (ICT) encompassing judicious
approach of Insulin pump, Comprehensive care, Therapeutic modulation as a new paradigm to mitigate the risks of hypoglycemia
in T1DM.
P077
Can functional and postural alterations affect young
subjects with type 1 diabetes mellitus?
P. Francia1, B. Piccin2, E. Casalini1, M. Gulisano1, S. Toni2
School of Human Health Sciences, Florence, Italy, 2Diabetes UnitMeyer Children’s Hospital, Florence, Italy
1
Objectives: It is well known that diabetes mellitus can affect the
patient’s quality of movement. The aim of this study was to evaluate
the early occurrence of functional and postural alterations in young
subjects with type 1 diabetes mellitus (T1DM).
Methods: In 15 patients with diabetes (10/5:M/F), mean age
11.5 1.8 yrs, duration of diabetes 5.6 2.6 yrs, mean HbA1c
7,4 0,8%, body mass index (BMI) 19.5 4,6 kg/m2, and in
37 (23/14:M/F), age-, and BMI-matched healthy controls, were evaluated: muscle strength of lower limb (Vertical Jump, Standing Long
Jump), lower back and hamstring flexibility, (Sit and Reach Test),
hand’s and ankle’s joint mobility (prayer sign, inclinometer), posture
on the sagittal plane in quiet standing (baropodometric analysis,
images).
Results: Results of muscle strength and flexibility showed no significant differences between the patients group and controls (VJ:
26.3 9.6 cm
vs
27.5 37 cm;
SLJ:
141 31 cm
vs
146.6 18.1 cm; SRT: −3,7 9.5 vs 0.5 6.9).
On the sagittal plane all the evaluations carried out have shown
that the inclination of the axes that originate from the center of the
lateral malleolus and passing through the centre of the head of the
fibula or the tragus of the ear, were directly correlated (r = 0.34,
p < 0.001). The patients group showed a significantly higher
inclination of the axis passing through the head of the fibula than that
passing through the tragus compared to controls. This result underlines the presence of a posture with a higher flexion of the lower
limbs’ major joints in the young patients investigated. (−3.7 5.4 vs
−0.4 5.1; p < 0.05).
Conclusions: The results of this pilot study confirm that young
patients with diabetes do not show a significant deficit of strength or
flexibility. The increased ankle flexion detected in the patients group
could affect the posture and then the quality of gait. This parameter
should be further investigated and, if confirmed, it could suggest
appropriate interventions.
P078
High prevalence of hypertension in children and
adolescents with type 1 diabetes identified through
the 24 hours ambulatory blood pressure monitoring
L. Iughetti, V. Bianco, F. Bonvicini, C. Cattelani, G. Malmusi,
F. Roncuzzi, V. Spaggiari, S. Madeo, P. Bruzzi, B. Predieri
University of Modena and Reggio Emilia, Department of Medical and
Surgical Sciences of the Mother, Children and Adults, Modena, Italy
Objectives: In children and adolescents with type 1 diabetes (T1DM)
the usefulness of 24-hours ambulatory blood pressure monitoring
(ABPM) to predict kidney diseases and cardiovascular morbidity is still
controversial. Aim of this study was to identify blood pressure
abnormalities using both traditional clinic and 24 h-ABPM tools and
their relationship with anthropometric, kidney, and metabolic data.
Methods: Forty patients (52.5% males) with T1DM (age = 13.6
2.56 yrs; T1DM duration >1 yr) were recruited in the study.
Anthropometric, metabolic (HbA1c, lipid profile, renal function parameters), and blood pressure (clinic visit and 24 h-ABPM) data were
collected. Hypertension was defined as:
A) systolic blood pressure (SBP) above 95 centile according to age,
gender, and height centile, and
B) SBP above 95 centile in more than 25% of 24 h-ABPM.
Results: Hypertension was found in 9 out of 40 patients (22.5%)
using data by clinic visit while through 24 h-ABPM its prevalence significantly increased to 57.5% (χ2 = 8.58, p = 0.003). Subjects with
hypertension, according to 24 h-ABPM, had a longer duration of
T1DM than normotensive ones (8.04 3.22 vs. 5.76 1.85 yrs,
respectively, p = 0.013). Six out of 40 patients did not present the
phenomena of dipping (3/6 classified as hypertensive). Considering
the whole population, a significant and positive correlation was
demonstrated between 24 h-ABPM SBP and BMI-SDS (r = 0.38,
p = 0.020) and clinic visit SBP (r = 0.42, p = 0.007). No other significant data was found.
Conclusions: The 24-hours ABPM has allowed us to identify a higher
prevalence of hypertension compared to that we found using SBP
data from the clinic visit. Despite subjects with hypertension have
had T1DM for longer time, our data did not support a relationship
between SBP, metabolic control, lipid profile, and renal function. We
can considered ABPM a useful tool to precociously identify these
patients who may benefit from early therapeutic treatment to prevent disease progression.
P079
Severe hypoglycemia rate is not associated with
better glycemic control in children with type
1 diabetes- an observational cohort study
M. Grandemange1, M. Habiba2, S. Nivot-Adamiak1, M.-A. Guitteny1,
M. De Kerdanet1
1
Centre Hospitalo-Universitaire de Rennes, Rennes, France, 2Centre de
Lutte contre le Cancer Eugène Marquis, Rennes, France
Objective: Improvement in glycemic control is supposed to increase
the risk of severe hypoglycemia (SH), since the DCCT study. Recently,
we observed an increased glycemic control in diabetic children from
66
our cohort of Rennes University Hospital. The objective of this study
was to analyze the occurrence of SH.
Method: We included patients with diabetes type 1, aged less then
18 years who were attending at University Hospital of Rennes from
January 2010 to December 2015. Data on HbA1c,the frequency of
low (<60 mg/dl) glycemia vs. all recorded glycemia on glucometer
downloads over 60 days (LGGD)-reflecting the rate of hypoglycemia,
sex, age and diabetes duration was collected prospectively every
three months. SH was defined as the occurrence of hypoglycemia
with seizure and/or coma requiring glucagon or intravenous glucose.
Patients were allocated to two groups according to the occurrence or
non-occurrence of SH. Data was compared using Chi-square and ttest, level of significance was 5%.
Results: Four thousand one hundred and thirteen quarterly observations from 276 patients were analyzed. Mean HbA1c decreased from
7.7% in 2010 to 7.3% in 2015 (p < 0.0001) and LGGD passed from
9.7% in 2010 to 5.4% in 2015 (p < 0.0001). Fifty-two events of SH
were recorded in 36 patients (1 to 4 events each) during this 6-year
period. Mean HbA1c level in the group with SH (7.5%) did not differ
significantly from the group without SH (7.4 %), (p > 0.05). By comparing mean LGGD between the groups, we observed an LGGDthreshold of 9% beyond which the risk of SH seemed to be increased
(p < 0.05). Sex, age and diabetes duration did not differ between the
groups.
Conclusion: Our data shows a significant improvement of glycemic
control over a 6 year-period in a cohort of children with type 1 diabetes. The occurrence of SH was not associated with a reduced HbA1c
level. Besides, we observed a threshold of 9% for LGGD beyond
which the risk of severe hypoglycemia could be increased.
P080
Audit of pediatric ketoacidosis (DKA) in Sweden:
pump use and health contacts before admission
J.H. Wersäll1, P. Adolfsson2, G. Forsander3, E. Örtqvist4, R. Hanas5
1
University of Gothenburg, Department of Anaesthesiology and Intensive
Care, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg,
Sweden, 2University of Gothenburg, Institute of Clinical Sciences,
Sahlgrenska Academy, Gothenburg, Sweden, 3University of Gothenburg,
Institute of Clinical Sciences, Sahlgrenska Academy, University of
POSTER TOURS
Gothenburg and The Queen Silvia Children’s Hospital, Sahlgrenska
University Hospital, Gothenburg, Sweden, 4Astrid Lindgren Children’s
Hospital, Karolinska University Hospital, Department of Woman and
Child Health, Astrid Lindgrens Children’s Hospital, Karolinska Institutet,
Stockholm, Sweden, 5University of Gothenburg, Department of
Pediatrics, NU Hospital Group, Uddevalla, Sweden; Institute of Clinical
Sciences, Sahlgrenska Academy, Gothenburg, Sweden
Objectives: In 2015, there were 7209 pediatric patients up to the
age of 17.99 years in Sweden. There were 668 cases of new-onset
diabetes. The primary objective of this ongoing study is to investigate
if the incidence of DKA is higher when the treatment regimen is CSII
compared to MDI. The secondary objective is to investigate contacts
taken with the health care services up to one month prior to admission for DKA.
Methods: A two-year prospective study was designed, running from
Feb 2015 to Jan 2017, including all pediatric DKA cases in Sweden.
Data is collected through questionnaires filled out by the primary
caregivers and the attending physicians regarding pre-admission
events and treatments, as well as in-patient parameters. The chisquare test was used for comparison between the CSII and the MDI
groups, and the Mann–Whitney U-tests for pH comparisons (SPSS,
IBM Corporation).
Results: During the first 16 months of the study, 184 episodes of
DKA were reported (118 newly diagnosed). In 2015, 57% of all pediatric patients used insulin pumps (SWEDIABKIDS registry data).
Among DKA cases with previously known diabetes, 65% were in the
CSII group (p = n.s). At admission for DKA, patients in the MDI group
had a median pH of 7.17 and the patients in the CSII a median pH of
7.24 (p < 0.001). Among patients with new-onset diabetes, 48% had
contacted the health care services within 1 month before admission
for DKA. The time range from the first contact with a health care provider within one month until admission for DKA was 0–14 days. Of
patients who had contacted a health care provider before admission
due to clinical symptoms of diabetes, 35% had not been referred to a
pediatric center.
Conclusions: DKA in pump-treated individuals was associated with a
significantly less degree of metabolic disturbance. Among patients
with new-onset diabetes, it was common that symptoms that were
likely related to diabetes did not bring to immediate referral to a
pediatric center.
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Poster Tour 11: Diabetes Care
P081
Longitudinal trajectories of metabolic control from
childhood to young adulthood in type 1 diabetes
from a large German/Austria registry: a groupbased approach
A. Schwandt1,2, J.M. Hermann1,2, C. Boettcher3, D. Dunstheimer4,
J. Grulich-Henn5, B. Rami-Merhar6, J. Rosenbauer2,7, C. Vogel8,
R.W. Holl1,2
1
University of Ulm, Institute of Epidemiology and Medical Biometry,
ZIBMT, Ulm, Germany, 2German Center for Diabetes Research (DZD),
Munich-Neuherberg, Germany, 3Centre of Child and Adolescent
Medicine, Justus Liebig University, Division of Pediatric Endocrinology &
Diabetology, Giessen, Germany, 4Clinical Center Augsburg, Department
of Pediatrics, Augsburg, Germany, 5University of Heidelberg, Department
of Pediatrics, Heidelberg, Germany, 6Medical University of Vienna,
Department of Pediatrics and Adolescent Medicine, Vienna, Germany,
7
Leibniz Center for Diabetes Research at Heinrich Heine University
Düsseldorf, Institute for Biometrics and Epidemiology, Düsseldorf,
Germany, 8Childrens’ Hospital Chemnitz, Department of Pediatrics,
Chemnitz, Germany
Objectives: The aim was to identify distinct pattern of HbA1c over
adolescence in young patients with type 1 diabetes (T1D).
Methods: 6,433 T1D patients from the observational multicenter
DPV database were analyzed (follow up from 8–19 years, baseline
diabetes duration ≥2 years, HbA1c aggregated per year of life). To
identify distinct subgroups of subjects following a similar HbA1c pattern of change over time, we applied latent class growth modelling
(LCGM, SAS 9.4, proc traj) as trajectory approach. We used multinomial logistic regression analysis to assess which determinates are
associated with group membership.
Results: At baseline, median age was 8.5 [Q1;Q3:8.4;8.6] years with
diabetes duration 4.1 [2.8;5.5]years and HbA1c 7.3 [6.7;8.0]%. Using
LCGM we observed five distinct HbA1c longitudinal pattern (Fig 1).
At age 8, 12 and 16 we observed differences in HbA1c, selfmonitoring of blood glucose (SMBG), pump use, daily insulin dose,
BMI-SDS, body height-SDS, physical activity and migration across all
trajectories (all p ≤ 0.001), but not in gender. Groups with similar initial HbA1c, but higher HbA1c increase were categorized by lower frequency of SMBG and physical activity and smaller body height-SDS
(all p < 0.01).
Conclusion: Using the trajectory approach, we found five distinct
classes with different patterns of metabolic control over puberty.
HbA1c increase during puberty might be due to diverse health awareness, psychosocial or genetic factors or treatment differences.
P082
When to start carbohydrate counting?
A retrospective case–control study
N.B. Mothojakan1, S. Bishar Abdirahman1, F.B. Ahad1, M.A. Osman1,
C. Brett2, A.R. Moodambail2
1
Barts and the London, School of Medicine and Dentistry, London,
United Kingdom, 2Barts Health NHS Trust, London, United Kingdom
Objectives: To evaluate two patient groups with Type 1 Diabetes at
a secondary care paediatric diabetic clinic, who started carbohydrate
(carb) counting to adjust meal time bolus insulin doses from diagnosis
(Group A) or greater than 3 months after diagnosis (Group B). Glycaemic control, impact of carb counting on different aspects of their life
and attitudes towards carb counting were assessed.
Method: Out of 78 children initially included, 62 had been carb
counting for more than a year. Qualitative data was collected in the
form of questionnaires given to patients or carers.
Results: There were 62 children included in the study: 2 under
5 years old, 31 between 5–11 years old, 22 between 12–16 years
old and 7 over the age of 16. 30 children in Group A began carb
counting from diagnosis, as recommended by NICE guidelines 2015.
On average, HbA1c was 7.15% (55.8 mmol/mol) at 6 months and
7.82% (61.8 mmol/mol) at 1 year. 32 children in patient group B
began carb counting after 3 months of diagnosis (6 children before
1 year and 26 after 1 year of diagnosis). On average, HbA1c was
8.85% (73.6 mmol/mol) at 6 months and 9.03% (75.2 mmol/mol) at
1 year. The impact of carb counting is displayed in the graph below.
Conclusions: We assessed the glycaemic control of two groups that
started carb counting at different time points after diagnosis. Group
A had on average a better glucose control and preferred to start at
this point compared to those that started carb counting later.
[Impact of Carbohydrate Counting]
P083
Impact of continuous glucose monitoring systems
on metabolic control and glycemic variability in well
controlled diabetes
D. Goksen, S. Ozen, G. Demir, H. Cetin, S. Darcan
Ege University, Izmir, Turkey
[Figure 1]
Aim: To assess the impact of long term monthly use of CGM on glycemic control in well controlled children and adolescents.
Materials and Methods: 12-month, prospective study conducted
among patients with T1DM. Patients aged 2–18 years who had been
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followed up for at least for 1 year and with a mean HbA1c < % 7,5 in
the prior year were included. The frequency of hypo and hyperglycemia data was collected from patients’ continuous glucose monitoring
report. iPro®2 Professional CGM was used over a 5-day period in all
patients every month for 6 months. In the next six months patients
were advised to do at least four finger stick test per day and the
SMBG results were reviewed. At the end of the second six months
iPro®2 Professional CGM was placed again. The frequency of hypo
and hyperglycemia, the duration of hypo and hyperglycemia and AUC
for hypo and hyperglycemia were compared.
Results: Mean age of the patients was 12 3,14years. 12 of the
patients were on insulin pump therapy and 10 were on MDI. Compared with baseline, non-significant but positive differences were
observed in HbA1c levels during the study period in pump patients
whereas there was no change in MDI patients. Hypo and hyperglycemic excursions and AUC for hypo and hyperglycemia are given in
Table 1.
II (428 128 vs. 349 105 p = 004) compared with those who
did not.
Conclusions: Among young people with T1DM, most do not have
concerns regarding sex that are related to their diabetes, and most do
not take specific measures before or after sex. One-third, however,
fear from hypoglycemia during sex, mostly singles and those who
experienced hypoglycemia in the past. Caregivers should address
these concerns.
P085
An individual health care plan (IHCP) for a child or
young person in an education setting who has
diabetes within the children and young people´s
North West diabetes network (CYPNWDN)
culminating in a national individual health care plan
M. Carson1, D. Anderson2, S. Singleton3
Baseline
3rd month
6th month
12th month
Mean glucose
(mg/dl)
165 31
158 25
165 21
164 28
no high
excursions
18,4 9,9
17 3,1
18 3,9
16 4,2
No low
excursions
3,9 4,0
5,7 4,1
5,6 6,0
4,4 4,3
AUC
hyperglycemia
40,6 24,9 35,9 18,7 39,1 17,5 40,9 21,8
AUC
hypoglycemia
0,48 0,78 0,55 0,69 0,67 1,0
0,47 0,64
[Hypo and hyperglycemia during the study period]
No significant differences in hypo and hyperglycemic excursions
and AUC were observed between different treatments groups. As a
result; continuous glucose monitoring systems did not affect metabolic control or glycemic variability in well controlled diabetes.
P084
Sexual lifestyle among young adults with type
1 diabetes
O. Pinhas-Hamiel1,2,3, E. Tisch1, R. Frumkin Ben-David1, C. Graf-BarEl1, M. Yaron1,2, V. Boyko4, L. Lerner-Geva2,4, N. Levek1
1
Maccabi Health Care Services, Jeuvenile Diabetes Center, Raanana,
Israel, 2Tel Aviv University, Sackler School of Medicine, Tel Aviv, Israel,
3
Edmond and Lily Safra Children’s Hospital, Pediatric Endocrine and
Diabetes Unit, Ramat Gan, Israel, 4Gertner Institute, Women and
Children’s Health Research Unit, Ramat Gan, Israel
Background: Sexual lifestyles including sexual activity, problems, satisfaction, and the formation and maintenance of relationships, are
greatly affected by physical health. Data are limited regarding the
sexual lifestyle of adolescents and young adults with type 1 diabetes
(T1DM). Fear from hypoglycemic episodes during sexual intercourse
and intimacy issues can impact individuals with T1DM. The aim of
this study was to assess sexual lifestyles of individuals with T1DM.
Methods: 53 T1DM patients, 27(51%) males, mean SD age 279
83 years completed the Hypoglycemia Fear Survey-II (HFS-II) and
the Sex Practices and Concerns questionnaire.
Results: Thirty-seven (70%) reported they never or almost never had
concerns in their sexual lifestyles that were related to their diabetes.
None experienced severe hypoglycemia during sex, but 21(40%)
reported occasional mild hypoglycemic events. More than two-thirds
do not take any measures to prevent hypoglycemia before sex
(decreasing insulin dose, snacks, and measuring blood glucose levels).
Fear of hypoglycemia during sex was reported by 18(35%); those
who reported increased fear experienced mild hypoglycemic events
during sex (611% vs. 265% p = 001), were singles (944% vs. 647%
p = 002) and had higher scores on the Worries subscale of the HFS-
1
Leeds Teaching Hospitals NHS Trust, Children and Young People’s
North West Diabetes Network, Leeds, United Kingdom, 2Salford Royal
NHS Foundation Trust, Children and Young People’s North West
Diabetes Network, Salford, United Kingdom, 3Blackpool Teaching
Hospitals NHS Foundation Trust, Children and Young People’s North
West Diabetes Network, Blackpool, United Kingdom
Objectives: To design an IHCP for roll out to the CYPNWDN in line
with the National Paediatric Diabetes Service Improvement Plan.
Methods: Subgroup formed of PDSN´s, Dietitians, Schools Nurses
and Parent Representatives from CYPNWDN. National and international guidelines used along with essential elements. Two versions
designed: Standalone IHCP and an IHCP to work alongside the East
of England’s Diabetes Guidelines for School, Colleges and Early Year
Settings.
Results: In August 2013 IHCP was piloted for 6 months in 3 Hospitals
followed by a survey to teachers, parents and PDSN’s before roll out
to the remaining 17 Hospitals within the CYPNWDN. Survey
revealed that 100% of the parents using the IHCP found it either
easy or very easy. 90% found it easy in comparison to previous
IHCP´s. 90% of school staff found it either very easy or easy to use.
November 2013 saw the launch of the guidance from the’ CYP East
of England Diabetes Network’ - the IHCP was included with this
guideline. The standalone IHCP was presented in December 2013 at
the ’National CYP Diabetes Network Meeting’ - feedback received
and provisionally endorsed as the ’National IHCP’ pending comments
from each regional network in January 2014 with further review in
November 2015 with national roll out of the national IHCP in January
2016. Review took place and regional Network Lead Nurses invited
comment following recent changes made to NICE Guidelines (2015)
and the ’Supporting Pupils at School with Medical Conditions’,
Department of Education.
Awards: Quality in Care Commended - October 2014, Winner
Excellence in Diabetes Specialist Nursing at Nursing Standard Awards
May 2015. The IHCP is supported by JDRF and Diabetes UK via their
websites including the Department of Education.
Conclusion: A standardised IHCP across England and Wales which
will be reviewed every 2 years or when national or international
guidelines are updated. To also be translated into other languages for
International roll out.
P086
Technology downloads: families friend or foe?
T. Stephenson, E. Baker
York Teaching Hospital NHS Foundation Trust, Paediatrics, York, United
Kingdom
Objectives: The ethos of paediatric diabetes care is to reduce the
long-term complication risk through optimising glycaemic control,
whilst providing family centred care. Although outpatient attendance
four times a year is encouraged in the UK, families should also be
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empowered to achieve and maintain target HbA1c levels through
insulin adjustments based on blood glucose patterns (NICE, 2015).
The objective of this small study was to determine the use of technology downloads by families to review glycaemic control.
Methods: A short survey of patients (>8 years) and parents attending
paediatric diabetes clinic in a small outlier hospital in Yorkshire was
conducted over 4 months in 2016. The primary goal was to ascertain
how often technology downloads were being reviewed with additional exploration of promoting and hindering factors.
Results: 29 responses were obtained (15 patients, 14 parents).
11 responses related to CSII therapy and 18 to MDI regimens. None
of the parents or children using MDI therapy downloaded their meter
between clinics compared to 6/11 of those using pumps. The most
likely factor promoting download consideration was being asked to
by the team. 16/29 felt regular downloads would enhance their diabetes control. However, only 9/18 and 7/11 MDI and pump users
respectively were confident to make changes based on their downloaded glycaemic patterns. Identified barriers included; finding the
download technically challenging, reliance on the diabetes team for
interpretation and a further educational need.
Conclusion: Regular review of glycaemic control is promoted by diabetes teams and recognised as beneficial by patients and parents.
However, this small study highlights dependency on healthcare professionals to facilitate this. Empowering families to make changes
independent of, or in collaboration with the diabetes team, could simply result from the expectation to perform technology downloads
between clinics and download interpretation education.
P087
Effect of basal insulin on glycosylated haemoglobin
in children and young people (CYP) with type
1 diabetes mellitus (T1DM)
J. Pichierri1, E. Storr1, C. Peters2, P. Hindmarsh1
1
University College London Hospitals, London, United Kingdom, 2Great
Ormond Street Hospital, Endocrinology, London, United Kingdom
Objective: To evaluated the relative contribution of basal and bolus
insulin in determining HbA1c.
Methods: We related HbA1c to the contribution of basal and bolus
insulin to the total daily dose of insulin in 227 (110 M) CYP with well
controlled T1DM (mean HbA1c 7.3%, range 5.2-8.5) aged
2–19.5 years.
Results: Insulin pump settings (total daily dose (TDD), total basal and
bolus dose and percentage basal as well as number of basal rates per
24 hours) were obtained and related to age, sex, body mass index
(BMI) and HbA1c. There were no differences between the sexes for
age, BMI, TDD/kg, basal or bolus measures or HbA1c. HbA1c did not
change across the age range and was not influenced by TDD, basal
or bolus amount or % basal insulin delivery. The percentage basal
insulin increased with age: 0.6% /year (r-0.19; P = 0.01) but this was
related to BMI rather than age (P = 0.002). Both BMI and age determined independently total basal and bolus insulin requirements
(P < 0.001). Number of basal rates per day were inversely related to
HbA1c (r = 0.14; P = 0.04).
Conclusion: Glycosylated haemoglobin (HbA1c) is related to episodes
of hyperglycaemia which in turn are influenced largely by the bolus
insulin component. The role for basal/background insulin in determining HbA1c is less clear. These data suggest that there is an increase
in both basal and bolus requirements with age but in this tightly controlled group of patients no clear relationship was established with
HbA1c. The relationship with BMI probably reflects insulin sensitivity
whereas the age effect may reflect other determinants impacting on
insulin action.
P088
High remission rate in children with type1 diabetes
in Sweden and association with lower HbA1c at
diagnosis
U. Söderström1, J. Åman2, U. Samuelsson3
1
Childrens Hospital Sörmland, Örebro University, Pediatrics, Eskilstuna,
Sweden, 2Örebro University Hospital, Örebro University, Pediatrics,
Örebro, Sweden, 3Linköping University Hospital, Linköping University,
Pediatrics, Linköping, Sweden
Objective: To study remission rate, defined as <0.5 U/kg/BW, in
children with Type 1 diabetes (T1D) in relation to clinical parameters
at diagnosis and during the first 2.5 years (15 first clinical visits).
Methods: Data obtained from 4162 subjects, age 1–18 years at diagnosis, 44.8 % females. These individuals were registered in the Swedish pediatric diabetes quality registry (Swediabkids) and diagnosed
between 2007/01-2012/05.
Results: As seen in table 1 the HbA1c values were lower in children
within remission but they had about the same BMI and duration as
children without remission.
Table 1.
A logistic regression analysis showed that HbA1c, pH, and pglucose at onset were related to remission at visit 5, while sex, BMISDS and age were not. At visit 10 and 15 HbA1c at onset was still
associated with remission. Severe hypoglycemia and ketoacidosis
were as common in both groups of subjects. Using insulin pump was
related with remission after visit 10 but not before; 40% vs 28%,
p < 0.001 and at visit 15 the figures were even more pronounced;
59% vs 39%, p < 0.001. Physical activity had no impact on remission
until visit 15.
Conclusion: Remission in children with T1D was associated with
lower HbA1c and higher pH at onset. During clinical follow-up remission was still associated with lower HbA1c and a higher rate of pump
treatment and to physical activity.
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Poster Tour 12: Diabetes Epidemiology
P089
Study of type 1 diabetes onsets for the last 4 years
in a major hospital
G.M. Lou Francés1, E. Corella Aznar1, S. Laliena Aznar1, M. Ferrer
Lozano1, M.R. Rubio Abella2
1
Miguel Servet Children’s Hospital, Paediatric Diabetes Unit, Zaragoza,
Spain, 2Miguel Servet Children’s Hospital, DUE Paediatric Diabetes Unit,
Zaragoza, Spain
Objectives: To analyse the relationship of epidemiological, clinical
and analytical data of onsets in patients with Type 1 Diabetes (T1D)
in our Hospital.
Methods: Retrospective analytical study in 0–15 years patients diagnosed of T1D between the years 2012–2015 in a major Hospital.
Results: 91 patients, age at onset 9,16 years (0,9-15,5). Three different strata of age at onset: 10–15 yeas old (48,4%), 5–9 (35,2%) and
0–4 (16,5%). 54,9% were male. Winter was the season with more
diagnostics (28,6%), followed by summer,spring and autumn. 53,8%
were diagnosed in their primary health center. 16,5% presented
related antecedents of T1D; 31,9% of T2D and 24,2% other autoimmune pathologies. 91,2% presented polydipsia, 89% polyuria, 65,9%
weight loss and 27,5% polyphagia.Symptoms lasted 28,45 days.Average of glycemia was 442 mg/dl.37,3% presented ketoacidosis(DKA).
Average age in patients with DKA was 9,39. Average insulina level:
1,02microU/ml, C-peptide: 0,94 ng/ml. HbA1c: 11,73%. 81,3% presented positive GAD antibodies.At diagnosis 10% presented positive
celiac markers and 5,5% thyroid antibodies.Insulin dose at discharge
was varied(average 0,98U/Kg/d).
C-peptide levels are higher in younger children. DKA is more frequent in girls and it is directly related to finding thyroid antibodies,
high glycemia, triglycerides and insulin dose; DKA has a negative correlation with insulin level. HbA1c is lower if there are related antecedents T1D, T2D or autoimmune pathologies. High HbA1c has
positive correlation with polyphagia, ketonemia, C-peptide levels,
GAD antibodies and needs more of an Insulin dose.
Conclusions: The main prevalence is on the oldest group (10–15 y)
and in winter. And more DKA in girls.It is important the knowledge
and study of characteristics at onset T1D to do an early diagnosis
and to decrease DKA incidence. 53,8% were diagnosed in primary
Health Center. It is essential to educate other areas do populations
more sensitive to earlier diagnosis and to prevent complications at
onset.
P090
IDF Life for Child six-country epidemiology study preliminary results from Azerbaijan, Bangladesh,
Mali and Pakistan
G.D. Ogle1,2, G. Ahmadov3, B. Zabeen4, S. Besancon5, A. Fawwad6,
J. Noble7, F. Kakkat1, D. Govender1, M. Silink1,8, C. Wasserfall9,
K. Azad4, A.T. Sidibe5, Y. Ahmedani6, A.C. Middlehurst1,2,
M. Atkinson9
1
International Diabetes Federation Life for a Child Program, Sydney,
Australia, 2Diabetes NSW, Sydney, Australia, 3Endocrine Center, Baku,
Azerbaijan, 4BIRDEM Institute, Dhaka, Bangladesh, 5Sante Diabete,
Bamako, Mali, 6Baqai Institute of Diabetology and Endocrinology, Baqai
Medical University, Karachi, Pakistan, 7Children’s Hospital Oakland
Research Institute, Oakland, United States, 8Children’s Hospital
Westmead, Sydney, Australia, 9University of Florida College of Medicine,
Gainesville, United States
Objectives: Significant knowledge voids exist in both the epidemiology and disease heterogeneity of youth onset diabetes in most
under-resourced countries. The International Diabetes Federation
Life for a Child Program and its partner centres addressed this need
in six countries, with initial results available for four countries:
Azerbaijan, Bangladesh, Mali, and Pakistan.
Methods: Consecutive new- or recent-onset cases of diabetes in
subjects < 21 years were enrolled, up to a minimum of 100 cases /
country. Clinical features, GAD-65 and IA2 autoantibodies, C-Peptide,
and HLA-DRB1 were evaluated. DNA was also collected on 200 control subjects in each country.
Results: Results are presented for Azerbaijan, Bangladesh, Mali, and
Pakistan in sequence. Patient enrolment was n = 106, 100, 132, 100.
Diagnosis of type 1 diabetes (T1D) was 98%, 84%, 98%, 100%.For
T1D, male/female ratio 1.17, 0.79, 1.02, 1.38; peak age onset 9–11,
12–13, 15–16, 14–15 years; diabetic ketoacidosis at diagnosis 58%,
10%, 44%, 21%; GAD-65 positivity 62%, 26%, 59%, and (n = 74 analysed) 59%; IA2 positivity 39%, 11%, 22%, and (n = 83) 16%; C-peptide < 1.0 ng/mL 93%, 26%; 14%, (n = 94) 13%. HLA-DRB1
population frequencies varied significantly among countries as did
locus-level DRB1-T1D association: Azerbaijan (p < 10−24), Bangladesh
(p = 0.03), Mali (p = 0.02), Pakistan (p < 10−14). Association strength
for individual alleles, especially DRB1*03:01, varied widely among
countries. As a side note, access to a home refrigerator for insulin
storage was 99%, 57%, 44%, 97%.
Conclusions: Marked variation in clinical, biochemical, and HLA-DRB1
allelic associations were observed among four countries, suggesting
that not all patients have classic T1D. Additional analysis and further
studies may expand treatment options for some subjects, and reveal
novel forms of diabetes. The findings indicate need for stratification
of T1D patients for current management and potential future individual immunomodulatory interventions.
P091
Do lifestyle habits influence the development of
the metabolically healthy obese phenotype in
youth?
M. Henderson1,2, M.-E. Mathieu2,3, S. Radji2, T. Barnett2,4, QUALITY
Cohort Collaborative Group
1
University of Montreal, Pediatrics, Montreal, Canada, 2CHU SainteJustine Research Center, Montreal, Canada, 3University of Montreal,
Kinesiology, Montreal, Canada, 4INRS-Institut Armand-Frappier, Laval,
Canada
Objective: It is unclear how lifestyle habits influence metabolically
healthy obese (MHO) and metabolically unhealthy obese (MUO) phenotypes in youth. We compared lifestyle habits and insulin dynamics
at age 8–10 years in relation to MHO and MUO profiles at age
10–12 years.
Methods: The QUALITY cohort comprises Caucasian youth (n = 630)
with at least one obese biological parent. We defined MHO as children with a BMI ≥ 97th percentile for age and sex and none of the
following risk factors: triglycerides > 1.2 mmol/L, fasting glucose >
6.1, HDL-cholesterol < 1.04, or blood pressure > 95th percentile for
age, sex, height. MUO were defined as having at least one of these
risk factors. Fitness was measured by VO2peak. PA and sedentary
behavior (SBacc) were measured using accelerometry. Hours of sleep
and screen time were self-reported. Dietary intake was measured by
24-hour recalls. Insulin sensitivity and secretion were measured with
Matsuda-insulin sensitivity index (ISI) and the ratio of the area under
the curve of insulin to glucose over the first 30 minutes (AUC I/G
30 min) and 120 minutes (AUC I/G 120 min) of an OGTT, respectively. Lifestyle habits and insulin dynamics at baseline were compared across MHO (n = 58) and MUO (n = 90) using t-tests.
Results: MHO children versus those that were MUO had at baseline:
1) lower adiposity (36.1 vs. 39.3% body fat, p = 0.005);
2) higher Matsuda-ISI (7.4 vs. 5.4, p < 0.0001);
3) lower AUC I/G 30 min (38.6 vs. 52.4, p = 0.0006); and
4) lower AUC I/G 120 min (40.5 vs. 55.3, p = 0.002).
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MHO also engaged in less screen time (2.7 vs. 3.5 hrs/day,
p = 0.019), and consumed less sugar-sweetened beverages (93 vs.
150 mls/day, p = 0.014) compared to MUO youth. There were no
differences between the groups in terms of PA, fitness, SBacc, or
sleep.
Conclusions: Specific lifestyle habits, such as screen time and diet,
may be important targets to prevent obese children from developing
metabolic complications as they enter puberty.
P092
Epidemiological characteristics of newly diagnosed
children with type 1 diabetes in a single diabetes
center during the last 16 years
F. Tzifi, I. Kosteria, I.-A. Vasilakis, E. Christopoulos-Timogiannakis,
G. Chrousos, C. Kanaka-Gantenbein
National and Kapodistrian University of Athens School of Medicine, First
Department of Pediatrics, Diabetes Center, Division of Endocrinology,
Diabetes and Metabolism, Athens, Greece
Objectives: The aim of the present retrospective study was to assess
the epidemiological features
(age, gender, incidence) of newly diagnosed children with Type
1 Diabetes (T1D) in a single Diabetes Center during the last 16 years
(2000–2015).
Methods: The study group consisted of six hundred and eight children diagnosed with T1D during the period 2000–2015. Data of children, regarding gender, dates of birth and dates of first diagnosis
were retrieved from patients’ files and analyzed. Patients were
divided in four groups according to the year’s period of T1D
diagnosis:
a) diagnosis between 2000–2003 (n = 103),
b) between 2004–2007 (n = 161),
c) between 2008–2011 (n = 177) and
d) between 2012–2015 (n = 167).
According to age of diagnosis, three groups were analyzed: 0–5
years old (n = 144), 5–10 years (n = 226) and ≥ 10 years
old (n = 235).
Results: Mean age at diagnosis was 8.21 4.01 years. No gender differences in the studied cohort was noticed (females: males = 298:310,
p = 0.626). A significant increase (≈60%) in the annual incidence of
newly diagnosed T1D patients after the year 2004 was noted, with the
annual number of newly diagnosed T1D cases rising between 40 and
50, contrary to the previously (2000–2003) annually diagnosed cases
ranging from 19 to 34 (p = 0.001). The majority of children
were > 5 years old, and no increase of T1D incidence in younger ages
(<5 years) during the four periods was noted (p = 0.749).
Conclusions: There was a significant increase in the annual incidence
of newly diagnosed T1D pediatric cases after 2004, when the annual
incidence stabilized, while no increase of T1D diagnosis in preschool
ages was noted in the large cohort studied.
P093
Partial remission and predictive factors in a cohort
of 117 children and adolescent with T1DM
A. Zennaki, M. Touhami, A. Aoui, S. Niar, M. Naceur, C. Latroch,
M. Gharnouti, K. Bouziane-Nedjadi
(27% < 5 years, 36% aged 5–9 and 37% 10–14). Inaugural ketoacidosis was present in 30 children (26%). Partial remission (insulin less
than 0.5 UI/Kg/day and HbA1c ≤ 7.5%) was obtained in 21 children
(17.95% of cases) with an average duration of 5.2 4.2 months
(min. 3-max. 15). The remission was significantly more frequent in
children who had no ketoacidosis at diagnosis (p < 0.01), no siblings
with T1DM (p < 0.05) and in girls (p < 0.02). There was no significant
correlation with HbA1c levels at admission, level of maternal education
or occupation, geographic origin, age groups or insulin regimen used.
Ketoacidosis at diabetes onset is a negative predictor of partial
remission. The absence of T1DM in siblings and female gender are
predictors of partial remission specific to our work environment.
P094
Clinical and epidemiological characteristics of
pediatric population diagnosed of type 1 diabetes
mellitus. 20 years of evolution in a region of
northern Spain
M.L. Bertholt Zuber1, C. Luzuriaga Tomás1, J. Andrés De Llano2,
I. Palenzuela Revuelta1, S. Pozas Mariscal1, J. Pérez Gordón1
1
Hospital Universitario Marques de Valdecilla, Endocrinologia Pediátrica
(Pediatria), Santander, Spain, 2Hospital Rio Carrión, Pediatria, Palencia,
Spain
Objective: To characterize the pediatric population of our region
diagnosed of DM1.
Methods: Retrospective cohort study of all patients < 15 years, diagnosed in our region of northern Spain, between 01/01/1995 and
31/12/2014. Variables: sex, seasonality, background. At debut: age,
clinical presentation, analytical results, pancreatic reserve, HLA II,
HbA1c, pancreatic β cell antibodies, other autoimmune disease. Calculation of incidences and trends in the period. Comparison between
age groups.
Results: 207 patients: 51% female. Average age at debut 8.8 3.7
years: 0–4 years 16%, 5–9 years 38%, 10–14 years 4%. Slight predominance in winter 31.9% (p = 0.04). Family history: type 1 diabetes
15.5%, other autoimmune diseases 10.6%. Average hospital stay
8.5 2.9 days. Results at debut: glucose 446.2 161.7 mg/dl;
pH 7.3 0.1;
bicarbonate
17.4 5.8 mEq/l;
Ketonemia
4,1 2,4 mmol/l; HbA1c 11.4 2.3%. Debut’s ketoacidosis percentage 42%, increase of 0.5% per year (p > 0.05). Variable global annual
incidence, average 14.1 cases/100,000 (6 to 25.8); annual rise of
2.08% (p > 0.05). Average annual incidence by age group: 6.8/
100,000 in the group of 0 to 4 years, 16.4/100,000 in the group of
5 to 9 years and 18.6/100,000 in the group of 10 to 14 years. Annual
trend increase in the group of 0 to 4 years (annual percentage of
change (APC) of 24%), and in 5 to 9 group (APC 1,6%). Slight
decrease in 10 to 14 year´s group (APC −1.2%). Incidence by health
zones with marked variability; regions above 30/100,000; 4 rural
zones with low incidence (<5/100,000).
Conclusions: The general characteristics of the population of our
region diagnosed of type 1 diabetes do not differ from those
described in others of the country and the world. Changes in trends
by age group suggest a shift in the age at debut to younger ages in
predisposed subjects. The group of children younger than 5 years
and those with family history of autoimmune diseases are groups of
high risk and should be closely monitored.
University Hospital, Pediatrics, Oran, Algeria
Partial remission, in type 1 diabetes, should have beneficial effects on
acute and chronic complications.
The aim of the study was to describe partial remission and evaluate
its predictive factors in a cohort of children and adolescents with
T1DM during the first 15 months of the disease.
Children and adolescents under 15 years, admitted between June
2013 and July 2014, having started insulin treatment within a month
before admission were studied.
One hundred and seventeen consecutive cases were analyzed. At
admission, sex ratio was 0.86, age was 8.2 4.3 years
P095
Diabetes mellitus type 1 in pediatric patients with
African background in Germany, Austria and
Luxembourg: analysis based on the DPV registry
K. Konrad1,2, N. Prinz3,4, C. Kastendieck5, A. Herbst6, C. SteiglederSchweiger7, M. Witsch8, T. Kapellen9, O. Razum10, C. Brack11,
K. Raile12, R.W. Holl3,4
1
Elisabeth Hospital Essen, Pediatrics, Essen, Germany, 2University
Children´s Hospital Cologne, Pediatric and Adolescent Medicine, Cologne,
72
Germany, 3University of Ulm, Institute of Epidemiology and Medical
Biometry, ZIMBT, Ulm, Germany, 4German Center for Diabetes Research
(DZD), Munich-Neuherberg, Germany, 5Clinic Bremen-Nord, Pediatrics,
Bremen, Germany, 6Hospital Leverkusen gGmbH, Pediatric and
Adolescent Medicine, Leverkusen, Germany, 7Medical University
Salzburg, Pediatric and Adolescent Medicine, Salzburg, Austria, 8Centre
Hospitalier de Luxembourg, Diabetes Endocrinology Care Clinic
Pediatrique (DECCP), Luxembourg, Luxembourg, 9University Children´s
Hospital Leipzig, Pediatric and Adolescent Medicine, Leipzig, Germany,
10
School of Public Health, Bielefeld, Germany, 11Outpatient Pediatric
Clinic Celle, Celle, Germany, 12Charité - Berlin, Pediatric Diabetology,
Berlin, Germany
Objectives: The African continent, where diabetes was previously
thought to be rare, has witnessed a surge in the condition, but epidemiological data for diabetes are scare. We aimed to analyze demographic characteristics and medical care of pediatric patients with
African background in Germany, Austria and Luxembourg.
Methods: We studied 38.820 diabetes patients (<21y) from the multicenter diabetes patient follow-up registry, DPV. Patients born in
Africa or with at least one parent born there were classified as African background. We used multivariable regression models adjusted
for age, sex, and diabetes duration (SAS 9.4) for group comparison.
Results: In total 127 (0.33%) patients had African background
(T1DM: n = 115, 0.30%; T2DM n = 4, 0.01%; other n = 8, 0.02%).
Group of patients was heterogeneous with most patients from the
Northern Africa region (n = 65, 50.78%) and Sub-Saharan Africa
(n = 57, 44.53%). Patients with African background and T1DM had
higher HbA1c (adjusted mean with SD: 9.18 0.14 vs. 8.16 0.01;
p < 0.001), diabetes self-monitoring of blood glucose was lower
(4.45 0.16 vs. 5.25 0.01; p < 0.001) and insulin pump therapy
was used less frequently (10.3% vs. 40.0%; p < 0.001). Insulin dose
per kg body weight/day was not significantly different (0.83 0.02
vs. 0.86 0.002). Rate of severe hypoglycemia with coma per 100 patient-years (6.0 0.03 vs. 2.8 0.01) and diabetic ketoacidosis
(5.5 0.03 vs. 2.5 0.001) were higher, but difference lacked significance due to low numbers. Differences in long-term diabetes complications were significant. Retinopathy (1.3 0.01 vs. 0.2 0.0002)
and microalbuminuria (16.5 0.03 vs. 7.1 0.001); both p < 0.001.
Conclusions: Diabetes control in patients with African background is
poor compared to patients without African origin. Treatment of these
patients is a challenge for pediatric diabetes teams and there seems
to be a need for specific treatment offers that incorporate different
health beliefs.
POSTER TOURS
P096
Seasonal variation of type 1 diabetes mellitus
diagnosis in Polish children - a multicentre study
A. Szypowska1, A. Ramotowska1, M. Wysocka-Mincewicz2,
A. Mazur3, L. Lisowicz3, I. Ben-Skowronek4, J. Sieniawska4,
B. Klonowska5, D. Charemska5, J. Nawrotek6, I. Jałowiec6,
ska8, B. Pyrżak8,
A. Bossowski7, M. Jamiołkowska7, I. Rogozin
M. Szalecki2,9
1
Medical University of Warsaw, Department of Paediatrics, Warsaw,
Poland, 2Children’s Memorial Health Institute, Department of
Endocrinology and Diabetology, Warsaw, Poland, 3Medical Faculty
University of Rzeszow, II Department of Paediatrics, Paediatric
Endocrinology and Diabetes, Rzeszów, Poland, 4Medical University of
Lublin, Department of Paediatric Endocrinology and Diabetology, Lublin,
Poland, 5University of Warmia and Mazury, Department of Clinical
Pediatrics. Faculty of Medical Sciences, Olsztyn, Poland, 6General District
Hospital, Endocrinology and Diabetology Ward, Kielce, Poland, 7Medical
University in Białystok, Department of Pediatrics, Endocrinology,
Diabetology with a Cardiology Division, Białystok, Poland, 8Medical
University of Warsaw, Department of Pediatric and Endocrinology,
Warsaw, Poland, 9UJK, Faculty of Health Sciences, Kielce, Poland
Objectives: The current concept of damage of beta cells in type
1 diabetes (T1D) includes environmental factors in genetically susceptible individuals. The aim of the study was the evaluation of the seasonal variation of type 1 diabetes mellitus in Polish
children < 18 years of age.
Methods: The study group consisted of 2174 children (1007 girls)
with the mean age 9.3 SD 4.5 years, with newly diagnosed T1D in
the years 2010–2014. This cohort study included data of children at
the age of 0–17 years with newly recognized T1D correlated with
weather conditions such as temperature and hours of sunshine. The
data was obtained from east and central Poland. The meteorological
data was provided by Institute of Meteorology and Water
Management.
Results: We noted significant seasonality in the incidence of T1D
(p < 0.001). The lowest number of children was diagnosed with T1D
during May, Jun and July and the highest incidence was observed
from September to February with peak in January. 423(19%) children
were diagnosed in the warmest months (June to August with the
mean temperature 16.8 C) compared to 636(29%) recognised in the
coldest months (December to February with the mean temperature
−1.6 C), p < 0.0001. T1D onset was noted more frequently in
Autumn-Winter (September to February) than in Spring-Summer
(March to August); 1270 (58%) vs. 904 (42%) cases, p < 0.0001. The
seasonal variation demonstrated different pattern in the youngest
children 0–4 years of age than in older groups. There were no significant differences between boys and girls (p = 0.142) with regard to
the seasonal variation of diabetes onset.
Conclusions: Significant seasonality in T1D onset with peak values
during the cold month might support the hypothesis that some environmental factors (eg. infections) may interfere with T1D onset. Different seasonal variation pattern in younger ages suggests that
environmental factors may have a different effect in the youngest
children compared to older subjects.
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Poster Tour 13: Genetics, Immunology and the Environment
P097
Clinical and metabolic characteristics of an Italian
cohort of children at risk to develop T1D
R. Lidano, A. Petrelli, N. Rapini, S. Arcano, E. Del Duca, M.L. Manca
Bitti
Tor Vergata University, Pediatric Diabetology, Rome, Italy
Objective: To determine whether a close follow-up of a cohort of
children at risk to develop type 1 diabetes (T1D) results in a lower
prevalence of ketoacidosis (DKA) compared to T1D children in the
Italian population. To evaluate the effect of diagnosis at an early
stage of disease in preserving residual ß-cell function.
Methods: First degree relatives of T1D patients and subjects with
occasional hyperglycemia were recruited (153 subjects, median age
9.2 years) and screened for HLA (DQ2/DQ8) and specific ß cells
autoantibodies (IAA, IA2, GAD and ZnT8). Subjects were stratified in
medium-high and low risk based on the number of positive autoantibodies and screened periodically for autoantibodies, basal c peptide
and glycosylated hemoglobin (HbA1c) to evaluate risk progression
over time. Median follow up time was 42 months. Early diagnosed
T1D patients were compared with a cohort of onset age-matched
patients from the general population through monitoring basal c-peptide, exogenous insulin dose, and HbA1c for 18 months after
diagnosis.
Results: 102 subjects (82%) were stratified based on the number of
positive autoantibodies. During follow-up, 6 of 23 medium-high risk
group subjects developed T1D. Diagnosis was performed by a random, postprandial, or fasting glucose in two children, and by a scheduled OGTT in four children. No DKA was found, compared to 67% of
T1D patients from the general population (p = 0.0067). Early diagnosed T1D patients showed a lower HbA1c (p = n.s.) and insulin
requirement (p < 0.05) at onset and at 12 and 18 months after diagnosis, compared to other patients. C-peptide levels were higher at
onset (p = 0.01) and persist higher after 18 months (p = n.s.).
Conclusion: Close follow up of at risk children lead to an early diagnosis with a low rate of DKA and symptoms compared to general
population. Interestingly, early diagnosis with a prompt start of insulin
therapy might preserve residual ß-cell function.
P098
Celiac autoimmunity and confirmed celiac disease
(CD) before and after the onset of childhood type
1 diabetes (T1D): a prospective cohort study in
Skåne, Sweden
A. Gustafsson1, M. Cerqueiro Bybrant2,3, F. Frederiksen4, A.-K.
Albin5,6, H. Elding Larsson6, B. Jönsson7, K. Larsson8, A. Carlsson6,9
1
Lund University/CRC, Lund, Sweden, 2Karolinska Institutet, Women´s
and Children’s Health, Stockholm, Sweden, 3Vithas Hospital, Department
of Pediatrics, Malaga, Spain, 4Karolinska Institutet, Stockholm, Sweden,
5
Helsingborg Hospital, Department of Pediatrics, Helsingborg, Sweden,
6
Lund University/CRC, Department of Clinical Science, Lund, Sweden,
7
Ystad Hospital, Department of Pediatrics, Ystad, Sweden, 8Kristianstad
Hospital, Department of Pediatrics, Kristianstad, Sweden, 9Skåne
University Hospital SUS, Department of Pediatrics, Malmö, Sweden
Objectives: To investigate the prevalence of celiac autoimmunity
and confirmed CD before and after the onset of T1D, and to find predictive factors for the development of celiac autoimmunity after the
onset of T1D.
Methods: Children who were diagnosed with T1D between May
2005 and December 2010 in Skåne, Sweden, were included in a prospective cohort (n = 513). Data on celiac autoimmunity and confirmed CD, were extracted from the children’s journals. Patients who
developed celiac autoimmunity after the diagnosis of T1D were
compared with children who did not develop celiac autoimmunity
within 5 years, according to gender, HLA-type, islet cell autoimmunity, age at onset, body measurements and laboratory analysis.
Results: Patients with known CD before T1D were 1.9% (10/513)
and patients with celiac autoimmunity at T1D diagnosis were 6.4%
(33/513). Of the children with no celiac autoimmunity at the T1D
diagnosis, another 4.9% (23/470) developed celiac autoimmunity
within 5 years. The age at onset was lower for the children who
developed celiac autoimmunity with an age of 5.4 years, compared to
9.7 years in the celiac autoimmunity negative group (p < 0.001).
More patients who developed celiac autoimmunity had the HLAgenotype DQ2/DQ8 and no one in this group had the HLA-genotype
DQX/X (p < 0.001). The celiac autoimmunity patients also had more
often IAA (p = 0.036) and less often ZnT8QA (p = 0.027), were
shorter and lighter (p < 0.001) and had a lower BMI (p = 0.018). No
significant differences were found regarding gender, laboratory analysis or the other islet cell autoantibodies.
Conclusion: The cumulative prevalence for celiac autoimmunity was
12.9% (66/513), of which 7.4% (38/513) had a confirmed CD, and
the majority of these cases was seen either before or at the T1D
diagnosis. Predicted factors for developing celiac autoimmunity after
the onset of T1D were lower age at T1D onset and the HLAgenotype DQ2/DQ8, which may be useful when repeatedly screening for CD.
[Pic 1]
P099
Effect of screening for islet autoantibodies on
diabetic ketoacidosis at diagnosis of type
1 diabetes in children
A. Rewers1, L. Yu2, F. Dong2, M. Rewers2
1
University of Colorado, Pediatric Emergency, Aurora, United States,
University of Colorado, Barbara Davis Center for Childhood Diabetes,
Aurora, United States
2
Objectives: Diabetic ketoacidosis (DKA) at diagnosis of type 1 diabetes (T1D) is a preventable life-threatening complication with potential
long-term sequelae. Decreased DKA prevalence has been reported in
children screened for islet autoantibodies and followed with education regarding symptoms of diabetes. The impact of a research
screening available in a defined population for 12 years, on DKA at
diagnosis, was estimated controlling for demographic factors, health
insurance and T1D family history.
Methods: The study population included 3439 children for whom
DKA status was known, out of the 3544 diagnosed with T1D before
age 18, in Colorado, in 1998–2012. Of those, 133 children or 4% had
participated in a study that screened for islet autoantibodies: Diabetes Autoimmunity Study in the Young, Type 1 Diabetes TrialNet, or
74
The Environmental Determinants of Diabetes in the Young. Insurance
status at diagnosis was categorized into private, governmentprovided or none.
Results: DKA was present in 1339 of the youth at T1D diagnosis
(38.9%; 95% CI 37.3-40.6%). Among those previously screened for
islet autoantibodies, only 9 (6.8%) had DKA while 52 would be
expected. In multiple logistic regression controlling for age, sex, ethnicity and health insurance, prior participation in a research screening
for islet autoantibodies had a powerful protective effect on DKA at
diagnosis -OR = 0.2 (95%CI 0.2-0.4), independent of T1D in a 1stdegree (0.4; 0.3-0.5) or 2nd-degree relative (0.6; 0.5-0.8).
Conclusions: Participation in research studies that screen children
for islet autoantibodies and educate regarding symptoms of diabetes
and home glucose monitoring during child’s illness can prevent ~80%
of DKA. The existing technology is sufficient to consider a widespread screening of all children for islet autoantibodies and intensive
follow-up of those positive, as one of the approaches to prevention
of DKA.
P100
Nucleotide substitutions in CD101, the human
homolog of diabetes susceptibility gene in nonobese diabetic mouse, in patients with type
1 diabetes mellitus
M. Okuno1,2, Y. Kasahara3, N. Takubo4, M. Okajima3, S. Suga5,
J. Suzuki2, T. Ayabe1, T. Urakami2, T. Kawamura6, N. Kikuchi7,
I. Yokota8, T. Kikuchi9, S. Amemiya9, T. Ogata1,10, M. Fukami1,
S. Sugihara11, Japanese Study Group of Insulin Therapy for Childhood
and Adolescent Diabetes (JSGIT)
1
National Research Institute for Child Health and Development,
Departments of Molecular Endocrinology, Tokyo, Japan, 2Nihon
University School of Medicine, Department of Pediatrics and Child
Health, Tokyo, Japan, 3Kanazawa University, Department of Pediatrics,
Kanazawa, Japan, 4Juntendo University, Department of Pediatrics,
Tokyo, Japan, 5National Hospital Organization Mie Hospital, Department
of Pediatrics, Tsu, Japan, 6Osaka City University, Department of
Pediatrics, Osaka, Japan, 7Yokohama City Minato Red Cross Hospital,
Department of Pediatrics, Yokohama, Japan, 8Shikoku Medical Center
for Children and Adults, Department of Pediatrics, Division of Pediatric
Endocrinology and Metabolism, Zentsuji, Japan, 9Saitama Medical
University, Department of Pediatrics, Saitama, Japan, 10Hamamatsu
University School of Medicine, Department of Pediatrics, Hamamatsu,
Japan, 11Tokyo Women’s Medical University Medical Center East,
Department of Pediatrics, Tokyo, Japan
Objectives: Genome wide association studies have identified more
than 50 susceptibility genes for type 1 diabetes mellitus. However,
low frequency risk variants could remain unrecognized. The present
study aimed to identify novel type 1 diabetes susceptibility genes by
newly established methods.
Methods: We performed whole-exome sequencing and genomewide copy-number analysis for a Japanese family consisting of two
patients with type 1 diabetes and three unaffected relatives. Further
mutation screening was carried out for 127 individuals with sporadic
type 1 diabetes. The functional consequences of identified substitutions were evaluated by in silico analyses and fluorescence-activated
cell sorting of blood samples.
Results: Familial molecular analysis revealed co-segregation of the
p.V863L substitution in CD101, the human homolog of an autoimmune diabetes gene in the non-obese diabetic mouse, with type 1 diabetes. Mutation screening of CD101 in 127 sporadic cases detected
the p.V678L and p.T944R substitutions in two patients. The p.V863L,
p.V678L, and p.T944R substitutions were absent or extremely rare in
the general population and were assessed as “probably/possibly damaging” by in silico analyses. CD101 expression on monocytes, granulocytes, and myeloid dendritic cells of mutation-positive patients was
weaker than that of control individuals.
Conclusions: These results raise the possibility that CD101 is a susceptibility gene for type 1 diabetes.
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P101
Vitamin D status and vitamin D receptor gene
polymorphisms and susceptibility to type 1 diabetes
in Korean population
C.K. Cheon1
1
Pusan National University Children’s Hospital, Pediatrics, Yangsan,
Republic of Korea
Objectives: Type 1 diabetes mellitus (T1DM) is one of the T-cell
mediated autoimmune diseases and vitamin D suppresses activation
of T-cell and has immunomodulatory effects. The aim of this study
was to investigate the association between vitamin D status and Vitamin D receptor (VDR) gene polymorphisms and T1DM.
Methods: One hundred and thirteen controls and eighty-one
patients with T1DM were enrolled in the study. . TaqI, BsmI, and ApaI
polymorphisms were detected using polymerase chain reactionrestriction fragment length polymorphism. Serum 25-hydroxyvitamin
D (25(OH)D) was determined using chemiluminescent immunoassay (CLIA).
Results: Serum 25(OH)D levels showed a vitamin D deficiency or
insufficiency in 72% of the patients. The mean levels of vitamin D
were significantly higher in healthy controls as compared to patients
with T1DM (P = < 0.05). TaqI and BsmI differences were significant
after applying Bonferroni correction (P = < 0.05, respectively). The
TT genotype carrier frequency among controls was higher than
among the T1DM patients (P = < 0.05; OR, 2.98; 95%CI: 1.19-7.42).
T allele frequency was higher among controls than T1DM patients
(P = < 0.05; OR, 2.78; 95%CI: 1.15-6.72). The frequency of bb genotype carriers among controls was higher than among T1DM patients
(P = < 0.05; OR, 4.13; 95%CI: 1.4-12.10). The frequency of the b
allele among controls was higher than that among T1DM patients
(P = < 0.05; OR, 3.20; 95%CI: 1.19-8.60).
Conclusions: This study indicated that T and b alleles which have
high vitamin D level are protective against T1DM in Korean subjects.
P102
Diabetic ketoacidosis at onset of type 1 diabetes in
children: role of demographic, clinical and
biochemical features along with genetic and
immunological markers as risk factors. A twentyyear experience in a tertiary Belgian centre
A. Vicinanza, H. Dorchy
University Children´s Hospital Queen Fabiola, Diabetology Clinic,
Brussels, Belgium
Objectives: Diabetic ketoacidosis (DKA) is the leading cause of morbidity and mortality in children with type 1 diabetes (T1D). Little is
known about the association between genetic and immunological
markers and the risk of DKA at T1D onset. The aim of this study was
to create a multivariable model foreseeing the onset of DKA in newly
diagnosed patients in a multi-ethnic environment like Belgium.
Methods: This retrospective study included 532 T1D paediatric
patients (age < 18 yr at diagnosis) recruited at our hospital from
1995 to 2014. DKA and its severity were defined according to the
2014 criteria of ISPAD. Genetic risk categories for developing T1D
were defined according to the results by the Belgian Diabetes Registry. Multivariate statistical analyses were applied to investigate risk
factors related to DKA and its severity at diagnosis.
Results: The mean age at diagnosis of the total population was
7.8 yr (range 0.2-17.5). Overall 42% of patients presented DKA at
diagnosis. This study outlined the major risk of DKA at diagnosis for
younger children (<3 yr) and for those belonging to ethnic minorities.
Children carrying neutral genotypes had 1.5-fold increased risk of
DKA at diagnosis than those with susceptible or protective genotypes
(p = 0.047), an observation not previously reported. Neutral genotypes were more frequent in ethnic minorities and these parameters
were both independently predictive of DKA at T1D onset. Only solitary positive IA-2A increased the risk of DKA at diagnosis
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independently of its severity (p = 0.025). The proposed multivariable
model could help to predict the probability of DKA in 70% of newly
diagnosed cases.
Conclusions: This was the first reported implication of IA-2A positivity and neutral genotypes predisposing to DKA at diagnosis regardless of its severity. Earlier diagnosis through genetic and immunologic
screening of high-risk children could decrease DKA incidence at diabetes onset.
DRB1*09:01, which was already reported to be associated to Japanese childhood-onset type 1 diabetes.
Conclusions: The high prevalence rate of ZnT8Abs in child-onset
Japanese type 1 diabetes was reported, However, this study has
revealed that ZnT8Abs was detected in a higher proportion of
patients with adolescent-onset autoimmune type 1 diabetes than in
those with childhood onset. They seem to be a valuable marker to
differentiate clinical and immunological phenotypes.
P103
The prevalence ZnT8 antibodies and clinical
features in 1022 Japanese patients with childhood
and adolescent onset type 1 diabetes
P104
Analysis of chosen polymorphisms rs2476601 A/G
- PTPN22, rs20541 A/G - IL13, rs29941 A/G KCTD15 in pathogenesis of type 1 diabetes in
children
T. Kawamura1, E. Kawasaki2, K. Minamitani3, T. Mukai4,
T. Mochizuki5, S. Nakamura6, E. Tachikawa7, Y. Kawada8, T. Ayabe9,
I. Yokota10, S. Sugihara11, Japanese Study Group of Insulin Therapy
for Childhood and Adolescent Diabetes (JSGIT)
1
Osaka City University Graduate School, Pediatrics, Osaka, Japan, 2Shin
Koga Hospital, Diabetes & Endocrinology, Kurume, Japan, 3Teikyo
University Medical Center, Pediatrics, Chiba, Japan, 4Asahikawa-Kosei
General Hospital, Pediatrics, Asahikawa, Japan, 5Osaka Police Hospital,
Pediatrics, Osaka, Japan, 6Mominoki Hospital, Pediatrics, Kouchi, Japan,
7
Tokyo Women’s Medical University, Pediatrics, Tokyo, Japan, 8Kyusyu
Rosai Hospital, Pediatrics, Kitakyusyu, Japan, 9National Research
Institute for Child Health and Development, Molecular Endocrinology,
Tokyo, Japan, 10Shikoku Medical Center for Children and Adults,
Pediatrics, Zentuji, Japan, 11Tokyo Women’s Medical University Medical
Center East, Pediatrics, Tokyo, Japan
Objectives: Zinc transporter 8 antibody (ZnT8Abs) is one of autoantibody in type 1 diabetes. The aim of this study was to determine the
prevalence and role of antibodies to ZnT8Abs in Japanese childhood
and adolescent onset type 1 diabetes.
Research design and Methods: The sera of 1022 Japanese patients
with childhood and adolescent onset Type 1 diabetes was collected
at the registry of a cohort in Japanese Study Group of Insulin Therapy for Childhood and Adolescent Diabetes (JSGIT). ZnT8Abs were
measured by a radio-immuno-assay using recombinant ZnT8 COOHterminal or NH2-terminal proteins. GAD antibodies (GADAbs) and IA2 antibodies (IA-2Abs) were also measured. HLA-DR typing was performed by PCR-amplified DNA and nonradioactive sequence-specific
oligonucleotide probes.
Results: ZnT8Abs were detected in 24.0% patients. GADAbs and IA2Abs were 41.3 and 54.4% respectively. Among the 138 patients
who were both negative with GADAbs and IA-2Abs, only 8 patients
were ZnT8Abs positive. Among the patients within 1-year after the
onset, 49.1% of them had ZnT8Abs. The prevalence of ZnT8Abs was
rapidly decreased with the duration of the disease compared with
GADAbs and IA-2Abs. ZnT8Abs was higher in the patients with the
adolescent-onset than in those with childhood onset. ZnT8Abs were
associated with adolescent, a high GADAb titer and female. It was
not observed that the relationship between ZnT8Abs and HLA
A. Bossowski1, A. Góralczyk1, J. Goscik2, N. WawrusiewiczKurylonek3, W. Mlynarski4, A. Kretowski3
1
Medical University of Białystok, Dep. of Paediatrics, Endocrinology,
Diabetology with Cardiology Division, Białystok, Poland, 2Medical
University of Białystok, Centre for Experimental Medicine, Białystok,
Poland, 3Medical University of Bialystok, Dep.of Endocrinology,
Diabetology with Internal Medicine, Białystok, Poland, 4Medical
University of Łódź, Dep. of Pediatric, Oncology, Hematology and
Diabetology, Lodz, Poland
Background: Type 1 Diabetes is multifactorial disease with a genetic
susceptibility and environmental factors. The Tyrosine phosphatase
non-receptor type 22 (PTPN22) gene polymorphism is known to be
associated with T1DM, but it has not been established in a Caucasian
children population yet. The interleukin 13 (IL13) and the potassium
chanel tetramerization domain containing 15 (KCTD15) gene polymorphisms impact on the development of Type 1 DM in children has
not been reported yet.
Objective and hypotheses: To estimate the association of polymorphisms of PTPN22, IL13 genes and KCTD15 polymorphisms with
the predisposition to T1DM in children.
Method: The study was performed in 94 patients with T1DM and
160 healthy volunteers. The three single nucleotide polymorphisms
(SNPs): rs2476601 - PTPN22, rs20541- IL13 , rs29941 -KCTD15
were genotyped by TaqMan SNP genotyping assay using the realtime PCR.
Results: Rs2476601 A alleles were more frequent in patients with
T1DM in comparison to healthy subjects (p = 0.004 with OR = 2).
Rs20541 A alleles were more frequent in T1DM patients in comparison to healthy subjects (p = 0.002 with OR = 2). Rs29941 A alleles
were more frequent in T1DM patients in comparison to healthy subjects (p = 0.001, OR = 7).
Conclusion: Rs2476601 A/G - PTPN22, rs20541 A/G - IL13 ,
rs29941 A/G - KCTD15 polymorphisms could contribute to development of T1DM in children. The main risk factor for rs2476601,
rs20541 and rs29941 is allele A.
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Poster Tour 14: Monogenic Diabetes
P105
Onset of type 2 diabetes in a toddler ?
A. Moretti1, R. Cardani2, A. Trettene1, L. Lenzi3, S. Toni3,
A. Salvatoni1,2
University of Insubria, DSCM-Pediatric Unit, Varese, Italy, 2ASSTSettelaghi, Mother & Child Department - Pediatric Unit, Varese, Italy,
3
University of Florence, Pediatric Diabetology Unit, Meyer Children’s
Hospital, Florence, Italy
1
Objectives: To report a case of a normal weight Italian girl who
showed temporary diabetes in two occasions, neonatally and at the
age of two year, and successive later development of overt diabetes
of uncertain classification.
Case report: FP is the eldest daughter of a caucasian couple, born
at the end of normal pregnancy by natural delivery with a birth
weight adequate to gestational age. In the first week of live she
showed temporary hyperglycemia, glycosuria and ketonuria. Insulin
and C-peptide in serum resulted respectively 0.5 mcU/mL and < 0.3
mcg/ml. Blood glucose (BG) monitoring was started showing mainly
normoglycemia with occasional high-borderline BG values with
HbA1c in the normal range. KCNJ11 and MODY2 were excluded by
genetic test. At 2 years of life hyperglycemia, ketonuria and HbA1
of 6.9% were documented and insulin treatment was started, and
discontinued after two weeks, for complete spontaneous remission.
T1DM related antibodies (ICA, GADA, IAA, IA2, ZNT8) and HLA D3
and D4 antigens were all negative and an IVGTT showed a FPIR of
47 mcU/mL (1st centile). NGS identified two variant of the HNF1-α
gene: 79A > C (pIle27Leu) reported as associated with insulin resistance, and G1720A > G (pSer574Gly) associated with increased risk
of type 2 diabetes. At the age of 8 year the girl developed over diabetes (HbA1 of 8.4%, CGM reported a BG value (mean SD) of
152 40 mg/dl and a maximun glycemic value of 311 mg/dl). On
the basis of the genetic results we started treatment with metformin (initial dose: 250 mg OD, final dose: 500 mg BID) with a progressive reduction of both fasting and postprandial glycemia
(mean sd BG by CGM 125.5 32.1 mg/dl).
Conclusions: The interest of this case arises from the difficulty, even
in the presence of overt diabetes, to find a correct diagnostic and
therapeutic orientation. The good therapeutic response to metformin
and genetic mutations suggest the hypothesis of an exceptionally
early onset of type 2 diabetes.
P107
The case of lipoatrophic diabetes in eleven year
old girl
G. Svetlova1, T. Kuraeva1, A. Mayorov2, V. Peterkova1
1
Endocrinology Research Center, The Institute of Pediatric
Endocrinology, Moscow, Russian Federation, 2Endocrinology Research
Center, The Institute of Diabetes, Moscow, Russian Federation
Lipodystrophy syndromes are genetically heterogeneous disorders
characterized by partial or total loss of adipose tissue in the body and
insulin resistance. The clinical signs could manifest at different age
and include lipodystrophy, insulin resistance, diabetes mellitus and
hypertriglyceridemia, and hepatic steatosis.
Clinical case: Patient M., 11 years old, was admitted to Endocrinology
unit with hypermasculine lipodystrophy. The girl had accelerated
growth, loss of subcutaneous fat. Her height was 158 cm, SDS 1.76.
Body weight 35.8 kg, BMI: 14.34 kg/m2, SDS BMI: −1.89. She had
grey axillar acanthosis, hypertrichosis of the lower legs, curly hair.
Puberty stage was B2P1, she had early puberty since the age of 8. She
had muscular hypertrophy and contractures of the interphalangeal
wrist joints. Fasting glycaemia was 12.7 mmol/L and HbA1c was 9.7%.
Cholesterol was high, 17.97 mmol/l, triglycerides - 90.46 mmol/l,
protein-179 g/l, leptin-2 ng/ml, insulin-105.1 mcU/ml. On the background the carbohydrate and animal origin fats free diet during a week,
the blood glucose levels decreased to 4.5 - 7.7 mmol/l, cholesterol - to
4.2 mmol/l, HDL - to 0.57 mmol/l, triglycerides - to 10 mg/l, protein
was 94 g/l, ALT- 93 E/l, AST- 45 E/l. Proton MR- spectroscopy
revealed a predominantly brown fat. Hyperinsulinemic euglycemic test
clamp- M-index −2.5, which corresponds to the severe insulin-resistance. Molecular genetic analysis revealed a heterozygous mutation p.
D136V in the gene LMNA (MIM #: 150330, reference sequence
NM_170707.2). This mutation has never been previously described, its
pathogenicity is not clear, her parents ae healthy and don’t have the
mutation.
Conclusion: Taking into consideration that the patient has got not
previously described mutations in LMNA, we can assume a new dominant mutation in this gene, which leads to the development of a generalized form of lipodystrophy. About its pathogenicity can be
assessed after conducting tests in vivo.
P108
Impact of insulin therapy on body mass index and
pulmonary function in patients with cystic fibrosisrelated diabetes mellitus in a non-Caucasian
population
T. Martins, R.M. Noronha, N. Damaceno, L.H. Muramatu, L.E. Calliari
Santa Casa of Sao PauloFaculty of Medicine, Pediatric Endocrinology
Unit, Sao Paulo, Brazil
Objective: Cystic fibrosis is the most common autosomal recessive
disease among Caucasians and mortality rates are high. Recent therapeutic advances have increased survival rates, resulting in increased
risk of comorbidities, such as cystic fibrosis-related diabetes (CFRD).
Current guidelines recommend early diagnosis and treatment of
CFRD with insulin; however, few studies have evaluated the clinical
impact of therapy. Moreover, published studies have focused on Caucasian populations. The objective of this study was to evaluate the
effect of insulin on BMI and pulmonary function in a non-Caucasian
cohort with CFRD.
Research design and Methods: This retrospective study analyzed
the medical records of patients reviewed at the Multidisciplinary
Center of Cystic Fibrosis of São Paulo School of Medicine, Brazil.
BMI and pulmonary function (measured by forced vital capacity
[FVC] and forced expiratory volume [FEV] in 1 second) were
assessed. The relevant time interval commenced one year before (T12) and ended one year after (T + 12) the introduction of insulin (T0).
Results: The zBMI values were as follows: −0.434 1.3 (T-12),
−0.462 1.3 (T-6), −0.547 1.3 (T-3) -0.607 1.3 (T0) 0.478 1.3 (T + 3), −0.534 1.3 (T + 6), −0.547 1.3 (T + 12).
Between T-12 and T0, there was a zBMI reduction of −0172
(p < 0.05). Following T0, zBMI increased and then stabilized. FVC
and FEV worsened between T-12 and T0 and stabilized after T0.
Conclusions: Early insulin therapy has a positive effect on BMI and
pulmonary function in non-Caucasian patients with CFRD.
P109
The Wolfram-like syndrome: a case report
P. Konecna1, D. Prochazkova1, Z. Dolezel1, J. Skotakova2,
L. Fajkusova3
1
Faculty Hospital Brno, Pediatrics Department, Brno, Czech Republic,
Faculty Hospital Brno, Radiology Department, Brno, Czech Republic,
3
Faculty Hospital Brno, Centre of Molecular Biology and Gene Therapy,
Brno, Czech Republic
2
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Background: The Wolfram-like syndrome-WFSL is rare autosomal
dominant disease characterised by triad: congenital progressive hearing loss, diabetes mellitus and optic atrophy.
Case report: The patient was kept under observation from birth for
Peters anomaly type III, congenital glaucoma, megalocornea. At the
age of 4 months his hearing was examined and severe hearing
impairment to deafness was diagnosed, one-sided deformity of the
auricle with atresia of the bony and soft external auditory canal;
non-differentiable eardrum; missing os incus. He was under observation from infant age for severe psycho-motor retardation. From the
age of 2.5 years treated for hypothyreosis. At the age of 3 1/4 years
the patient was examined for growth retardation, failure to thrive.
Insulin-treated diabetes mellitus was diagnosed. Molecular-genetic
examinations revealed de novo mutation c.2425G > A (p.
(Glu809Lys) in WFS1 gene. No mutations were proved in the biological parents.
Conclusions: The mutation (p.(Glu809Lys) in WFS1 gene is associated with occurance of the Wolfram-like syndrome-WFSL.
[OPTIMAL GLYCEMIC CUT-OFF BY ROC CURVE]
P110
Continuous monitoring system evaluation for the
diagnosis of carbohydrate metabolism in cystic
fibrosis (CF) patients
P111
CFRD clinical care: experience of Diabetology Unit
and Tuscany Regional Centre for Cystic Fibrosis of
Meyer Children’s Hospital
M. Clemente1, L. Bilbao1, L. Costas2, S. Gartner3, D. Yeste1,
A. Campos1, E. Armengol1, M. Losada1, A. Carrascosa1
B. Piccini1, G. Taccetti2, A.S. Neri2, F. Barni1, M. Guasti1, E. Casalini3,
L. Lenzi1, S. Toni1
1
1
Vall d’Hebron Hospital, Paediatric Endocrinology, Barcelona, Spain,
IDIBELL, Department of Epidemiology, Barcelona, Spain, 3Vall d’Hebron
Hospital, Paediatric Cystic Fibrosis Unit, Barcelona, Spain
2
Objectives: Oral glucose tolerance test (OGTT) is validated test to
diagnose glucose abnormalities in CF patients, however it is not
always sufficiently sensitive and specific. Continuous glucose monitoring (CGM) could be an alternative tool.
Methods: Prospective study of CF patients aged ≥10years. OGTT
and CGM were performed. Patients with exacerbations,steroids,GH,
immunosuppressed, insulinised or transplanted were excluded.
Patients were classified in normal glucose tolerance (NGT), abnormal glucose tolerance (AGT) or cystic fibrosis-related diabetes(CFRD)
by OGTT. After OGTT CGM(IproTM2 ) was performed.
Changes in BMI and FEV1 in the preceding year were assessed
(DSD BMI and Δ%FEV1,respectively (current-one year ago). Different
criteria were established and ROC curve was used to determine optimal glycaemic cut-offs to define the classification in NGT, AGT or
CFRD by CGM. STATA statistical software.
Results: Thirty patients. Mean age: 14.6 2.6 years, 53.3% female.
36.7% homozygous F508del, 40% heterozygous F508del, 23.3%
other.
OGTT: 47%NGT,47% AGT and 6% CFRD. CGM revealed glucose
peaks >200 mg/dl in 21% of CF patients with normal OGTT (66%
≥2peaks in different days). 21% of AGT patients on OGTT presented
fasting blood glucose (FBG) >126 mg/dl during monitoring.
CGM: patients were classified as NGT, AGT or CFRD using different criteria and selecting the most sensitive and specific (Figure) As
greater was the loss of BMI and FEV1 more sensitive and specific
was CGM to detect glucose tolerance abnormalities (AUC ROC curve
0.75 in ΔBMI < 0 vs 0.64 in ΔBMI > 0; AUC 0.66 in ΔFEV1 < 0 vs
0.62 in FEV1 > 0).
Conclusions:
1. Diagnostic criteria of glucose metabolism in CF patients based on
CGM results are proposed.
2. Carbohydrate metabolism abnormalities detected by CGM are
related to deterioration in lung function and nutricional status in
the previous year.
3. CGM reveals early glucose tolerance abnormalities, undiagnosed
by OGTT and correlated with clinical outcomes.
Tuscany Regional Centre of Pediatric Diabetes, Meyer University
Children’s Hospital, Florence, Italy, 2Tuscany Regional Centre of Cystic
Fibrosis, Meyer University Children’s Hospital, Florence, Italy, 3University
of Florence, Florence, Italy
Background: Epidemiological and clinical data on medical care for
cystic fibrosis-related diabetes (CFRD) is limited.
Objectives: To evaluate the state of clinical care and the adherence
to guidelines for CFRD patients followed at Diabetology Unit and
Cystic Fibrosis Unit of Meyer children’s hospital.
Methods: Data were retrieved from the electronic medical files, analyzed and compared to the latest International Society for Pediatric
and Adolescent Diabetes (ISPAD) and American Diabetes Association/Cystic Fibrosis Foundation (ADA/CFF) guidelines.
Results: 65 out of 305 (21.3%) CF patients were diagnosed with
CFRD between 1988 and 2014. Mean age at diagnosis was
25.9 10.9 years. 32.3% of cases were diagnosed in pediatric age.
8 patients (12.3%) died in the last 5 years and 29 (44.6%) underwent
lung transplant. Insulin therapy was initiated at diagnosis in 90.7% of
cases. 52.6% of subjects were treated with basal-bolus regimen,
either with multiple daily injections (MDI) or with continuous subcutaneous insulin infusion (CSII; 5 patients). 14% and 28.1% of patients
were treated respectively with long acting or rapid acting insulin analog only. 3 subjects (5.3%) discontinued insulin therapy. Patients
attended the CF clinic regularly (mean 6 4 visits yearly), whereas
they were seen less often than recommended by the diabetes multidisciplinary team (2 vs 4 times yearly). Self-monitoring blood glucose
(SMBG) was performed by 59.6% of patients. HbA1c was measured
more than 3 times per year only in 32.7% of patients in the last
2 years. Nevertheless metabolic control was good. Only 12.2% of
patients had a HbA1c over the recommended target of 7%
(53 mmol/mol). Mean HbA1c during the last two years was 6.1%
(43 mmol/mol) in adults (5.2-9.9%) and 6.3% (45 mmol/mol) in children (5.4-8.1%). Only 36.8% of patients performed complete screening for microvascular complications.
Conclusions: We found suboptimal adherence and compliance to
standards of care among CFRD patients analyzed.
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P112
Dapagliflozin in a girl with Rabson-Mendenhall
syndrome, RMS
G. Forsander
Univ of Gothenburg, Institut of Clinical Sciences, Dept of Pediatrics,
Gothenburg, Sweden
Background: Donohue- and Rabson-Mendenhall syndrome are rare
autosomal recessive disorders caused by mutations in the insulin
receptor gene, INSR. Phenotypic features include extreme insulin
resistance, linear growth retardation, paucity of fat and muscle, and
soft tissue overgrowth. Severe hyperinsulinism with pancreatic β-cell
decompensation, hyperandrogenism, hyperglycemia and ultimately
ketoacidosis adds to the picture. Early mortality due to advanced
complications of diabetes is common. INSR has also been entailed
in magnesium homoeostasis and nephrocalcinosis. The diabetes
POSTER TOURS
treatment in the cases of DS-RMS is extremely hard since the insulin
receptors are not responding to insulin.
Case description: A girl born SGA in 2007 and diagnosed with RMS
with the genetic deletion p.V66/del.ex18 had a serum insulin level of
>9000 and showed obvious signs of achantosis nigricans. Treatment
with IGF-1 at the age of 2 y resulted in cardiomyopathy and was withdrawn. She was further on treated with metformin and CHO-reduced
diet, got a PEG and trachestomia and substitution was given with
potassium and magnesium. Since 3 y back, the plasma glucose values
are significantly more stabilized and lowered by adding Dapagliflozin
(Forxiga). The HbA1c-value is now around 55 mmol/mol. No adverse
effects as UTI or fungal infection have been shown. Mentally this girl
developes very nicely and is attending normal school education.
Conclusion: Dapagliflozin is a relatively new T2D drug on the market
that significantly rise the glucose excretion by the kidneys and
thereby lowers the plasma glucose value. It can be a drug to consider
in the treatment of RMS.
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Poster Tour 15: Nutrition, Exercise & Epidemiology
P113
Assessment of nutritional knowledge of Greek
patients with type 1 diabetes and their parents
K. Pappa, M. Dimitriadou, A. Karaiskou, P. Triantafyllou,
A. Christoforidis
Aristotle University, 1st Pediatric, Thessaloniki, Greece
Objectives: To assess the level of nutritional knowledge of patients
with type 1 diabetes and their parents in our center and its associations with glycemic control using a questionnaire that was developed
and applied in another center that would allow comparisons between
the two centers.
Methods: Patients with type 1 diabetes, aged > 12 years and their
parents were recruited during their regular visits at the Outpatient
Pediatric Diabetes Clinic of our Department. All participants were
asked to fill out a translated version of the Nutrition Knowledge Survey (NKS). Caregivers also completed a second questionnaire consisted of demographic information, whereas data regarding disease
treatment and control were extracted from patient’s medical records.
Results: The mean total NKS score of all questionnaires completed
was 60.36%. Mothers scored significantly higher (mean NKS score:
64.66% 14.37) compared to fathers (mean NKS score:
58.57% 16.90) and patients (mean NKS score: 52.85% 16.97). A
significant inverse correlation was recorded between HbA1c levels
and “Carbohydrate counting” domain score (r = −0.275, P = 0.016),
whereas “Healthful eating” domain score was linearly correlated with
maternal (r = 0.281, P = 0.015) and mid-parental age (r = 0.288,
P = 0.017).
Conclusions: The application of the NKS questionnaire in our center
showed a significant association between carbohydrate counting
knowledge and glycemic control, outlined differences in diabetes
nutrition knowledge status between the center where NKS was originally developed and our center and highlighted a higher nutritional
knowledge level of mothers compared to fathers and children.
P115
Influence of physical activity on metabolic control,
body composition and cardiovascular system in
children and adolescent with T1DM
A. Trettene1, R. Cardani2, C. Maffoni1,2,3, M. Zavattoni1,2,3,
A. Salvatoni1,2
University of Insubria, DSCM-Pediatric Unit, Varese, Italy, 2ASSTSettelaghi, Mother & Child Department - Pediatric Unit, Varese, Italy,
3
ADIUVARE - onlus, Varese, Italy
1
Objectives: Our study aims to evaluate the effect of physical activity
(PA) on body composition, metabolic control, systolic and diastolic
blood pressure (SBP and DBP) and heart rate (HR) in young patients
with type 1 diabetes mellitus (T1DM).
Methods: We performed a cross-sectional study on 81 patients
(45 male) with T1DM aged 16.0(5.6) years, with disease duration of
86(62) months and free of coeliac disease and/or thyroiditis. Every
patient was asked to report which type of physical activity was used
practicing every week and how long. Depending on the type of sport
practiced and the time spent in their practice, the total hours of physical activity per week were divided into three categories of exercise:
aerobic, anaerobic and mixed. Body composition was assessed
through body mass index (BMI), body impedance and skinfolds, and
metabolic control was evaluated through mean and SD of HBGM,
HBGI, LBGI and HbA1c. For each patient were also taken into
account the following parameters: systolic and diastolic pressure,
heart rate and insulin need. Data are reported as median (IQR). Simple and multiple regression analysis and Mann–Whitney test were
used for statistical analysis.
Results: The time spent on PA was inversely correlated with fat mass
% (FM%) (R2 = 0,194; p < 0.0002). FM% was directly correlated with
SDS-DBP (R2 = 0.082; p < 0.01) while BMI was directly correlated with
the SDS-SBP (R2 = 0.066; p = 0.02). Mixed exercise was associated
with significant lower FM% then the aerobic and anaerobic one [17.9
(6.4) vs 27.5 (15); p < 0.001]. We did not find correlations between the
amount and type of PA and any of the others parameters we collected.
Conclusions: Our results seem to highlight a positive effect of exercise, particularly the mixed one, on body composition and that the
latter improves DBP. Furthermore, it does not seem that PA has a
significative effect on metabolic control.
P116
Indian Diabetes Risk Score (IDRS) for type
2 diabetes mellitus screening in young adults: effect
of yoga and meditation
V. Sharma
Shri Mahamaya Vaishnav Devi Mandir Research Institute, New Delhi,
India
Background: India is the country with the top most people with diabetes, and with time life style is changing among pediatric and adolescent populations well as aged peoples. Current research based on
the prevalence and management of diabetes in Delhi metro population by Yoga and Meditation. There are several study are going on
the patients about their social and mental problem in younger diabetic children as well as their family.
Methods: 32 school children (age group 10–20 years) and 35 aged
diabetic patients (age 60–70 years) are scored using IDRS which
includes age, family history of diabetes, exercise status and Waist circumference. After scoring them they are categorised into mild, moderate and high risk group. All group were treated with Yoga and
Meditation for daily one month with balance diet at Shri Mahamaya
vaishnav devi mandir research institute, New Delhi, India.
Results: We get 8%, 79% and 13% children in high risk, moderate
and low risk group respectively for developing type 2 DM. After one
month their blood glucose and insulin levels were closer to normal
levels with increase in work efficiency in both younger and aged diabetic patients. Present study highlight that the successful treatment
of diabetic children and adolescents not only requires anti-diabetic
drugs; but also family care, life style education, harmonised mindbody-soul, awareness, psychological support, preventive approach
toward activity of daily living.
Conclusion: Through counselling with meditation and yoga, we can
help people to acknowledge and share the emotional challenges
raised by diabetes complications. Therefore preventive diabetes education programme & promotion of Yoga and meditation will be future
plan of action which can be suggested in the form of regular exercise
and diet planning for the students as part of an integrated approach.
P117
An audit of dietary intake of Australian children
with diabetes attending the Royal Children´s
Hospital, Melbourne
H. Gilbertson1,2, K. Reed3, S. Clark1, F. Cameron2,3
1
Royal Children’s Hospital, Nutrition and Food Services, Melbourne,
Australia, 2Murdoch Children’s Research Institute, Melbourne, Australia,
3
Royal Children’s Hospital, Endocrinology and Diabetes, Melbourne,
Australia
Objective: To understand what children with diabetes at the Royal
Children’s Hospital are eating compared to their peers and explore
dietary intake impact on HbA1c outcome.
80
Methods: An open cross-sectional dietary audit of children and adolescents with diabetes aged 2-17 years was conducted using an ageappropriate validated Food Frequency Questionnaire. Total energy,
macronutrient intake and diet quality were calculated and compared
to dietary advice provided and national intake data. Body weight, participation in physical activities, and dietary intake influences on glycaemic control were investigated.
Results: 785 patients were recruited and clinic data collected, from
which 457 dietary surveys were completed. Dietary intakes were
overall nutritionally adequate with macronutrient distribution (% total
energy intake) being lower carbohydrate (49%), higher fat (33%),
higher saturated fat (15%) and higher protein intake (19%) than
recommendations, but similar to their peer group. Energy intakes
were excessive of requirements in the 4–13 year age groups. Rates
of overweight (27%) and obesity (9%) were significantly higher than
national data (18% and 7% respectively). Optimal glycaemic control
(HbA1c < 58 mmol/mol) was achieved by 43% of cohort, with a
greater proportion being females. HbA1c was shown to improve with
higher carbohydrate intake and lower fat intake and deteriorate with
increased age and those classified as underweight. Mean reported
rates of physical activity in the group was 1.3 1.0 hours/day with
60% meeting national recommendations. Rates declined with
increased age.
Conclusions: This audit has provided a snapshot of our clinic population and identified areas requiring targeted education/support to
improve health outcomes which include dietary adherence, rates of
overweight/obesity, appropriate energy intakes and optimal glycaemic control targets. Furthermore it provides good baseline data to
evaluate the efficacy of future interventions.
P118
Eating behaviour patterns in Polish and Italian
children with type 1 diabetes mellitus
E. Niechcial1, A. Mongiardo2, A. Krasinska1, A. Petitti2, M. Ferrari2,
B. Skowronska1, P. Fichna1, A. Scaramuzza2
1
Poznan University of Medical Sciences, Department of Paediatric
Diabetes and Obesity, Poznan, Poland, 2Luigi Sacco Hospital, University
of Milano, Department of Paediatrics, Milan, Italy
Objectives: Children with diabetes should follow the same dietary
recommendations as a healthy peers. Nonetheless, they have to
adjust insulin dosage to food intake. Nutrition education and modelling healthy habits in children with diabetes will help to maintain better diabetes control. We aimed to identify eating behaviour patterns
in Polish and Italian children with type 1 diabetes mellitus.
Methods: The study is conducting among 50 Polish and 50 Italian
children, aged 7–18 years with type 1 diabetes mellitus who follow
a routine check-up visit at Diabetes Centre in Poznan (Poland) and
in Milan (Italy). A self-administrated Children´s Eating Behaviour
Questionnaire is used to assess the frequency and quality of food
intake.
Preliminary Results: The study cohort has already comprised
43 Italian children (girls:23; boys: 20). In the end of August the
study will be finished. The mean age was 13.5 years. 74,4% of
children admitted that other’s people support is very important in
maintaining a healthy diet and 77% had a nutrition consultation.
All children had regular meals (67%-5 meals per day; 33%-4 meals
per day) and breakfast. Typical breakfast contains milk, biscuits,
cornflakes (58%, 72% and 28% respectively). All children had at
least one snack per day and they usually ate: fruits, sandwich,
crackers, chocolate, ice-cream (60.4%, 53%, 28%, 16.3% and 14%
respectively). 37.2 % children added sugar to beverages (87.5%
one spoon, 12.5% two spoons). 11.6% of respondents took multivitamins. Majority consumed fruits and vegetables less than three
times per day (67.4% and 95.3%, respectively) , 74.4% had fish less
than 2–4 per week, 81.4% ate meat once a week or more and
95.3% drank water every day. 56% drank slim milk or low fat milk
2–4 per week or more.
POSTER TOURS
Conclusions: Most of children had healthy eating habits. Children
need support in maintaining a healthy diet and a nutrition consultation should be a part of diabetes management.
P119
High proportion of type 2 diabetes among newly
diagnosed children and adolescents in La Reunion
Island, a French oversea territory
A. Tezier1, L. Houdon1, K. Burlot2, M. Lang3, P. Pigeon Kerchiche4,
E. Bismuth1
1
CHU de la Réunion, Saint Pierre, Réunion, 2Centre Hospitalier Gabriel
Martin, Saint Paul, Réunion, 3Hopital d’Enfants, Saint Denis, Réunion,
4
CHU de la Réunion, Saint Denis, Réunion
Objectives: La Reunion Island, a 843 000 inhabitants French oversea
territory located in the Indian Ocean, exhibit one of the highest rate
nationwide of adult obesity and type 2 diabetes (DT2). Although
more than 1/4 of the pediatric population is also overweight or
obese; little is known on pediatric onset diabetes. Our goal was to
estimate the incidence of Pediatric onset diabetes in La Reunion and
to describe diabetes etiologies.
Methods: Data on all new cases of diabetes 0–18 years old admitted
in any one of the 3 pediatric centers in La Reunion from January 1rst
2010 to December 31st 2014 were collected. Family history, clinical
(symptoms, age, gender, BMI), biological (Ketones, pH, HCO3-,
HbA1c), and immunological (ICA, IA2, IAA, GAD antibodies) data at
diagnosis, along with follow up findings (insulin requirement, associated symptoms, genetic testing) were retrospectively recorded from
paper and electronic charts to classify diabetes etiologies.
Results: Over the 5-year period 170 children and adolescents were
diagnosed with diabetes representing an estimated incidence of
12.5/100,000 per year. Mean aged at diagnosis was 9.4 4.8 yrs old
with 23% of the patients younger than 5 years old. Most of them
(75%) had a family history of diabetes and 15% were obese at diagnosis. Final diagnosis was type 1 diabetes for more than 80%. T2D
represented 9.4% of the patients (n = 16) with a mean aged at diagnosis of 14.9 yrs old [10.8 -17.5], Body Mass index 4.1 2.1 SDS
[0.3-8.5], mostly girls (3:1), and all pubertal. Mean HbA1c for DT2
patients was 10.8 3.4% [5.5-16.8]; 2 cases presented with ketosis
and 2 in ketoacidosis (25%).
Conclusions: Incidence of pediatric onset diabetes in La Réunion
appears to be similar to mainland France but with a worrisome proportion of almost 10% of the patients with DT2. Strategy prevention
should be implemented in this population to reduce childhood obesity and limit the growing burden of DT2.
P120
Type 2 diabetes in Bangladeshi children and
adolescents - an emerging problem
B. Zabeen1, J. Nahar2, S. Tayyeb1, N. Nhar2, K. Azad1
1
BIRDEM Institute, CDiC and Paediatrics, Dhaka, Bangladesh, 2BIRDEM
Institute, Paediatrics, Dhaka, Bangladesh
Introduction: Type 2 diabetes mellitus is emerging as a new clinical
problem within pediatric practice. Recent data shows the prevalence
of Type 2 diabetes among children and adolescents is increasing in
some ethnic groups around the world.
Methods: A total of 1369 children and adolescents with diabetes
attended CDiC Clinic in BIRDEM, a tertiary care Hospital in
Bangladesh over six years period: January 2010 to December 2015.
Among them 144 children were diagnosed as type 2 diabetes who
were included. Demographic and clinical data were recorded including age, gender, duration of diabetes, HbA1c, BMI SDS, Waist/height
ratio, BP, insulin dose and oral drugs. Urinary Albumin concentration
was measured by DCA 2000 analyzer.
Result: The number of children with type 2 diabetes increased more
than seven fold from 2010 (2%) to 2015 (15%). Median age was 13.0
POSTER TOURS
[11.0-15.0] and ten patients (7%) were below 10 years of age at the
onset. Family history was positive in 92% patients and 10% mother
had H/O GDM. Mean waist-height ratio was 0.60 .07 and more
than 90% were obese or overweight. Mean HbA1c was 10.5 2.8
and after 3 months was 8.4 2.2. Fatty liver on USG was found in
27 (19%) patients. Microalbuminuria developed in 10% children and
adolescents. Among them 20% were newly diagnosed. Life style
81
modification was advised in most of the patients. Insulin was started
initially along with Metformin in thirty-one patients (22%) and could
be stopped in thirteen (42%) of them in 3 months period.
Conclusion: Though it was uncommon in previous years, the number
of type 2 Diabetes increased over the years in our country. Life style
modification along with oral drug could be the first choice in most of
the children and adolescents with type 2 diabetes.
82
POSTER TOURS
Poster Tour 16: Psychosocial Issues
P121
Involving parents of young children in designing
and delivering a supportive intervention at new
diagnosis of type 1 diabetes (T1D)
M.E. Hilliard1, C. Tully2, W. Levy1, A.M. Butler1, K. Fegan-Bohm1,
M.C. Monaghan2,3, R. Streisand2,3
1
Baylor College of Medicine and Texas Children’s Hospital, Pediatrics,
Houston, United States, 2Children’s National Health System,
Psychology & Behavioral Health, Washington, United States, 3George
Washington University School of Medicine, Pediatrics, Washington,
United States
Objective: Given the unique challenges of managing T1D in young
children, new strategies are needed to promote glycemic control and
parent quality of life. Other parents with experience parenting young
children with T1D may be well-suited to offer support during the
especially difficult period after diagnosis. In preparation for a stepped
care behavioral intervention trial, parents of children with T1D were
involved in designing and delivering peer support over 9 months
post-diagnosis.
Methods: Before trial start, diabetes providers referred potential parent advisors: parents of children diagnosed ≥1 year ago with T1D
under age 7. Study staff screened referred parents and invited those
who were interested to join the parent advisory board to give feedback on intervention components. A subset with interest, recognized
suitability, and availability to be more involved, were trained as parent coaches, in which they would be paired with parents of newly
diagnosed young children to offer supportive contact related to
adjusting to diagnosis and parenting a young child with T1D.
Results: Of the 35 parents nominated, 30 were eligible to be advisors based on child’s current age, age at diagnosis, and English fluency, and 10 (90% female; 80% Caucasian; Child age =
7.7 2.0 years; Age at diagnosis = 3.8 1.0 years) consented to
be parent coaches. Training included a 4-hour group session and
individual calls focusing on coach roles, reflective listening/communication skills, and research ethics. Parent coach outcomes to be
measured include quality of life, parenting stress, mood, and selfefficacy.
Conclusions: Trained lay peer coaches are a low-cost, translatable
resource that can potentially offer highly relevant support after diagnosis. Peer coach support could be delivered universally, permitting
targeted resources to be allocated to parents with higher needs. The
ongoing trial will evaluate outcomes of peer coaching in combination
with more intensive intervention components.
P122
Fear of hypoglycemia in parents of children with
type 1 diabetes: results from diabetes MILES Youth - The Netherlands
J. Aalders1, E. Hartman1, G. Nefs1, A. Nieuwesteeg1, C. Hendrieckx2,3,
J. Speight2,3,4, H.-J. Aanstoot5, P. Winterdijk5, E. van Mil6, F. Pouwer1
1
Tilburg University, Center of Research on Psychological and Somatic
Disorders [CoRPS], Department of Medical and Clinical Psychology,
Tilburg, Netherlands, 2Deakin University, School of Psychology, Geelong,
Australia, 3The Australian Centre for Behavioural Research in Diabetes,
Diabetes Victoria, Melbourne, Australia, 4AHP Research, Hornchurch,
United Kingdom, 5Diabeter, Center for Pediatric and Adolescent
Diabetes Care and Research, Rotterdam, Netherlands, 6Kidz&Ko, Jeroen
Bosch Hospital, ’s-Hertogenbosch, Netherlands
Objectives: To identify sociodemographic and clinical correlates of
parental fear of hypoglycemia (PFOH) among parents of children
(4–18 years) with type 1 diabetes (T1D), and to examine the relationship between PFOH, mindfulness and mindful parenting.
Methods: This study is part of Diabetes MILES Youth-The Netherlands, a national cross-sectional study of children with T1D and their
parents. For these analyses, data from 421 parents were available.
Questionnaires included HFS-P Worry (PFOH), FMI-short (mindfulness) and IM-P (mindful parenting).
Results: Hierarchical multiple regression analysis showed that
younger age of the parent, lower educational level, non-Dutch
nationality and more blood glucose measurements per day were
related to higher PFOH. Other parent characteristics (gender, marital
status, employment status), child characteristics (age, gender) and
other diabetes-related factors (HbA1c, diabetes duration, pump therapy, history of severe hypoglycemia, ketoacidosis and diabetesrelated hospitalisations) were not associated with PFOH. Moreover,
lower mindfulness was related to higher PFOH. However, adding
mindful parenting to the model negated the previous contribution of
general mindfulness to PFOH. In this model, lower mindful parenting
was related to higher PFOH. Regarding the subdomains of mindful
parenting, less non-judgmental acceptance of parental functioning
and less emotional non-reactivity in parenting were related to
more PFOH.
Conclusion: With respect to sociodemographic and clinical factors,
younger age, non-Dutch nationality, lower parental educational level
and more blood glucose measurements per day were associated with
higher PFOH. In addition, parents who were less mindful, in general
or specifically in terms of their parenting, experienced more PFOH.
Hence, training parents of children with T1D who experience PFOH
how to become more mindful might help them to cope better with
their concerns about their child’s risk of hypoglycemia.
P123
Longitudinal association between quality of life and
HbA1c
A. Stahl-Pehe1,2, S. Landwehr3, K. Lange4, C. Bächle1,2, K. Castillo1,2,
R.W. Holl5, J. Rosenbauer1,2
1
German Diabetes Center, Düsseldorf, Germany, 2German Centre for
Diabetes Research (DZD), Düsseldorf, Germany, 3Heinrich Heine
University, Düsseldorf, Germany, 4Hannover Medical School, Hannover,
Germany, 5University of Ulm, Ulm, Germany
Objective: The purpose of the study was to prospectively explore
the relationship between chronic-generic and condition-specific quality of life (QoL) and HbA1c using data of a cohort study of young
patients with type 1 diabetes (T1D) across Germany.
Methods: The baseline survey conducted 2009–2010 included
patients aged 11 to 21 years with T1D onset occurring from age 0–4
years. The follow-up survey was conducted in 2012–2013. Additional
clinical data of routine care procedures from the German/Austrian
DPV Initiative were linked. QoL was assessed by the self-report DISABKIDS chronic generic module (DCGM-12) and diabetes module
(DM) with treatment and impact scale. Regression analyses were performed with the baseline DISABKIDS scores and socio-demographic
and health-related covariates as predictors, and the outcome followup HbA1c.
Results: A total of 560 patients with a mean follow-up time of
3.0 years (SD 0.6) were included in the analyses. At baseline, they
had a mean age of 15.9 (SD 2.3) years, a diabetes duration of 13.0
(2.0) years and a mean HbA1c of 8.3 (1.3) % (67 (14.2) mmol/mol).
Univariate analyses indicated associations between the QoL scores at
baseline and HbA1c at follow-up (β[DCGM-12] = −0.017 (standard
error
0.004),
β[DM
treatment] = −0.010
(0.002),
β[DM impact] = −0.018 (0.003), p < 0.001). The associations
remained significant after adjustment for sex, age, socioeconomic status, family composition, hospitalization, insulin pump therapy, diabetes duration, satisfaction with treatment/care, and overweight
(β[DCGM-12] = −0.012 (0.004), β[DM treatment] = −0.007 (0.002),
83
POSTER TOURS
β[DM impact] = −0.014 (0.003), p < =0.003). However, the associations were no longer present when additionally adjusting for baseline
HbA1c (p > 0.05).
Conclusions: Self-reported QoL was associated with HbA1c after
three years in the course of T1D among adolescents and emerging
adults with long-duration T1D, but mainly mediated by correlation
with HbA1c at baseline.
P124
Validation of a diabetes self-care measure for
parents of children with type 1 diabetes
M. Evans1, M. Feldman2, L. Davis3, J. Weissberg-Benchell2
1
Ann & Robert H. Lurie Children’s Hospital of Chicago, Child and
Adolescent Psychiatry, Chicago, United States, 2Ann & Robert H. Lurie
Children’s Hospital of Chicago, Department of Psychiatry & Behavioral
Sciences, Northwestern University, Chicago, United States,
3
Northwestern University, Department of Psychiatry & Behavioral
Sciences, Northwestern University, Chicago, United States
Objective: Managing Type 1 diabetes requires daily complex behaviors (insulin administration, diet, activity). Development of these
self-care skills becomes increasingly important as children with type
1 diabetes move towards adolescence. We aim to validate a new
measure that assesses parent’s perceptions of their child’s diabetes
self-care skills to guide interventions that can enhance adherence and
diabetes knowledge.
Methods: Participants were from 41 diabetes camps throughout the
U.S. Parents (N = 616) completed the Diabetes Skills Checklist to
assess the diabetes self-management skills of their children (N = 616;
mean age = 10.3, age range = 8-11.99, female = 53%, ethnicity =
91.1% White, 5.6% Latino, 2.4% Black). Parents also completed a
measure of their own diabetes-specific distress (P-PAID-C). Principal
axis factor analysis (PAFA) was performed to validate the 23-item
Parent version of the Diabetes Skills Checklist.
Results: Item-to-total correlations < .3 and items with communalities < .3 were deleted when running PAFA with promax rotation,
resulting in a 13-item measure, with a Cronbach’s alpha of .86. The
4 factor structure (knowledge about diet, diabetes and exercise, insulin adjustment, and knowledge about insulin) accounted for 59.7% of
the variance. Total scores were significantly correlated with parent
reported distress r (586) = −.27, p < .000 and hemoglobin A1c
(HbA1c) r(598) = −.13, p < .002.
Conclusions: The Diabetes Checklist-Parent Version is a brief measure of parent perceptions of their child’s diabetes self-care skills. Parent perceptions of better self care-skills were associated with less
distress and lower A1c. Results closely match the factor structure of
the Diabetes Checklist for parents of teenagers. This scale also has
practical application as a brief screen during clinic visits and for interventions targeting adherence and diabetes knowledge in children.
P125
Differences in perception of a child eating
behaviours in parents of overweight children with
type 1 diabetes - a pilot study
czyk1, K. Piechowiak1, A. Szypowska2
B. Zdun
1
The Public Paediatric Teaching Hospital, Warsaw, Poland, 2Warsaw
Medical University, Warsaw, Poland
Objectives: The maintenance of HbA1c below 7.5% as recommended by ADA and ISPAD guidance is crucial in treatment of children with type 1 diabetes. The other important parameter is a
patient´s weight. The aim of this study was to compare perception of
a child eating behaviours and factors affecting choice of food in par-
ents of children with diabetes type 1 considering their weight and
metabolic control.
Methods: Parents of children with diabetes duration > 1 year filled
in the Polish version of the Child Eating Behaviour Questionnaire and
the Food Choice Questionnaire. We analysed 165 fully answered
questionnaires (parents of 83 girls/82 boys, mean age - 12; mean diabetes duration - 5 years; mean HbA1c - 7.7; mean z-score - 0,45;
mean total daily insulin dose - 38.7; mean base - 14.2).
Results: 78 (47.3%) children achieved good metabolic control.
32 (19.4%) children were overweight (z-score > 1). We found significant difference between parents of children with (z-score > 1) and
children with (z-score ≤ 1) in perception of satiety responsiveness
(p = 0.0113) and relationship between z-scores and enjoyment of
food (r = 0.201, p = 0.0106), food responsiveness (r = 0.2175,
p = 0.0057) and emotional over-eating (r = 0.154, p = 0.05). HbA1c
significantly correlated with satiety responsiveness (r = 0.156,
p = 0.48) and food responsiveness (r = 0.187, p = 0.0172). There was
a significant correlation between children’s age and parental choice
of food in consideration of weight control (r = 0.1.94, p = 0.137),
food price (r = 0.206, p = 0.0087), mood (r = 0.165, p = 0.357) and
ethics (r = 0.153, p = 0.05). We found relationship between age and
emotional over-eating (r = 0.309, p = 0.0001).
Conclusions: 19.4% children had problems with weight. Parents of
overweight children had more problems with satiety recognition in
their children and emotional meaning of food. Children’s age may
pose a risk factor for overweight. Interventions targeted weight control should include both children and parents.
P126
Implementation of patient reported outcomes
through quality improvement methods to enhance
pediatric diabetes care
S. Corathers1, J. Kichler2, C. Mara3
1
Cincinnati Children’s Hospital and Medical Center, Endocrinology,
Cincinnati, United States, 2Cincinnati Children’s Hospital and Medical
Center, Behavioral Medicine and Clinical Psychology, Cincinnati, United
States, 3Cincinnati Children’s Hospital and Medical Center, Anderson
Center for Health System Excellence, Cincinnati, United States
Objectives: 1) Integrate patient reported outcomes (PRO) into routine pediatric diabetes visits in an academic center
2) Use PRO data to support improved outcomes: glycemic control
and quality of life.
Methods: Quality Improvement (QI) methodology (building a team,
setting goals, developing consensus, iterative testing) was used to
expand capacity for PROs of interest (quality of life, barriers to adherence, transition readiness) beyond the existing systemic process of
depression screening. Evidence review was conducted to select relevant measures; logic was created in the electronic medical record
(EMR) to identify eligible populations and frequency of survey administration. Surveys are completed on an EMR-integrated computer tablet, including real-time data access and score interpretation to guide
discussion of responses and referrals, as indicated. Diabetes module
Quality of Life, (PedsQL 3.2 (Varni et al., 2013) was the initial PRO
examined.
Results: Since initiation of PedsQL administration in January 2016,
completion rates average 74%, 1582 of 2225 eligible patients completing the questionnaire. Subscale analysis of the population at our
center compared to national averages of the 3.0 version ((Hilliard
et al., 2013). (See Table).
Conclusions: Building upon existing infrastructure, PRO measures
can be successfully integrated into routine diabetes visits. Subscale
scores for PedsQL can inform design of QI-driven interventions tailored to local needs and resources.
84
*
POSTER TOURS
Subscale
CCHMC Data Youth & Parent
combined Jan — Mar 2016 (n = 1245)
Mean (SD)
Barriers
Adherence
PedsQL Diabetes Moduble * YOUTHreport (n = 4571)
Mean (SD)
MCID**
76.89 (17.23)
79.9 (18.1)
84.15 (15.40)
82.4 (16.0)
Worry
65.12 (22.26)
Communication
82.01 (19.15)
PedsQL Diabeters Module* PARENTreport (n = 4440)
Mean (SD)
MCID**
10.86
70.4 (19.3)
10.57
9.99
77.2 (6.4)
9.56
74.4 (22.7)
12.01
72.4 (22.0)
8.52
79.0 (22.7)
7.53
74.2 (25.0)
7.91
Peds QL Data Source: Diabetes Care 36:1891–1897, 2013.
**
MCID = Minimal Clinically Important Difference.
[Table 1]
P127
Adapting to type 1 diabetes in very young children:
a crowdsourcing method for characterizing parents´
perspectives
J. Pierce1, K. Aroian2, C. Caldwell3, J.L. Ross4, J. Lee5, E. Schifano1,
T. Wysocki6
1
Nemours Children’s Hospital, Center for Health Care Delivery Science,
Orlando, United States, 2University of Central Florida, College of Nursing,
Orlando, United States, 3Nemours Children’s Health System,
Marketing & Communications, Jacksonville, United States, 4NemoursJefferson Pediatrics, Division of Pediatric Endocrinology & Metabolism,
Philadelphia, United States, 5University of Michigan, Division of Pediatric
Endocrinology, Ann Arbor, United States, 6Nemours Children’s Health
System, Center for Health Care Delivery Science, Jacksonville, United
States
Objectives: Parenting very young children with type 1 diabetes (YCT1D) is immensely challenging and parental coping is associated with
child outcomes. This paper reports qualitative work using crowdsourcing methods to design a web-based coping resource created by parents for parents.
Methods: A “Crowd” of 170 parents of YC-T1D (onset < 6 years old
and now < 10 years old) enrolled after internet recruitment. The
researchers sent parents 19 open-ended questions in sets of 3–5
questions weekly over five 1-week periods about parenting YC-T1D.
Parents shared written responses with other members via the internet and they were paid modestly. Trained coders identified themes
evident in those responses.
Results: The Parent Crowd submitted a mean of 115 responses to
the 19 questions; 88 parents answered every question and
152 answered at least one. Resulting themes reflected affective,
behavioral, cognitive and social challenges of parenting YC-T1D, and
also examples of positive effects of T1D.The researchers organized
the themes in a social-ecological framework comprising five levels of
influence: Child (25 themes), Parents (39 themes), Family (41 themes),
Social Circle (21 themes), and Community (21 themes) and validated
the taxonomy in a second iteration of parental feedback. The initial
sample was not sufficiently diverse and so the researchers recently
engaged 13 racial and ethnic minority parents, who supplemented
and affirmed the Parent Crowd´s work. Researchers and the Parent
and HCP Crowds will use the resulting taxonomy to guide the design
of the content, functions and governance of a social media portal.
The Parent Crowd will now specify website functions that could
enhance coping with identified challenges.
Conclusions: This crowdsourcing initiative efficiently yielded rich
data to inform planning of a web-based coping resource designed by
and for parents of YC-T1D. Parental use of the completed website
will then be evaluated in a randomized, controlled trial.
P128
Drug use among adolescents with diabetes.
A literature search and pilot study
K. Ramaker1, R. Mentink1, M. Tillman1, L. Hanck2
1
OLVG, Diaboss, Diabetescentre for Children and Young Adults,
Amsterdam, Netherlands, 2Jellinek, Amsterdam, Netherlands
Objectives: Illicit drug use is common among adolescents. Depending
on the type of drug, the prevalence is between 0,1 and 8,0%. Little is
known about the prevalence among adolescents with diabetes.
Methods: A literature search was done. Only 17 articles were usefull.
They showed drugs are used by adolescents with diabetes and they
can influence blood glucose levels. There is a higher chance of hyperglycaemia, ketoacidosis and metabolic acidosis.
We investigated in a pilot study the prevalence of drug use among
adolescents with diabetes in Amsterdam.
An anonymous questionnaire was distributed among adolescents
(16–25 years old), treated by Diaboss. The questionnaire included
15 questions about their characteristics, frequency of drug use, type
of drug, experiences with drug use, and advice to other adolescents
with diabetes and to diabetes specialists.
Results: The response rate was 35% (n = 62), mean age 19,4 years.
29% (n = 18) use drugs. Cannabis is used most frequently. 13 adolescents take precautions considering their diabetes. 4 Adolescents
report hypoglycaemia, 10 adolescents hyperglycaemia. No adolescent
report a hospital admission or visit to the emergency department.
23% of all adolescents were educated by their diabetes specialist;
53% were asked about their drug use. Advice to other adolescents
with diabetes is ’use drugs with people you trust’ (n = 25) and ’keep
your mind clear to be able to think about your diabetes’ (n = 19).
Advice to diabetes specialists is ’be honest and open’ (n = 19) and ’do
not say drug use is forbidden when having diabetes’ (n = 19).
Conclusions: Of literature search and the study: It is not uncommon
for adolescents with diabetes to use drugs; the prevalence in this
study is even higher than that of the general population. Adolescents
require education on the effect of drugs on their diabetesregulation
by their diabetes specialists.
Consider illicitit drug use as a possible cause of diabetic ketoacidosis and test urine on drugs.
85
POSTER TOURS
Poster Tour 17: Latebreakers
P129
Pharmacokinetics (PK), Pharmacodynamics (PD),
and safety following single or repeated 3 mg doses
of nasal glucagon (NG) in adults with type 1 or type
2 diabetes (T1D or T2D)
H. Dulude1, É. Sicard2, M. Rufiange2, C.A. Piché1, C.B. Guzman3,
S. Zhang3, T. Shen3, J.G. Jacobson3, M.X. Zhang4
Locemia Solutions, Montreal, Canada, 2Altasciences/Algorithme
Pharma, Montreal, Canada, 3Eli Lilly and Company, Indianapolis, United
States, 4Eli Lilly Canada Inc., Toronto, Canada
1
Objectives: Examine PK, PD and safety of single or repeated 3-mg
NG doses given in randomized sequence in a 4-period, cross-over
study.
Methods: Subjects (insulin-using adults with T1D or T2D, BMI 18.535.0 kg/m2) received 4 NG treatments (trts) ≥1 wk apart. Trts were
given 4 hrs after a low-carbohydrate breakfast. Trts were: 1) Single
3-mg NG; 2) 3-mg NG plus another 3-mg NG 15 minutes later (same
nostril); 3) 3-mg NG plus another 3-mg NG 15 minutes later (opposite
nostril); 4) 2 concurrent 3-mg NG doses (both nostrils).
Results: 32 subjects were enrolled (T1D: 23, T2D: 9). Numbers of
subjects who received trts 1 to 4 were 27, 28, 25 and 29, respectively. Baseline (BL) blood glucose range was 40–181 mg/dL. For Trts
1 to 4, PK parameters of change from BL for glucagon were: mean
area under the curve 0-3 hr: 2471, 4097, 4639 and 3611 hr.pg/mL,
median Tmax: 0.17, 0.33, 0.50 and 0.33 hrs; PD parameters of change
from BL for glucose were: mean area under the effect concentration
0-3 hr: 157, 168, 190 and 194 hr∙mg/dL, median Tmax: 0.75, 1.00,
1.00 and 1.00 hrs. Repeated NG doses resulted in higher glucagon
concentrations, but gave glucose responses comparable to single
dose (graph). The only serious adverse event (AE; cellulitis) was not
drug-related. Most AEs resolved in ≤5 minutes.
Conclusions: Although repeat dosing resulted in greater systemic
glucagon exposure, it did not result in a meaningful increase in
observed glucose response. All NG treatments were well-tolerated.
Lilly and Company, Indianapolis, United States, 5Pediatric Endocrine
Office, Baltimore, United States
Objectives: This multi-center, open-label study evaluated NG for
effectiveness and ease of use in treating moderate or severe hypo
episodes in patients (pts) with T1D, age 4 to ˂18 yrs.
Methods: Pts and caregivers (CGs) were taught how to use
NG. During naturally occurring symptomatic episodes of moderate or
severe hypo in real world settings, CGs administered 3 mg NG and
measured blood glucose (BG) over time. Adverse events (AEs), recovery of symptoms, and ease of use were solicited by questionnaires.
Results: Fourteen pts, who experienced 33 moderate hypo episodes
with neuroglycopenic symptoms and a BG ≤70 mg/dL, were included
in the efficacy and main safety analyses. Mean number of episodes
per pt was 2.4 (range 1 to 4). In all episodes, pts returned to normal
status within 30 minutes after NG dose. No calls to 911 (emergency
medical services) were needed. Mean baseline BG was 56 (range
42–70) mg/dL. Within 15 minutes after NG dose, mean BG rose to
114 (range 79–173) mg/dL, and continued to rise (figure). No serious
AEs occurred. For most episodes (61%), CGs administered NG
in < 30 seconds; in all cases administration took < 2 minutes. CGs
were satisfied or very satisfied with NG after most episodes (91%).
Conclusions: NG raised BG and resolved symptoms in all reported
episodes of hypo among children and adolescents with T1D. The
majority of CGs were highly satisfied with NG. Data suggest NG is a
viable alternative to currently available injectable recombinant
glucagons.
[BG Values After Nasal Glucagon Administration]
P131
Evaluation of the Freestyle Libre Flash glucose
monitoring system in children and adolescents with
type 1 diabetes
[Zhang_NG_ISPAD figure]
P130
Nasal glucagon (NG) for the treatment of moderate
to severe hypoglycemia (hypo) episodes in children
and adolescents with type 1 diabetes (T1D) in
home or school settings
L.C. Deeb1, H. Dulude2, M.X. Zhang3, S. Zhang4, B.J. Reiner5,
C.A. Piché2, C.B. Guzman4
1
Pediatric Endocrine Office, Tallahassee, United States, 2Locemia
Solutions, Montreal, Canada, 3Eli Lilly Canada Inc., Toronto, Canada, 4Eli
I. Gys1, A. Op ’t Eyndt1, E. Bevilacqua1, A. Wijnands1, P. Declercq2,
R. Zeevaert1, G. Massa1
1
Jessa Ziekenhuis, Pediatric Endocrinology and Diabetology, Hasselt,
Belgium, 2Jessa Ziekenhuis, Clinical Laboratory, Hasselt, Belgium
Background and aims: The FreeStyle® Libre Flash Glucose Monitoring System (FSLFGMS, Abbott) measures glucose concentrations in
the interstitial fluid for up to 14 days. It has been approved for use in
children aged >4 yrs in January 2016. Experience in children is still
limited. We evaluated the accuracy and usability of the FSLFGMS in
children with type 1 DM.
Methods: 24 children with type 1 DM (10 girls), aged 4.7-15.9 yrs
were included. Subjects wore a sensor on the back of their upper
arm. For the first 14 days they regularly measured capillary blood
86
glucose (BG) with their usual BG meter (Accu-Chek® Mobile (ACM),
Roche (n = 8), Contour® Next Link (CNL), Bayer (n = 9); OneTouch®
Verio® IQ (OTV), LifeScan (n = 7)) followed by a sensor glucose scanning. FSLFGMS readings were compared to BG measurements by
surveillance error grid analysis; the mean absolute relative difference
(MARD) was calculated. After 14 days subjects were asked to fill in a
questionnaire on the usability of the FSLFGMS.
Results: 938 FSLFGMS readings were paired with BG results.
FSLFGMS were higher than BG (170 94 mg/dl vs 156 82 mg/
dl; p < 0.001). FSLFGMS readings were highly correlated with BG
(r = 0.957; p < 0.001). 74.20% of the data pairs were in the none risk
zone; 24.20% in the slight risk zone and 1.60% in the moderate risk
zone. The FSLFGMS overestimated BG (hypo deviations > hyper
deviations). Overall MARD was 16.5%. MARD varied with BG meter:
CNL 16.3%, ACM 21.4%, OTV 10.7% (p < 0.001). 14 patients (58%)
reported sensor problems, mainly early detachment of the sensor.
Nonetheless, the usability questionnaire indicated high levels of
satisfaction.
Conclusion: Results showed a good agreement between the
FSLFGMS readings and capillary BG measurements in children.
FSLFGMS overestimated BG creating a higher risk for hypoglycaemia.
The wearing of the sensor requires special attention. Further studies
in children are imperative in order to optimize the use of the
FSLFGMS in the paediatric population.
P132
Check it! Positive psychology intervention improve
quality of life and adherence in adolescents with
type 1 diabetes
S. Jaser1, R. Whittemore2, N. Patel1, L. Choi3, W. Russell1
1
Vanderbilt University Medical Center, Pediatrics, Nashville, United
States, 2Yale School of Nursing, New Haven, United States, 3Vanderbilt
University Medical Center, Nashville, United States
Objectives: Adolescents with type 1 diabetes (T1D) struggle with
adherence to the demanding treatment regimen. Positive psychology
interventions have improved adherence in adults with chronic illness
(Charlson et al., 2010) but have not been tested in pediatric populations. We conducted a randomized trial to estimate the effects of a
positive psychology intervention on adherence, glycemic control and
quality of life.
Methods: Adolescents with T1D (n = 120, mean age 14.8 .4 yrs,
52.5% female, 87.5% White) were randomized to either an education
(n = 60) or positive affect (PA) intervention (n = 60). Blood glucose
monitoring (BGM) frequency was 3.3 1.8 times/day, and mean
A1C was 9.2 0.9%. Adolescents in the PA group received the intervention (gratitude, self-affirmation, parental affirmation, and small
gifts) via text messages or phone calls over 8 weeks. Questionnaires
and clinical data were collected at baseline 3 and 6 months. Data
were analyzed using generalized linear modeling.
Results: After adjusting for age, sex, race/ethnicity, income, depressive symptoms, pump use, and baseline measurement for each outcome, adolescents in the PA group demonstrated significant
improvement in quality of life at 3 months, compared to the education group (estimated mean difference = 3.9, P = .020), but this was
not sustained at 6 months (1.3, P = .569). The PA group showed a
trend toward improvement in parent-reported adherence (estimated
mean difference = 1.2, P = .129), particularly in the text group (1.5,
P = .136). There was no significant intervention effect on BGM, but
for those in the PA group, the odds of clinically significantly improvement (checking at least one more time/day) were about twice as high
as for those in the education group (OR = 1.9, P = .337). No significant effects were found for glycemic control.
Conclusions: A positive psychology intervention had significant, positive effects on quality of life and promising effects on adherence in
adolescents with T1D.
POSTER TOURS
P133
Deveopment of the support through art and
networking in diabetes (STAND) programme: a
psychological intervention for Adolescents with
type 1 diabetes
C. Crowe1, A. O Neill1, K. Farrell2, L. Hynes2, H. O Byrne1,
A. Kyriakou1, C. Mc Donnell1
1
The National Children’s Hospital, Diabetes and Endocrinology, Dublin,
Ireland, 2The National University of Ireland, Galway, Psychology, Galway,
Ireland
Objective: Adolescents with T1D regularly exhibit inadequate selfcare, accompanied by enhanced psychosocial stress, and lower quality
of life when compared to adults and children with a diagnosis of T1D
(Isabella et al., 2007). Group interventions offer cost effective and
psychologically meaningful opportunities to manage distress related
to living with a chronic illness (Yalom, 2000). This research aims to
outline the conceptualisation, development and implementation of a
novel 6 week psychotherapy programme for adolescents with T1D.
The research also assessed the inclusion of social media to support
psychological well being and medical regime adherence in conjunction with the group.
Methods: An audit of 135 adolescents attending clinic revealed that
less than 3% had engaged in a meaningful conversation about diabetes with a peer with diabetes. A comprehensive literature review of
psychological concepts that influence adolescents relationship with
and management of their T1D revealed the following 6 themes as relevant: Loss of Identity (Northam et al., 1996); Illness Perceptions
(Murphy et al., 1997); Coping Skills (Boland et al., 1999); Relationship
Conflict (Delamater et al., 2007); Eating Disorders (Takki et al., 2003);
and Transition to Adult Services (Eiser et al., 1993). A 6 week psychotherapy programme was developed with a target group of 12 adolescents aged between 16–18 years.
Results: Qualitative analysis of the participants experience of group
through content analysis revealed that group interventions were
superior to individual therapy in normalising the young person´s
experience of diabetes and social media offered an important adjunt
of support to maintain motivation and support outside of group
sessions.
Discussion: The benefit of the STAND programme in terms of promoting psychological wellbeing and the relevance of including social
media to maintain contact and support to adolescents with diabetes
outside of clinic is discussed.
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Poster Tour 18: President’s Choice
P137
Improved diabetes management in Swedish
schools: results from two national surveys
S. Särnblad1, K. Åkesson2, R. Ilvered2, G. Forsander3
1
Faculty of Medical Sciences, Department of Pediatrics, Örebro, Sweden,
Ryhov Hospital, Department of Pediatrics, Jönköping, Sweden,
3
Institution of Clinical Sciences, Sahlgrenska Academy and the Queen
Silvia Childrens Hospital, Sahlgrenska University Hospital, Gothenburg,
Sweden
occurred five months earlier and reached a testicular volume ≥20 ml
half a year earlier in T1D than in C boys (not significant). Both groups
of boys had a similar age of pubic hair development. Duration of diabetes was positively associated with older age of onset and of final
stages of puberty. No association of metabolic control or insulin dose
with pubertal timing was observed.
2
Objectives: Support in diabetes self-care management during school
day is essential to achieve optimal school performance and metabolic
control. Swedish legislation regulating to the support of children with
chronic diseases was strengthened 2009. The aim of this study was
to evaluate differences between the results of two national surveys
conducted 2008 and 2015 measuring parents’ and diabetes specialist
teams’ perception of support during school time.
Methods: All pediatric diabetes centers in Sweden were invited to
the study. In each center 10% of the families with a child treated for
T1DM and attending preschool class or compulsory school were
invited to participate. Parents’ and the diabetes teams’ opinions of
the support provided in school were collected in two separate
questionnaires.
Results: Forty-one out of 42 eligible diabetes centers participated. In
total, 568 parents answered the parental questionnaire. Metabolic
control among participating subjects was improved between the two
surveys (61.8 12.4 mmol/mol compared to 55.2 10.6 mmol/mol
in 2015). The proportion of children with a principal responsible staff
member increased from 43% to 59%, p < 0.01. An action plan to
treat hypoglycemia was present for 65% of the children in 2015 compared to 55% in 2008 (p < 0.01). More parents were satisfied with
the support in 2015 (65% compared to 55%, p < 0.01).
Conclusions: This study shows that the personnel support has
increased and that more parents are satisfied with the support of
self-care in school in 2015 compared to 2008. Even more efforts are
needed to implement the nation legislation to achieve equal support
in all Swedish schools.
P138
Puberty in boys with type 1 diabetes mellitus (T1D)
has an earlier onset compared to a simultaneously
recruited control group
X. Gaete1,2, M. Vivanco3, P. Romero3, P. López1,2, A. Rocha4,
C. Sepúlveda4, E. Codner1
1
University of Chile, Institute of Maternal and Child Research, Santiago,
Chile, 2Hospital San Borja Arriarán, Santiago, Chile, 3Hospital Roberto
del Río, Santiago, Chile, 4Hospital Exequiel González Cortés, Santiago,
Chile
Background: Recent studies have suggested some advancement in
the age of onset of puberty in healthy boys. However, no study has
compared the age of pubertal development in boys with T1D compared with a simultaneously recruited group of healthy children.
Objective: To evaluate the age of pubertal events in boys with TD1
and determine whether the duration of diabetes, metabolic control or
insulin dose are associated with age of puberty in T1D boys.
Methods: Boys aged 8–18 with T1D (n:130, age 13.4 2.7 years)
and healthy boys recruited from schools (C; n: 389, age 12.8 2.2
years) were studied. A pediatric endocrinologist evaluated pubertal
development. Genital development was assessed through inspection
(Tanner stage) and by evaluation of testicular volume. Age of pubertal
events was determined by probit analysis.
Results: T1D boys had an earlier age of genital Tanner stage 2 and
5 compared to C boys (Table). The onset of testicular growth
TD1 (years)
Control (years)
P
Genital Tanner stage 2
10.3 1.0
11.1 1.0
0.003
Genital Tanner stage 5
15.6 1.1
16.8 1.2
0.002
Testicular volume 4–9 ml
9.6 0.9
10.1 1.0
0.1
Testicular volume ≥20 ml
14.0 1.1
14.7 1.2
0.056
[Age of Genital Tanner Stage and Testicular Growth]
Conclusions: Boys with T1D treated with modern insulin therapy
appear to have an earlier age of onset and of final events of pubertal
development compared to a simultaneously studied group of healthy
children. These data suggest that pubertal delay is not a frequent
problem nowadays for T1D boys.
P139
Clinical characteristics and metabolic control of
type 1 diabetes in youth with autism spectrum
disorder: a DPV analysis based on 57074
patients < 21 years of age
J.-F. Lemay1, S. Lanzinger2, P. Plener3, A. Fürst-Burger4, T. Biester5,
D. Hilgard6, E. Lilienthal7, A. Galler8, G. Berger9, R.W. Holl2, DPV
Initiative
1
ACH/Cumming School of Medicine (U of Calgary), Paediatrics, Calgary,
Canada, 2University of Ulm, Institute of Epidemiology and Medical
Biometry, Central Institute for Biomedical Technology, Ulm, Germany,
3
Zentralinstitut für Seelische Gesundheit, Mannheim, Germany,
4
Braunschweig Kinderarztpraxis, Braunschweig, Germany, 5Hospital for
Children and Adolescent ’Auf der Bult’, Diabetes Centre, Hannover,
Germany, 6Gemeinschaftskrankenhaus, Paediatrics, Herdecke, Germany,
7
RUHR-Universitat, Diabetology, Bochum, Germany, 8Charité Universitätsmedizin Berlin, Endocrinology and Diabetology, Berlin,
Germany, 9Medical University Vienna, Pediatric and Adolescent
Medicine, Vienna, Austria
Objective: To compare clinical characteristics, diabetes management,
and metabolic control in youth with type 1 diabetes (T1DM) and
Autism Spectrum Disorder (T1DM-ASD) to those without ASD
(T1DM-nonASD).
Methods: Patients with T1DM (<21 yr of age) from the German/
Austrian diabetes patient follow-up registry (DPV) were analyzed.
Time frame was defined as last year of observation for each patient
between January 2005 and March 2016. ASD diagnosis was reported
based on ICD-10 /DSM-IV/DSM-5 codes. Linear, logistic or negative
binomial regression models adjusted for age, sex, diabetes duration
and year of observation were utilized to compare clinical characteristics and metabolic control of T1DM-ASD to T1DM-nonASD patients
(SAS 9.4).
Results: A total of 57074 patients were analyzed (111 (0.19%)
T1DM-ASD; 56963 T1DM-nonASD). Groups were similar for mean
age at diabetes onset and duration of diabetes but not for gender
(male T1DM-ASD: 85.6% vs. non-ASD: 52.8%; p-value < 0.001). Difference was found in HbA1c when adjusted for age, gender, duration
of diabetes, and year of observation (7.9% 0.2% T1DM-ASD vs. T1DM-nonASD 8.2% 0.01%; p-value = 0.04). Number of SMBG
tests /day was more frequent in the T1DM-ASD (5.6/day 0.2) vs. T1DM-nonASD (5.2/day 0.01; p-value =0.03). T1DM-ASD patients
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POSTER TOURS
were more often treated with psycho-stimulants (17.1% vs. 2.1%; p
value < 0.001) and anti-depressive medications (3.6% vs. 0.7%; p
value < 0.001). Unadjusted comparisons showed no difference for
severe hypoglycemia events, diabetes ketoacidosis episodes, insulin
dose unit/kg/day, rate of insulin pump therapy, number of diabetes
education session received/year and BMI-SDS.
Conclusions: Despite their ASD, metabolic control was better in
T1DM-ASD group possibly due to their adherence to routines and
daily schedules. However, awareness of ASD remains important in
the treatment of T1DM, as these two conditions require long-term
multi-disciplinary medical follow-up for optimal outcome.
P140
Assessment of solar irradiation as a protective
factor towards T1D risk in Sardinia
P. Valera1,2, A. Sanna1, S. Pretti1, C. Mannu3, G. Bruno4, M. Songini5
1
University of Cagliari, Civil-Environmental Engineering and Architecture,
Cagliari, Italy, 2National Research Council (IGAG-CNR), Institute of
Environmental Geology and Geoengineering, Cagliari, Italy, 3San Michele
Hospital, Diabetology, Cagliari, Italy, 4University of Turin, Medical
Sciences, Turin, Italy, 5St. Michele Hospital, Diabetology, Cagliari, Italy
Objectives: A North–south gradient in risk of T1D has been found in
Europe and a potential protective effect of solar irradiation has been
suggested. We performed an ecological analysis to assess whereas a
correlation between incidence of T1D and solar irradiation could be
documented within the high risk Sardinia island.
Methods: The percentage of direct solar irradiation of exposed territory was determined for each of the 377 municipal areas of the island
of Sardinia, through a DTM processing (Digital Terrain Model) with a
definition of 250 meters/pixel. Incidence data were available through
the Sardinian Diabetes Registry. A correlation analysis was performed
using the two sets of data, environmental and epidemiological, to
assess the ecological relationship between solar radiation and geographical distribution of T1D risk within Sardinia.
Results: A mild negative correlation (r = −0.14; p = 0.006) was found
between sun direct radiation and the geographical disease distribution of T1D risk.
Conclusions: The correlation between latitude and T1D risk is wellknown and the underlying hypothesis might a role of Vitamin D deficiency in the pathogenesis of the disease. Indeed, previous studies
have hypothesized a role of vitamin D deficiency in T1D risk. Our
results, which are based on ecological analysis performed within the
high risk Sardinia island, are suggestive and consistent with a protective role of sun exposure. Finally, the study confirms that ecological
analysis of simple correlation is a suitable statistical method to suggest hypotheses and conduct research.
P141
TRACCing teens on their journey to adult care
K. Evans1, N. Hamilton1, B. Seeley1, P. Gallego2
1
Childrens Hospital, London Health Sciences Centre, Paediatric Diabetes,
London, Canada, 2Childrens Hospital, London Health Sciences Centre,
Paediatric Endocrinology, London, Canada
Objectives: The Paediatric Diabetes group at Children’s Hospital /
London Health Sciences Centre identified a gap in transitioning adolescents and in their education about complications. The Transition
Readiness Adolescent Complications Clinic (TRACC) was developed
BGmax(mg/dl)
BGmin(mg/dl)
in July 2015. Clinical data and patient feedback on the 1st yr assessment of TRACC are described.
Method: Patients with type 1 diabetes (T1D) aged 17–18 years were
scheduled for TRACC clinic which involves an interdisciplinary team:
dietitian, social worker, transition coordinator and endocrinologist.
Clinic began with a group session for participants and parents
explaining the aims of the program. Adolescents were seen individually to review complications screening results (foot exam, lipid profile,
nephropathy screening). Transition topics were discussed according
to patient’s request. Eleven adolescents completed a satisfaction
questionnaire at the end of the clinic.
Results: Twenty-six adolescents (20 males) were seen at TRACC
between Jul 2015 and May 2016. Median age was 17.6 yrs. (IQR
17.4-17.8); T1D duration was 7.6 yrs. (IQR 4.4-11.6). Median A1C%
was 8.5 (IQR 6.9 - 10.6). 46% (12/26) of patients were managed on
insulin pump. Abnormal albumin-creatinine-ratio (ACR) was found in
20% (5/25); median ACR mg/mmol was 0.7 (IQR 0–1.75). Nine
patients (35%) were overweight/obese. Median BMI was 23.2 (IQR
20–26.7). Based on Canadian Diabetes Association guidelines, 80%
of patients had dyslipidemia. All patients had normal foot screening.
The most requested transition topics were driving, adult diabetes care
process and complications information.
Conclusions: This program facilitates the transition process by providing T1D adolescents with further education on prevention of longterm complications and discussion on transition topics. Our preliminary findings emphasize the need to ensure that this population
receives ongoing follow up care with an adult team.
P142
Participation of children and adolescents with type
1 diabetes mellitus in summer camp leads to a
reduction of hypoglycemic episodes. Results from a
2 year study
M. Papagianni, A. Vamvakis, K. Tsiroukidou, K. Kosta, I. Mameka,
C. Chatzakis, I. Tsanakas
Medical School, Aristotle University of Thessaloniki, Endocrine Unit, 3rd
Pediatric Department, Thessaloniki, Greece
Objectives: Aim of the study was to evaluate the influence of participation in a summer camp with increased physical activity (PA) and a
Mediterranean Diet (MD) model, on the glycemic control of children
and adolescents with type 1diabetes mellitus (TD1).
Methods: The study took place during 2014–2015 in a summer
camp in Northern Greece. Children and adolescents with TD1 participated for ten days each year in a program along with other children
and adolescents without any health problems. 30 patients (21 female,
9 male) aged 12,7 2,8 yrs old participated in the study during the
first year and 40 (24 female, 16 male) aged 11,8 2,6 yrs old during
the second year. They were supported by a full medical diabetes
team. Camp schedule consisted of an increased daily PA and a MD
nutrition model. Glycemic control parameters (measurements of
blood glucose, hypoglycemic episodes) were recorded for a 30 days
period before and after the camp. HbA1c was measured 1 month
prior to and after the camp as well.
Results: Paired sample t-test and Wilcoxon statistical analysis
showed a reduction at blood glucose (BG) levels (p > 0,05) and incidence of hypoglycemia for both years (p < 0,001, p = 0,012) after vs
before the camp period. HbA1c levels reduced at the first year
(p > 0,05) and remained the same at the second year
(p > 0,05)(Table 1).
BGmean(mg/dl)
HbA1c(%)
Episodes of Hypoglycemia
Before vs After
1rst Year
373(65)vs 348(72)
51(10)vs 52(8)
212(33)vs 200(35)
7,8(1,3)vs 7,3(1,1)
18(11)vs11(8) (p < 0,001)
2nd Year
352(85)vs 333(72)
52(9)vs 52(6)
204(39)vs 193(35)
7,2(1,2)vs 7,3(0,7)
15(11)vs10(5) (p = 0,012)
[Glycemic control before vs after the camp]
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Conclusions: Participation of children and adolescents with TD1 in
the summer camp beneficially affected their glycemic control by a
reduction of BG levels and episodes of hypoglycemia. It is a way of
educating patients with TD1, impacting positively on socialization,
acceptance and self-management of diabetes.
Conclusions: Our program, using multidisciplinary teams both from
pediatric and adult care, allows, for most of these adolescents with
poor glycemic control, a safe transition to adult care. However, better
strategies should be developed to also improve glycemic control
though the transition process.
P143
Improving the transition from pediatric to adult
diabetes care: towards a smoother multidisciplinary
educational transition program
P144
Frequency of parietal cell antibodies in children and
adolescents with type 1 diabetes in Austria
1
1
1
2
2
L. Houdon Nguyen , F. Anicet , S. Delgard , J.C. Maiza , A. Rio ,
E. Bismuth1
1
2
CHU Sud Réunion, Pédiatrie, Saint Pierre, France, CHU Sud Réunion,
Diabétologie, Saint Pierre, France
Objectives: In youth with diabetes, transitioning from pediatric to
adult care is a crucial period at risk of loss of follow up, metabolic
deterioration, and diabetes-related complications. To better address
those issues, we implemented in 2012 an educational diabetes transition program.
Methods: A 2-year organized multidisciplinary educational program
(pediatric endocrinologists, diabetologists, nurses, dieticians, psychologists, youth health worker) was proposed to all youth with diabetes
after the age of 16 yrs old. Individual and/or collective sessions to
enhance patients’ knowledge and self-management skills, and to sustain social, leisure, and recreational networks were performed. A
Transition Health Passport (THP), including a medical summary, is
filed by the patient in collaboration with the transition coordinator
nurse.
Results: Over a 3-year period, 28 adolescents (15 boys, 13 girls),
mean age 17,5 0,8 yrs, mean diabetes duration 8.5 4.5 yrs,
mean HbA1c 9,5 2.3%, have been included in the program. All participants completed the THP (4 individual sessions) and most of them
(86%) also attended collective sessions. Evaluation of the program
showed a high satisfaction of the participants and most of the
patients (80%, (20/25)) had at least one appointment with and adult
diabetologist within 12 months after the end of the program. Among
the 8 others patients, 5 were followed by their general practitioner,
3 were lost for follow up, and 1 had a ketoacidosis episode. Meeting
the adult’s staff and using ludic educational tools during sessions for
training in self-management was most appreciated.
E. Fröhlich-Reiterer1, S. Hofer2, B. Rami-Merhar3, H. Jasser-Nitsche1,
E. Schober3, M. Borkenstein1, R.W. Holl4
1
Medical University of Graz, Department of Paediatrics, Graz, Austria,
Medical University of Innsbruck, Department of Paediatrics, Innsbruck,
Austria, 3Medical University of Vienna, Department of Paediatrics,
Vienna, Austria, 4University Ulm, Institute of Epidemiology and Medical
Biometry, Ulm, Germany
2
Objectives: Parietal cell antibodies (PCA) are markers of autoimmune
gastritis (AG). AG can lead to hypergastrinemia and iron deficiency
anemia (IDA). Adults with type 1 diabetes (T1D) show a higher prevalence of PCA compared to healthy controls (up to 20% vs. 1%). The
aim of this study was to evaluate the frequency of PCA in children
and adolescents with T1D in Austria and to evaluate risk factors for
the development of PCA.
Methods: Within the DPV database (Diabetes Prospective Followup) a standardized, prospective, computer-based documentation program, 698 patients with T1D aged < 20 years (52% male, mean age
16.2 4.1 years, mean diabetes duration of 8.5 4.0 years and
mean age at diabetes onset of 7.6 4.1 years) were screened for
PCA in Austria using one assay and one laboratory.
Results: The frequency of PCA in T1D patients was 8.0%. PCA were
more common in females (p = 0.001) and were strongly correlated to
thyroid antibodies (p = 0.001). Comparing PCA positive patients to
PCA negative patients, we found lower MCV values of the red blood
cell count in PCA positive patients (p = 0.015). We found no differences in age, age at diabetes onset, diabetes duration nor in anthropometric parameters between the both groups.
Conclusions: Children and adolescents with T1D have a lower frequency of PCA, than reported for adults. Females and particular
female patients positive for thyroid antibodies seem to be at
increased risk for developing PCA.
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Poster Tour 19: Diabetes Care
P145
Evaluation of a novel method to detect residual ßcell function by dried blood spots in children and
adolescents with a recent diagnosis of type
1 diabetes
R. Willemsen1, K. Burling2, R. Diaz3, J. Edge4, A. Smith5, P. Barker2,
C. Guy1, D. Dunger1
1
University of Cambridge, Paediatrics, Cambridge, United Kingdom,
Cambridge University Hospitals NHS Foundation Trust, Core
Biochemical Assay Laboratory Clinical Biochemistry, Cambridge, United
Kingdom, 3Birmingham Children’s Hospital, Birmingham, United
Kingdom, 4Oxford Radcliffe Hospitals NHS Trust, Oxford, United
Kingdom, 5Northampton General Hospital NHS Trust, Northampton,
United Kingdom
2
Background: The majority of drug developments in type 1 diabetes
(T1D) are aimed at preventing decline of beta cell function (BCF). Traditionally, BCF is evaluated by the C-peptide response to the labourintensive mixed-meal-tolerance-test (MMTT), but there’s a need for a
more practical alternative. We developed a new method to measure
C-peptide in ´dried blood spots’ (DBS).
Objective: To explore the use of a novel method to detect residual
BCF in children recently diagnosed with T1D
Method: 26 T1D-subjects aged 6.9-16.5 yrs (10 M;16 F) had a
MMTT within 6 months of diagnosis and 12 months after diagnosis
with paired sampling of venous and DBS C-peptide at 0 and 90 minutes, and a urine sample for C-peptide/creatinine-ratio. In between
MMTT’s, weekly DBS C-peptide measurements before and after a
standard breakfast were collected at home.
Results: DBS and plasma C-peptide levels correlated well (n = 85
paired measurements; r = 0.95; p < 0.001). All but 2 subjects had
detectable fasting and postprandial DBS C-peptide throughout the
study. Median fasting DBS C-peptide levels (range) at 6, 9 and 12 mo
from diagnosis were 308 (<50-834), 210 (<50-1299) and 272 (<50967) pmol/l, respectively. In multiple regression models with duration
of diabetes and glucose as covariates of 21 cases with a median
(range) of 24(8–29) home DBS measurements, fasting and postprandial DBS C-peptide were negatively affected by diabetes duration in 67 and 71%, and positively affected by glucose levels in
67 and 43%, respectively. A significant interaction between fasting or
post-prandial glucose and diabetes duration was identified in 19 and
5% of cases, respectively, indicating that glucose responsiveness
decreased over time. The decline in fasting DBS C-peptide correlated
well with that identified by the MMTT (r = 0.80;p = 0.002) and the
urine C-peptide/creatinine ratio (r = 0.77;p = 0.004).
Conclusion: DBS C-peptide measurement can be a useful tool in
evaluating BCF in T1D intervention studies.
P146
The flexible lifestyle 3mpowering change (FL3X)
clinical trial: recruitment and retention strategies
F. Bishop1, K. Driscoll1, C. Hunter2, J. Kichler3, D. Maahs1, M. Seid3,
D. Standiford4, J. Thomas5, E. Mayer-Davis5
1
University of Colorado Denver, Barbara Davis Center for Childhood
Diabetes, Aurora, United States, 2NIH/NIDDK, Division of Diabetes,
Endocrinology, and Metabolic Diseases, Bethesda, United States,
3
Cincinnati Children’s Hospital and Medical Center, UC Department of
Pediatrics, Cincinnati, United States, 4Cincinnati Children’s Hospital and
Medical Center, Division of Endocrinology, Cincinnati, United States,
5
University of North Carolina at Chapel Hill, Department of Nutrition,
Chapel Hill, United States
Objectives: FL3X is an 18-month RCT to test the efficacy of an
adaptive behavioral intervention to improve A1c in adolescents with
type 1 diabetes (T1D). We describe how our innovative recruitment
process resulted in high retention.
Methods: FL3X participants (age 13–16 yrs, A1c 8-13%, T1D duration >1 yr) were asked to complete 5 measurement visits (baseline,
3, 6, 12 and 18 months) and those randomized to intervention had
additional diabetes coach visits every 4–6 weeks throughout the
study. FL3X used a 2-step recruitment process to ensure the teen
and parent made a well thought out decision to participate. After initial contact (in-person contact and/or a mailing to explain the study,
step 1), a follow-up phone call was completed with both parent and
teen to address barriers/issues to participation (step 2) before the
baseline visit was scheduled. These conversations incorporated motivational interviewing strategies to allow the parent and teen to identify, express, and discuss concerns about participation.
Results: Of 848 teens (mean age 14.9 yrs., 52% male, 81% white,
50% A1c > 9%) invited to participate, 249 teens (mean age 14.7 yrs.,
50% male, 86% white) completed a baseline visit following the 2-step
recruitment process. Of those who agreed to participate after recruitment step 2, 95% were consented/randomized. Participation rates
were similar for those with higher A1c (>9%, n = 134). FL3X has
>90% completion of the 5 study visits within window (target date 3
weeks): 94% completion of 3-month (n = 208), 95% of 6-month
(n = 177), 96% of 12-month (n = 120) and 91% of 18-month (n = 51)
visits to date (visits ongoing).
Conclusion: Using a 2-step recruitment process, FL3X successfully
enrolled 249 teens and parents, with a retention rate >90%. This
recruitment process demonstrates the benefits of thoughtfully helping participants understand study requirements and encouraging
open communication about potential concerns and barriers to participation prior to study enrollment.
P147
Pooled analysis of four randomized studies with
insulin glargine 100 U/mL vs NPH insulin in adults
with T1DM using a basal plus meal-time insulin
regimen
G. Bolli1, D.R. Owens2, G.R. Fulcher3, P.D. Home4, B.M. Frier5,
L. Gao6, W. Landgraf7
1
University of Perugia School of Medicine, Perugia, Italy, 2Swansea
University, Swansea, United Kingdom, 3University of Sydney, Sydney,
Australia, 4Newcastle University, Newcastle, United Kingdom,
5
University of Edinburgh, Edinburgh, United Kingdom, 6Analysta Inc.,
Somerset, United States, 7Sanofi, Frankfurt, Germany
Objectives: To examine the efficacy and safety outcomes in people
with T1DM treated with insulin glargine 100 units/ml (Gla-100) or
NPH insulin in a basal plus meal-time regimen.
Methods: Standardized patient-level data were pooled from four
RCTs of 28 weeks duration comparing once-daily Gla-100 at bedtime
and NPH insulin (55% QD at bedtime, 45% BID), in combination with
either human insulin (HI) or insulin lispro (lispro) at meal-times.
HbA1c, fasting plasma glucose (FPG), weight, insulin dose and confirmed hypoglycemia were analyzed from baseline to week 28 by
meal insulin type and overall.
Results: Of 1526 participants, 756 used Gla-100 (694 HI, 62 lispro)
and 770 NPH insulin (707 HI, 63 lispro). Baseline characteristics and
week 28 outcomes are shown (Table). HbA1c reductions were comparable between Gla-100 and NPH insulin overall, but greater with
Gla-100 and meal-time lispro. FPG decrement was significantly
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Overall
Gla100 (n = 756)
NPH (n = 770)
Meal-time Insulin $$$lispro
P
Gla-100 (n = 62) NPH (n = 63)
Meal-time human insulin
P
Gla100 (n = 694)
NPH (n = 707)
P
Age (years)
38.6 (17.7, 76.8) 38.4 (17.2, 77.1) NS
42.2 (19.5, 76.8) 39.3 (18.3, 67.1) NS
38.5 (17.7, 73.9) 38.4 (17.2, 77.1) NS
Diabetes duration
(years)
14.1 (0.7, 61.0)
14.0 (0.2, 50.0) NS
18.5 (2.2, 55.0) 16.00 (1.5, 50.0) NS
14.0 (0.7, 61.0)
HbA1c, baseline
(%)
7.91 (1.19)
8.00 (1.24)
NS
9.18 (1.05)
9.72 (1.30)
0.012 7.80 (1.14)
7.85 (1.11)
NS
HbA1c, 28 weeks
(%)
7.80 (0.03)
7.82 (0.03)
NS
8.47 (0.13)
8.93 (0.13)
0.018 7.78 (0.03)
7.77 (0.03)
NS
HbA1c change (%) –0.16 (0.03)
–0.55 (0.13)
0.018 –0.04 (0.03)
–0.14 (0.03)
NS
–1.01(0.13)
FPG, baseline
(mg/dL)
215 (91)
211 (94)
NS
243 (92)
FPG, 28 weeks
(mg/dL)
177 (3)
192 (3)
0.0003
159 (11)
(11)
FPG change
(mg/dL)
–36 (3)
–21 (3)
0.0003
–72 (11)
37.3 (1.7)
38.6 (1.8)
NS
Nocturnal (events/
person-year)
6.5 (0.4)
8.0 (0.5)
0.006
Total severe
(events/personyear)
0.7 (0.1)
0.9 (0.2)
NS
Nocturnal severe
(events/personyear)
0.19 (0.04)
0.33 (0.06)
Body weight,
week 28 (kg)
72.3 (0.1)
14.0 (0.2, 50.0) NS
–0.05 (0.03)
NS
213 (90)
210 (93)
NS
0.048
186 (3)
199 (3)
0.002
–40 (11)
0.048
–26 (3)
–12 (3)
0.002
59.4 (6.2)
60.3 (6.6)
NS
31.2 (1.5)
32.0 (1.5)
NS
10.7 (1.7)
11.5 (1.8)
NS
5.5 (0.4)
6.8 (0.4)
0.01
2.2 (0.6)
2.7 (0.8)
NS
0.5 (0.1)
0.6 (0.1)
NS
0.048
0.38 (0.16)
1.12 (0.33)
0.03
0.14 (0.04)
0.21 (0.05)
NS
72.3 (0.1)
NS
77.9 (0.4)
78.1 (0.4)
NS
71.5 (0.1)
71.5 (0.1)
NS
0.8 (0.1)
0.8 (0.1)
NS
2.1 (0.4)
2.3 (0.4)
NS
0.4 (0.1)
0.4 (0.1)
NS
Basal insulin dose
(U/kg) at week
28
0.31 (0.0)
0.35 (0.0)
<0.0001 0.44 (0.02)
0.44 (0.02)
NS
0.28 (0.0)
0.32 (0.0)
<0.0001
Meal-time insulin
dose (U/kg) at
week 28
0.39 (0.0)
0.39 (0.0)
NS
0.47 (0.02)
0.053 0.39 (0.0)
0.38 (0.0)
NS
223 (110) 191 NS
Confirmed
hypoglycemia
(PG <70 mg/
dL):
Total (events/
person-year)
Body weight
change (kg)
0.41 (0.02)
Median (Min, Max) for age and diabetes duration, Mean (SD) for baseline characteristics, and adjusted mean (SE) for week 28 outcomes. Change is from
baseline to week 28
greater with Gla-100 vs NPH insulin (P = 0.0003) with a significantly
lower basal insulin dose at week 28 for Gla-100 overall (P < 0.0001).
Event rates of confirmed nocturnal and severe nocturnal hypoglycemia were significantly lower with Gla-100 vs NPH insulin; rate ratios
0.80 and 0.57.
Conclusions: In this pooled analysis of adults with T1DM, FPG, insulin dose and nocturnal hypoglycemia rates were lower with Gla-100
than NPH insulin therapy. When Gla-100 was combined with mealtime insulin lispro, HbA1c and FPG appeared lower vs those on NPH
insulin.
P148
How do young people with type 1 diabetes
experience transition from pediatric to adult health
care? A sub study of the Norwegian Childhood
Diabetes Registry (NCDR)
K. Hodnekvam1,2,3, H.H. Iversen4, A.K. Drivvoll2, T. Skrivarhaug2,3,5
Telemark Hospital, Skien, Norway, 2Oslo University Hospital, Norwegian
Childhood Diabetes Registry, Oslo, Norway, 3Oslo Diabetes Research
Centre, Oslo, Norway, 4Norwegian Institute of Public Health, Knowledge
Centre for the Health Services, Oslo, Norway, 5Oslo University Hospital,
Department of Pediatric Medicine, Oslo, Norway
1
Objectives: To explore the experiences of young people with Type
1 diabetes (T1D) on transition from pediatric to adult health services .
A national, population-based cohort study as part of a quality
improvement project on transition in Norway.
Methods: A questionnaire based on a mixed-method model was
developed and sent by post to 784 adolescents/young adults with
T1D who were registered in the NCDR and transferred to adult
health services within the last 2–4 years. 8 were ineligible. Two
reminders were sent. Psychometric evaluation included explorative
factor analysis, tests of intern reliability and test-retest reliability. The
questionnaire addressed experiences with health personnel, content
of consultations, organization of services and preparedness for transfer. Most of the items had a five point scale .WSR test is used comparing patient experiences in pediatric vs. adult health care.
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Demographic data, questions on treatment regimens and comorbidity
are included. Characteristics of respondents vs. non-respondents are
assessed using ChiSquare test and Independent Samples t-test.
HbA1c is from the NCDR at time of transfer.
Results: 321 (41.4%) answered the questionnaire. 57.6% of the
respondents and 36.0% of the non-respondents were female. Mean
HbA1C at time of transfer was 8.8% in respondents, 9.1% in nonrespondents. Significant differences in patient experiences of pediatric and adult health care were found for continuity in services
(p < 0,001), interval between consultations (p < 0,001), confidence in
caretakers (p < 0,001) and all-in-all satisfaction (p < 0,001). Data from
medical journals will be collected and analyzed as part of this project.
Conclusions: This survey points at significant differences in experienced satisfaction between pediatric and adult health care in Norway.
Results should be taken into consideration when discussing quality
improvement in health services to adolescents and young adults with
lifelong chronic conditions.
P149
High hereditary risk for CVD among children with
type 1 diabetes mellitus (T1D ) according to BDD, a
Swedish prospective cohort study
D. Novak1, M. Novak2, J. Larsen1, G. Forsander3
1
Gothenburg University, Institut of Clinical Science, Pediatrics, Queen
Silvias Children’s Hospital, Göteborg, Sweden, 2Gothenburg University,
Institut of Health Care Science, Gothenburg, Sweden, 3Gothenburg
University, Institut of Clinical Science, Pediatrics, Queen Silvias Children’s
Hospital, Gothenburg, Sweden
Objectives: To evaluate the hereditary risk for CVD in children
with T1D.
Method: Better Diabetes Diagnosis (BDD) study is a nationwide Swedish prospective cohort study that since 2005 recruits all new-onset T1D
children and adolescents who are less than 18 years old. HLA genotyping, islet autoantibody assays (IAA, GADA, IA-2, Zn.T8.2) for each child
including their family’s cardiovascular health is recorded. This study
includes data on children who were recruited at the Queen Silvia’s Children’s Hospital during 2010–2014. Questions regarding maternal and
paternal high blood pressure, stroke, myocardial infarction (before the
age of 55 years), and hyperlipidemia were included in the analysis. A risk
score of 0–8 was calculated (0 = no, 8 = all four risk factors from both
of the parents were present). Data from Swediabkids, the Pediatric
National Diabetes Registry, on metabolic parameters and frequency of
screening for blood lipids and vascular complications and blood lipids in
the study population was recruited.
Results: A total of 275 children aged 0 to 18 years were diagnosed
with T1D during this four year period. All but one child participated
in BDD. Figure 1 presents the number of hereditary cardiovascular
risk factors. 17% of the participants had four or more risk factors.
The average HbA1c value for the study population was 56 mmol/
mol, during the year 2014, compared to the national average of
57.5 mmol/mol. The frequency of screening according to ISPAD was
equivalent to guidelines.
Conclusion: Every second child with T1D had at least two hereditary
risk factors. Screening efficacy for micro- and macrovascular complications as well as for blood lipids is important. Treatment with ACEinhibitors and/or statines should be prescribed when needed.
[CV hereditary risk factors]
P150
High A1c clinic - early review to support
compliance and improve glycaemic care
G. Margabanthu, B. Bassoy
Kettering General Hospital, Kettering, United Kingdom
Aim: High A1C clinic was introduced on a Friday every month to
offer early support, review and help improve glucose control. The
multidisciplinary clinic has a paediatrician and nurse specialist who
offer a joint plan. HighA1C leaflets are given and a management plan
is made which is reviewed monthly with a virtual access in between.
We review and present our results of this new service.
Methods: We evaluated our service from the data in our prospective
database from Jan 15 to April 16. Patients with A1C of more than
75 mmol/mol were reviewed monthly by the multidisciplinary team to
support diabetes management and discharged to regular diabetes follow
up once control was better. A1c results were reviewed and analyzed.
Results: 47 children out 165 patients over 16 months attended the
High A1C clinic. Majority were adolescents except 3 young children.
2 children were moved to adult services and 2 new referrals are
excluded from the study as they entered last month). There was no
sex variation.
17 patients were seen by the service and once the control was better with one sequence of clinic visits (9 needed one visit, 5 needed
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POSTER TOURS
two visits and 2 three visits and 1 four visits) they were discharged
to standard diabetes follow up.
10 needed the service on more than 2 sequence of visits of which
2 accessed twice, 3 accessed thrice, 3 accessed four times, 2 accessed
5 times. 5 out of the 10 were discharged once control was better.
16 young adults are in the service with ongoing MDT involvement
and have been seen between 2–10 times. All are young adults with
difficulties in compliance.
Conclusion: Majority of patients were back on target on their glucose control with the high A1c service with the others showing
improvement. This led to overall improvement in the HbA1c values.
Early review and support is crucial; the national diabetic tariff has
helped introduce a new service to tackle the poor compliance, high
A1c and achieve better control.
(2 minutes) was consequently found in the waiting time to be seen
by the specialist team, suggesting preparation inefficiency.
Conclusions: Waiting more than 15 minutes adversely affects teenagers’ clinic experience. Improvement actions include suggesting
young people arrive no more than 10 minutes before their appointment and professionals being informed and guided in strategies to
address preparation efficiency.
P152
Putting theory into practice: Implementation of a
transition program into routine diabetes care
A.-M. Goutbeek1, J. Rotteveel2, M. de Wit1, M.-J. Walenkamp2,
M. Goverde2, J. Bijl3, M. Finken2, R. IJzerman3
1
P151
‘I hate waiting around!’ - How long do young
people really wait to be seen in their diabetes
transition clinics?
M. Gardiner1, J. Hicks2, B. Griffiths2
1
Taunton and Somerset NHS Foundation trust, Taunton, United
Kingdom, 2Taunton and Somerset NHS Foundation Trust, Children’s
Diabetes, Taunton, United Kingdom
Objectives: Keeping young people engaged with their diabetes care
and specialist team are components vital for education to empower
self-management skills and to facilitate timely, supported transition
to adult diabetes services. Service users cite waiting around and
clinics running late as the worst aspect of their clinic experience.
Transition service providers hope to identify problems with appointment timing and process and to determine the extent of the issue
adversely affecting teenagers’ experiences.
Methods: Simple audit slips attached to individual patient notes and
completed by attending staff facilitated data collection at both clinic
venues over approximately 4 months. The Lead Specialist Nurse
directed, collated and analysed data, presenting actual (duration of
wait after scheduled appointment time) and perceived waiting times
(time of arrival to time seen).
Results: A mean wait of 22 minutes (perceived) was determined,
80% of which waited less than 30 minutes. 55% arrived more than
10 minutes ahead of their appointment time, thus increasing the
amount of time young people felt they were waiting.
83% of the cohort were seen late, 14% early and 3% on time, supporting patients’ expressed views.
Actual mean waiting time was 16 minutes and at neither venue
was the actual, perceived or corrected mean or median wait longer
than 28 minutes.
Significant difference was found between the two venues for mean
wait from arrival to first being seen by the clinic preparation nurse;
3 minutes versus 11 minutes. Interestingly, little difference
VU University Medical Center, Medical Psychology, Amsterdam,
Netherlands, 2VU University Medical Center, Pediatrics, Amsterdam,
Netherlands, 3VU University Medical Center, Internal Medicine,
Amsterdam, Netherlands
Objectives: Transfer of pediatric to adult diabetes care has great
impact, leading to high numbers lost to follow-up. The importance of
transition care has been stressed troughout the literature. However,
implementing and sustaining transition care seems to be difficult. We
present a working model that aims to integrate transition care into
routine practice and to decrease dropout rates.
Methods: Our center has 130 pediatric type 1 diabetes (T1D)
patients. Before 2011, patients started adult care with a written
transferal at age18. Dropout rates were relatively high. From 2011
on, transition care was implemented:
Pediatric T1D patients are assigned to age groups. Regular medical
checkups are scheduled at the same day for each age group. Quality
of Life is screened yearly (MY-Q, PedsQl) using a web-based environment, where children aged 12+ years and their parents also complete
an Individual Transition Profile (ITP). Results are discussed at the next
visit. When indicated, additional care or education is arranged. One
yearly visit consists of a peer group meeting with workshops. Parents
attend a parallel group consult with the pediatric psychologists to
offer peer support and psycho education on child development, parenting skills and transition. The year before transfer, patients are seen
twice by the pediatric and adult diabetes teams combined. In the year
after transfer, patients see the same nurse and physician every visit.
We will compare dropout rates in the years 2006–2010 to
2011–2016 to examine if our transition program is successful.
Results: Preliminary results show a low dropout rate since 2011:
63 adolescents transferred to the adult diabetes team. One patient
was lost to follow up. Dropout rates before 2011 are being investigated and will be presented.
Conclusions: Dropout seemed to decrease after implementation of
transition care into routine practice. Further analysis is needed to see
to which extent, and which factors contributed to this decrease.
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Poster Tour 20: Epidemiology
P153
Distinct clinical characteristics of pediatric patients
diagnosed with type 1 and type 2 diabetes in a
contemporary population-based cohort in Western
Australia (1999–2015)
A. Haynes1, G.J. Smith1, T.W. Jones1,2, E.A. Davis1,2
1
Telethon Kids Insititute, Subiaco, Australia, 2Princess Margaret Hospital,
Perth, Australia
Objectives: To compare clinical characteristics in children diagnosed
with type 1 (T1D) and type 2 (T2D) diabetes aged 10- < 17 years, in
Western Australia (WA) from 1999 to 2015.
Methods: Children aged 10- < 17 years, newly diagnosed with diabetes in WA between 1999 and 2015, were identified from the
Western Australian Children’s Diabetes Database, a populationbased, prospective, longitudinal diabetes registry. Data available
included diagnosis type, date, age and postcode at diagnosis, Indigenous status, HbA1c, BMI, blood pressure, ACR/AER and lipids.
Results: Of 746 eligible cases identified, 674(90.2%) had T1D and
72(9.8%) T2D. The mean age at diagnosis was 11.9(1.5) years in
cases with T1D and 12.6(1.5) in those with T2D (p = 0.02). Demographic differences included a higher proportion of cases with T2D
who were female(61% vs 45% vs. of T1D, p = 0.01), of Indigenous
descent(56% vs 3% of T1D, p < 0.001),in the quintile of most socioeconomic disadvantage(35% vs 3% of T1D, p < 0.001).At diagnosis,
cases with T2D had significantly higher systolic and diastolic blood
pressure Z-scores, and lower median HbA1c (Table). 3 years postdiagnosis, a greater proportion of children with T2D had microalbuminuria, and higher mean cholesterol and triglycerides levels (Table).
Objectives: To analyze recent time trends of the national prospective
population-based incidence study of all newly diagnosed patients
with type 1 (T1D) and type 2 (T2D) diabetes < 15 years in Austria.
Methods: All newly diagnosed cases of diabetes from
0 to < 15 years of age are registered prospectively. The diabetes type
was classified on the basis of clinical and laboratory findings according to ADA criteria. Time trends were estimated by linear regression
models. Case-ascertainment: 97%
Results: During the observation period (1999–2015) 3789 cases
(94.2%) were initially diagnosed with T1D (45.8% female), 65 cases
(1.6%) with T2D (61,5% female) and 170 cases (4.2%) as other forms
of diabetes (e.g. MODY, CFRDM).
From 1999 to 2007, a significant and constant increase of 0.81/
100 000 cases per year (APC 5.7 % per year) was observed in the
incidence rate of T1D (p < 0,0001), leading to an increase in incidence from 12,2/100.000/yr. in 1999 to 18.9/100.000/yr. in 2007
(J Pediatr 2009;155:190–3). From 2008–2015 the increase was
lower with a rise of 0.43/100.000/yr. cases per year (APC = 2.2%
per year), changing the incidence rate from 17,7/100.000/yr. (2008)
to 19,2/100.000/yr. (2015), with a peak incidence in 2012 (22,8/
100.000/yr.). In the very young age group (0–4 years) the increase in
incidence from 1999–2007 could not be observed in the later years
(13,1 (2008) to 12,3/100.000/yr. (2015), although a peak incidence
of 18,3/100.000/yr. in 2012 was seen.
The incidence rate of T2D did not change during the observational
period in this age group and remained very low (range 0,14-0,51/
100.000/yr.) (p =0,706 (1999–2007) and p = 0,275 (2008–2015).
Conclusions: The incidence of T1D-incidence in Austria < 15 yrs. is
still increasing, but seems to have reached a plateau, similar to other
European regions. In comparison the T2D diabetes in Austrian chil-
AT DIAGNOSIS
Type 1 diabetes (N = 674)
Type 2 diabetes (N = 72)
p-value
Median HbA1c at diagnosis % [mmol/mol]
12.2 [110]
9.6 [81]
<0.001
Mean SBP-Zscore SD
−0.29 0.91
0.49 0.94
<0.001
Mean DBP-Zscore SD
−0.78 0.75
0.48 0.90
<0.001
Mean BMI Z-scores (3 months post diagnosis) SD
0.4 1.2
3.2 1.6
<0.001
Mean HbA1c(95%CI) %;[mmol/mol]
7.9(7.8 - 7.9); [63(62–63)]
8.8(8.2 - 9.4); [73(66–79)]
<0.001
Microalbuminuria
16 (4%)
8 (13%)
Mean total cholesterol (95%CI) (mmol/L)
4.30 (4.22 - 4.37)
4.77 (4.49 - 5.06)
<0.001
Mean triglycerides (95%CI) (mmol/L)
1.12 (1.05 - 1.18)
2.11 (1.77 - 2.44)
<0.001
3 YEARS POST-DIAGNOSIS
[Significant differences by diagnosis]
Conclusions: Differences in clinical characteristics are still observed
in pediatric patients with T1D and T2D in WA, with a high prevalence of cardiovascular risk factors detected at diagnosis in those
with T2D.
P154
Incidence trends of type 1 and type 2 diabetes in
Austrian children < 15 years (1999–2015)
1
2
3
1
B. Rami-Merhar , S. Hofer , E. Fröhlich-Reiterer , M. Fritsch ,
T. Waldhör4, and the Austrian Diabetes Incidence Study Group
1
Medical University of Vienna, Department of Pediatric and Adolescent
Medicine, Vienna, Austria, 2Medical University of Innsbruck, Department
of Pediatric and Adolescent Medicine, Innsbruck, Austria, 3Medical
University of Graz, Department of Pediatric and Adolescent Medicine,
Graz, Austria, 4Medical University of Vienna, Department of
Epidemiology, Center for Public Health, Vienna, Austria
0.002
dren showed no increase and remained low during the 17 years of
observation, which is in contrast to most regions worldwide.
P155
Islet cell antibodies among children and adolescents
with type 1 diabetes mellitus in South Africa
K. Pillay
Private Practice, Durban, South Africa
Background: There is a paucity of information on the prevalence of
pancreatic antibodies in children of African descent with type 1 diabetes. Published information suggests lower prevalence of antibodies in
African children. This study was undertaken to determine the prevalence of GAD and IA2 antibodies in a group of South African children
with T1DM and to determine whether there are differences in prevalence between ethnic groups
Methods: A review of patients presenting to a single practice was
undertaken. The study population was limited to subjects that were
95
POSTER TOURS
less than 18 years at diagnosis, had onset if diabetes on/after
1 January 2002 and not later than 31 December 2014 with a clinical
diagnosis of type 1 diabetes. GAD and IA2 antibodies were performed by commercial laboratories. Ethnicity was determined by the
families and the investigator.
Results: Of 392 subjects with a diagnosis of diabetes mellitus,
364 fulfilled entry criteria. The age at diagnosis ranged from 0.6 to
17 years (median = 8.2 years). Of these, 91 (25%) were black African,
100 (27.5%) Asian, 162 (44.5%) white and 11 (3.0%) of mixed ethnicity (coloured). There was no data of Ab status in 68 of these subjects.
Of the remainder, 33 (11.1%) were negative for both antibodies,
134 were positive for 1 Ab and 129 (43.6%) were positive for both
antibodies. Thus, 263/296 (88.9%) had antibodies to 1 or both antibodies. There was no significant differences in prevalence of 1 or
both antibodies among the different ethnic groups; 87.2% among
black African children, 89.6% among Asian children, 89.4% among
white children and 88.9% among coloured children. There was no difference when stratified by age at diagnosis or year of diagnosis.
Conclusion: The prevalence of antibodies in children and adolescents
with type 1 diabetes is similar to that described from developed
countries. There was no difference in prevalence between difference
ethnic groups, age at diagnosis or year of diagnosis.
P156
Epidemiological trends of pediatric type 1 diabetes
in British Columbia, Canada
S. Amed1, N. Islam2, K. Reimer3, J. Sutherland3
1
University of British Columbia, Pediatrics, Vancouver, Canada,
University of British Columbia, Vancouver, Canada, 3BC Ministry of
Health, Victoria, Canada
2
Objective: To describe the trends in incidence and prevalence of
childhood type 1 diabetes (T1D) in British Columbia (BC), Canada.
Methods: Children < 20 years of age living in BC between April 1st,
2002 to March 31st, 2013 were identified within linked administrative health data (physician billing claims, hospitalization discharge
codes, and prescription dispensations). A validated diabetes casefinding definition and algorithm differentiating T1D and T2D were
applied to the linked data. Using the BC population of the corresponding year as the standard population, annual age-standardized
incidence [IR] and prevalence rates [PR] were calculated overall, and
by sex. Linear regression was used to test for temporal trends.
Results: In 2002/03, 225 (49% female [F]) new cases of T1D were
identified in individuals < 20 years, increasing to 247 (45.3% F) cases in
2012/13. The age-standardized IR [95% CI] increased from 23.26
(20.31-26.56) in 2002/03 to 27.03 (23.76-30.64)/100,000 population
in 2012/13 while in females and males IRs increased from 23.65 (19.4228.58) to 25.53 (21.02-30.75), and from 22.90 (18.89-27.56) to 28.44
(23.83-33.70), respectively. The prevalence of T1D increased from
1790 cases (47% F) in 2002/03 to 2264 (47% F) in 2012/13, while corresponding age-adjusted PR (%) increased from 0.18 (0.17-0.18) to 0.23
(0.22-0.24) increasing the overall prevalence by 33% over the 10-year
period. Males had consistently higher prevalence of T1D than females.
Conclusions: The incidence of T1D in BC has been stable over
10 years, with differences in males and females evident after 2010.
Our data differs from increasing T1D incidence reported in the
United States and Europe. Continued surveillance and research will
document future trends and provide insight into regional differences
in T1D incidence.
P157
Prevalence of type 1 diabetes in children of central
and east regions of Poland-multicenter study
M. Szalecki1,2, M. Wysocka-Mincewicz1, A. Ramotowska3, A. Mazur4,
-Skowronek5, J. Sieniawska5, B. Klonowska6,
L. Lisowicz4, I. Ben
D. Charemska6, J. Nawrotek7, I. Jałowiec7, A. Bossowski8,
ska9, A. Szypowska3
M. Jamiołkowska8, B. Pyrżak9, I. Rogozin
1
The Children’s Memorial Health Institute, Department of Endocrinology
and Diabetology, Warsaw, Poland, 2UJK, Faculty of Medicine and Health
Sciences, Kielce, Poland, 3Medical University of Warsaw, Department of
Paediatrics, Warsaw, Poland, 4Medical Faculty University of Rzeszow, II
Department of Paediatrics, Paediatric Endocrinology and Diabetes,
Rzeszów, Poland, 5Medical University of Lublin, Department of Paediatric
Endocrinology and Diabetology, Lublin, Poland, 6Faculty of Medical
Sciences, University of Warmia and Mazury, Department of Clinical
Pediatrics, Olsztyn, Poland, 7General District Hospital, Endocrinology and
Diabetology Ward, Kielce, Poland, 8Medical University in Białystok,
Department of Pediatrics, Endocrinology, Diabetology with a Cardiology
Division, Białystok, Poland, 9Medical University of Warsaw, Department
of Pediatric and Endocrinology, Warsaw, Poland
Incidence rate of T1D still increases but in Poland is unknown
because of lack whole country registry. The aim of the study was
accounting the prevalence, and it changes in time.
Material and Methods: Study cohort consist of children below
18 years of age with newly recognized T1D from east and central
sko-Mazurskie, Lubelskie,
Poland (regions of: Podkarpackie, Warmin
Świętokrzyskie, Podlaskie and Mazowieckie), between January 2010
and December 2014. After exclusion of children with the other types
of diabetes or diagnosed in the other regions 2164 children (96%)
with type 1 diabetes was taken to analysis. To estimate the overall
population size we used the data from the Central Statistical Office
for the population of regions. Statistical analysis with Statistica 6.0,
and statistical package R were performed, with p < 0.05 as
significant.
Results: For whole group of children (0–17) the IR was 1,5 fold in
the period of 5 years of observation (12,73% per year). The smallest
increase of IR was in group 15–18 of age (7,1% per year), the highest
in group of 10–14 years old was observed (17.8% per year). In the
group of the prepubertal children we observed increase of IR approximately 10% per year (group 0–4 years-9.84% per year, group 5–9
years old - 10,7% per year). The population of urban children (0–18
years) have significantly higher incidence rate than rural
ones (p < 0.02).
Conclusions: The incidence rate of T1D in Polish children living in
the east and central Polish regions increased 1.5 fold in the period of
5 years of observation with the highest rise in subjects aged 10–14.
Incidence rates of urban children is higher than rural ones. Further
monitoring of changes in childhood T1D trends in different Polish
regions and influence of potential environmental risk factors is
required to better understand causes of childhood diabetes.
P158
Epidemiology and characterization of type
1 diabetes in children in Gran Canaria
Y. Nóvoa1,2, A. De La Cuesta1, E. Caballero1, S. Quinteiro1,
A. Domínguez1, A. Howards3, A. Santana4, A. Wägner2,5
1
Hospital Universitario Materno Infantil de Canarias, Pediatric
Endocrinology, Las Palmas de Gran Canaria, Spain, 2Instituto
Universitario de Investigaciones Biomédicas y Sanitarias. Universidad de
Las Palmas de GC, Las Palmas de Gran Canaria, Spain, 3Mailman School
of Public Health. Columbia University, Biostatistics department,
New York, United States, 4University of Las Palmas de Gran Canaria,
Mathematics and Statistics Department, Las Palmas de Gran Canaria,
Spain, 5Hospital Insular de Gran Canaria, Endocrinology and Nutrition
Department, Las Palmas de Gran Canaria, Spain
Previous studies suggest that the childhood incidence of type 1 diabetes (T1D) in the Canary Islands may be the highest described to date
in Spain. In order to assess the incidence in Gran Canaria, we decided
to study the incidence of T1D in children < 14 years during the
2006–2015 period, as well as to describe their clinical and analytical
characteristics at onset.
Methods: Ours is the only pediatric endocrine unit in the island of
Gran Canaria. We calculated the annual and overall incidence for the
period using the internal registry of the unit as the primary source
and data from the local diabetes association and from the hospital´s
96
pharmacy as secondary sources. To describe the characteristics of
our patients at onset, we took a cross-sectional sample of patients
followed in the unit from June 2013 to June 2014, and retrospectively analyzed their characteristics at onset.
Results: We achieved a degree of ascertainment of 100%. The incidence of T1D for the study period is 29.79 / 100,000, with no differences by gender or age groups. No temporary or seasonal trends
were seen in the appearance of cases. 34.2% of patients presented
with diabetic ketoacidosis, with an increased frequency in the under
5 years age group. Regarding the genetic characterization, HLA
DRB1*03 and *04 were the most common among the DRB1* genes,
and DQB1*02 and *03 the most frequent among DQB1*. 86.8% of
our patients had at least 1 positive antipancreatic antibody (antiGAD,
anti-IA2 or anti-insulin). Associated autoimmune diseases (AAD) were
present in 7.9% of our patients after a mean follow up of 4.6 years.
The most frequently found was celiac disease, followed by thyroid
dysfunction.
Conclusions: Our findings support previous results placing the
Canary Islands as the region with the highest incidence of T1D in
Spain and one of the highest in Europe. No temporal nor seasonal
trend was observed in our patients. The prevalence of AADs is low,
with a predominance of celiac disease.
P159
National prevalence of type 1 diabetes in children
aged under 5 years in Ireland - identifying this
vulnerable population
E. Roche1,2, A.M. McKenna1, K.J. Ryder3, A.A. Brennan4,
M. O’Regan5, H. Hoey1
1
University of Dublin, Trinity College Dublin, Dublin, Ireland, 2National
Childrens Hospital, Department of Paediatric Diabetes, Growth and
Endocrinology, Dublin, Ireland, 3Tallaght Hospital, Information
Communication Technology Department, Dublin, Ireland, 4National
Children’s Hospital, Tallaght Hospital Dublin, Paediatric Diabetes Growth
and Endocrinology, Dublin, Ireland, 5University of Dublin, Trinity College
Dublin, Department of Statistics, Dublin, Ireland
Objective: Epidemiological monitoring with accurate definition of
disease frequency is key to inform effective and efficient healthcare
planning, resource deployment, utilization and support audit. These
data are critical for effective Type 1 diabetes (T1D) management, particularly in health systems, such as Ireland, where care may be delivered at multiple sites, with limited integration of data management
systems and in the absence of a unique patient identifier. The ability
to define and target sub groups of patients with T1D is important,
particularly young children under 5 years who present significant
management challenges and are especially vulnerable to the damaging effects of hypoglycaemia etc. Reliable prevalence data has been
limited to date in Ireland. The aim of this study is to provide robust
baseline national prevalence and key demographic data regarding
T1D in children aged under 5 years to inform their care provision.
Methods: Prevalent cases of Type 1 diabetes in children aged under
5 years were identified from the prospective Irish Childhood Diabetes
National Register (ICDNR*) in 2012 and 2013 and survey of the
20 national centres caring for children with T1D. All cases were verified and capture-recapture methodology applied to estimate
ascertainment.
Results: There were 114 cases (59 male) and 123 cases (64 male)
with T1D aged under 5 years at 31st December identified in 2012
and 2013 respectively. Two cases in 2012 and 1 case in 2013 were
not registered with the ICDNR. One case of non-Type 1 diabetes
POSTER TOURS
was excluded. No deaths were recorded. The point prevalence for
T1D in those aged under 5 years was calculated (Table 1).
Conclusions: The prevalence of T1D for children under 5 years was
0.31/1,000 and 0.34/1,000 in 2012 and 2013 respectively. Additional demographic data to support care provision and targeted interventions to this vulnerable group is provided. Monitoring of
prevalence will continue.
P160
Relationships between the North RhineWestphalian Index of Multiple Deprivation and the
spatial distribution of the incidence of type
1 diabetes in children and adolescents in North
Rhine-Westphalia, Germany
K. Castillo-Reinado1,2, W. Maier2,3, R. Holle2,3, A. Stahl-Pehe1,2,
C. Baechle1,2, O. Kuß1,2, J. Hermann2,4, R.W. Holl2,4, J. Rosenbauer1,2,
in cooperation with the German Center for Diabetes Research (DZD),
the German Pediatric Surveillance Unit (ESPED) and the DPV-Science
Initiative
1
German Diabetes Centre, Leibniz Institute for Diabetes Research at
Heinrich Heine University Duesseldorf, Institute for Biometrics and
Epidemiology, Duesseldorf, Germany, 2German Center for Diabetes
Research (DZD), Neuherberg, Germany, 3Helmholtz Zentrum Muenchen,
Institute of Health Economics and Health Care Management,
Neuherberg, Germany, 4University of Ulm, Institute of Epidemiology and
Medical Biometry, ZIBMT, Ulm, Germany
Objectives: To analyze the relationships between the North RhineWestphalian Index of Multiple Deprivation for 2010 (NRWIMD) and
the incidence of type 1 diabetes (T1D) in children and
adolescents < 20 years between 2007 and 2014 on municipality level
in North Rhine-Westphalia (NRW), the most populous federal state
of Germany.
Methods: Diabetes data were provided by the NRW Diabetes Incidence Register and municipality-level socio-economic data of 2010
by official statistics. The NRWIMD, a region-specific version of the
German IMD, was derived as weighted average of 7 domains of deprivation. Higher NRWIMD scores represent higher deprivation. For
analysis, the NRWIMD scores were categorized into deprivation
quintiles. Incidence and confidence interval (95%-CI) were calculated
per 100.000 person-years. Descriptive statistics were calculated to
characterize the regional distributions of T1D and the NRWIMD over
396 communities. Associations between the incidence rate and
NRWIMD quintiles were assessed by Poisson regression adjusting for
age and sex.
Results: Between 2007 and 2014, 6143 cases aged 0–19 years (53%
boys, mean age (SD) 8.7 (4.5) years) with incident T1D were registered in NRW. The overall incidence rate was estimated at 22.3
(21.7; 22.8) and ranged between 0 and 55.7 in the municipalities. The
NRWIMD ranged between 2.2 and 70.5. The relative risk in communities decreased with increasing NRWIMD quintile, the relative risks
of T1D in communities in the NRWIMD quintile Q2, Q3, Q4 and Q5
(most deprived) versus NRWIMD quintile Q1 (least deprived) were
0.98 (0.89; 1.08), p = 0.64; 0.93 (0.85; 1.03), p = 0.15; 0.92 (0.84;
1.00), p = 0.05; and 0.92 (0.85; 1.00); p = 0.06), respectively. The
trend test across NRWIMD quintiles was significant (p = 0.03), the
average relative risks per increase in NRWIMD quintile was 0.98
(0.96; 0.998)).
Conclusions: The results suggest that the risk of T1D in Germany in
recent years is somewhat lower in children living in deprived areas.
97
POSTER TOURS
Poster Tour 21: Education and Psychological Issues
P161
Early Detection of type 1 Diabetes in Youth: the
EDDY feasibility study to design, develop and
deliver a complex intervention to parents and
primary care to raise awareness of the symptoms of
type 1 diabetes in childhood, to prevent diabetic
ketoacidosis (DKA) at diagnosis
J. Townson1, L. Lowes1, S. Channon1, M. Robling1, D. Gallagher1,
S. Murphy1, D. Williams2, C. Hughes3, J. Gregory1
Cardiff University, Cardiff, United Kingdom, 2Diabetes UK, Cardiff,
United Kingdom, 3Cardiff and Vale NHS University Health Board,
Cardiff, United Kingdom
1
Objectives: To design, develop and test feasibility of delivering a
complex intervention to parents of children < 18 yrs and Primary
Care staff in 3 adjoining areas in South Wales, to increase awareness
of symptoms of diabetes to prevent DKA at onset.
Methods: The intervention was designed and developed using a coproduction model with public and General Practitioner (GP) advisory
groups. It was delivered through schools, nurseries and GP surgeries
in Cardiff, Vale of Glamorgan and Bridgend. Feasibility and impact of
the intervention for key stakeholders was evaluated using qualitative
methods.
Results: The parent component of the intervention comprised a reuseable shopping bag and information leaflet, with the hard-hitting
message ’untreated type 1 diabetes can kill’ and symbols depicting
four main symptoms. This was delivered to 323/329 (96%) schools,
approximately 101,371/105199 (96%) children. The GP component
of the intervention comprised a glucose/ketone meter with disposable lancets, posters and ’Unwell child? Think Diabetes’ aide memoire
stickers. Educational training days and visits were provided by Community Diabetes Liaison Nurses to 225/329 (68%) schools and 73/84
(87%) GP practices. All GP surgeries received the materials;
47 received 62 glucose/ketone meters and 25 reported already having one. Thematic analyses demonstrated the intervention was
acceptable to stakeholders. Potential impact was highlighted by a parent of a newly diagnosed child who stated that receipt of the bag
motivated her to seek medical help and by a GP who was prompted
to use the meter following a nurse visit, to diagnose a child.
Conclusions: The intervention was feasible to deliver and acceptable
to key stakeholders. This study was not designed to evaluate effectiveness but results suggest impact on parents and in primary care.
We propose minimal refinement of the intervention and full evaluation in a randomised controlled trial.
P162
Pediatric diabetes centres rated parental
responsibility and family support as most important
determinants of HbA1c using a 17-item
questionnaire: a pilot study
R. Van Vreckem1, S. Chao1, V. Beauloye2, K. Casteels3,
M. Coeckelberghs4, P. Collin5, L. Dooms6, K. Logghe7, K. Poschet8,
V. Van Casteren1, K. Doggen1, Initiative for Quality Improvement and
Epidemiology in Children and Adolescents with Diabetes (IQECAD)
Study Group
1
Scientific Institute of Public Health, Health Services Research, Brussels,
Belgium, 2UCL St-Luc, Brussels, Belgium, 3University Hospitals Leuven,
Leuven, Belgium, 4Queen Paola Children’s Hospital, Antwerp, Belgium,
5
Grand Hôpital de Charleroi, Charleroi, Belgium, 6Ziekenhuis Maas &
Kempen, Bree, Belgium, 7AZ Delta, Roeselare, Belgium, 8GZA Ziekhuizen
Sint-Vincentius, Antwerp, Belgium
Objectives: HbA1c is determined by factors related to treatment,
patient and environment. To compare HbA1c between centres, riskadjustment should account for biological, sociodemographic and psychosocial factors beyond control of care providers. We investigated
which factors pediatric diabetes centres (PDC) rated as contributing
most to excellent (EA1c) and poor HbA1c (PA1c).
Methods: A 17-item questionnaire was developed including potential
sociodemographic (e.g. ethnic minority parents), interpersonal
(e.g. family cohesion) and intrapersonal (e.g. self-efficacy) reasons for
EA1c (<6.5%) and PA1c (≥9.5%). These HbA1c cut-offs aimed to yield
200 patients/group. Belgian PDCs (N = 15) were invited to rate the
importance of these items on a scale of 1 (none) to 5 (high) for
patients with diabetes duration ≥1 year.
Results: Out of 215 and 198 eligible patients, 12 PDCs returned
valid questionnaires for 120 EA1c and 106 PA1c patients respectively. Compared to non-participants, participants performed more
self-measurements/day, more often had basal-bolus insulin, and less
frequently had ethnic minority parents. PDCs rated higher parental
responsibility (PR), family support (FS) and conscientiousness as most
important determinants of EA1c. PR and FS were rated highly (top 2)
in all patients except those with ethnic minority parents. Adolescence
and lower PR and FS were rated as most important determinants of
PA1c. FS was rated highly (top 2), regardless of pubertal status, sex
and parents’ ethnicity.
Conclusions: PDCs rated PR and FS as most important determinants
of both EA1c and PA1c. To improve acceptability of between-centre
comparisons, risk-adjustment for these factors should be considered.
This study suggests that lower PR and FS are important challenges
for PDCs. Policy measures should aim at increasing psychosocial support for at-risk patients and families. Questionnaire changes may alleviate the participation and representativeness issues of this pilot
study.
P163
Benefit finding in adolescents with type 1 diabetes:
prospective associations with treatment adherence
and metabolic control
J. Rassart1, K. Luyckx1, M. Ramsey2, D. Wiebe3, C. Berg2
1
KU Leuven, Leuven, Belgium, 2University of Utah, Salt Lake City, United
States, 3University of California, Merced, United States
Objectives: Although benefit finding has been associated with better
psychosocial well-being in numerous chronic illness populations, few
studies have examined benefit finding in the context of type 1 diabetes. In addition, little research has focused on children and adolescents. Adolescence is a difficult time for managing diabetes as
evidenced by deteriorating metabolic control, poorer adherence, and
heightened emotional distress. Understanding factors that predict
adolescents’ treatment adherence is important as self-management
behaviors established during adolescence may carry well into adulthood. In the present study, we investigated longitudinal interrelations
among benefit finding, treatment adherence, and metabolic control in
adolescents with type 1 diabetes.
Methods: Adolescents with type 1 diabetes aged 10 to 14 (Mage =
12.49 years, 54% girls) participated in a four-wave longitudinal study
spanning approximately 1.5 years (N = 252 at Time 1). At each wave,
adolescents filled out questionnaires on benefit finding and treatment
adherence. HbA1c values were obtained from treating clinicians.
Cross-lagged path analysis was used to examine longitudinal interrelations among the study variables.
Results: Higher levels of benefit finding were found to predict relative increases in treatment adherence over time, after controlling for
the effects of sex, age, illness duration and treatment type (pump
vs. injections). No significant cross-lagged associations emerged
between benefit finding and HbA1c.
98
Conclusions: Our findings suggest that benefit finding may serve as a
protective factor for adolescents with type 1 diabetes and may motivate these adolescents to more closely follow their treatment regimen. The period of adolescence might be particularly suitable for
interventions promoting patients’ benefit finding given the emergence of future-oriented thoughts and concerns, the increasing
responsibility for diabetes management, and the development of coping skills.
P164
School-age intelligence and psychosocial wellbeing
of the children with early-onset type 1 diabetes
with good or poor early glycemic control
R. Hannonen
Kymenlaakso Social and Health Services, Department of Child
Neurology, Kotka, Finland
Objectives: Good glycemic control from the early stage of type 1 diabetes (T1D) is beneficial on the child’s future physical health. However, less is known about its effects on cognitive or psychosocial
development. This study examined whether glycemic control one
year after diagnosis is associated with intelligence and psychosocial
wellbeing at school-age in children with early-onset T1D.
Methods: The study included 62 children with T1D diagnosed below
five years of age. The children were nine to ten years of age at the
time of the study. The children’s intelligence (IQ) was assessed with
the Wechsler Intelligence Scale for Children, and psychosocial wellbeing (internalizing and externalizing symptoms) was evaluated by
their mothers with the Behavior Assessment Scale for Children. Glycemic control was measured by the HbA1c level one year after diagnosis and at the time of the study. Children were divided into three
groups
with
good
(HbA1c < 7.6%,
n = 20),
non-optimal
(HbA1c = 7.6% - 8.4%, n = 28) and poor (HbA1c > 8.4%, n = 14) glycemic control one year after diagnosis. Multivariate GLM with post
hoc analyses was used to analyze group differences in IQ and internalizing and externalizing symptoms, when current glycemic control
was controlled for.
Results: Early glycemic control was associated with IQ and psychosocial wellbeing (p = 0.027). The children with poor early glycemic control had lower IQ (p = 0.023) and more internalizing symptoms
(p = 0.049) at school-age than the children with good early glycemic
control, when current glycemic control was controlled for.
Conclusions: Early poorly controlled diabetes may have long-lasting
effects on the child’s cognitive and emotional development.
P165
Level of Internet use among Greek adolescents
with type 1 diabetes
K. Daniilidou, M. Dimitriadou, M. Resta, P. Triantafyllou,
A. Christoforidis
Aristotle University, 1st Pediatric, Thessaloniki, Greece
Objectives: To investigate the reasons for Greek adolescents and
their families to use the Internet and additionally to investigate the
level of Internet use and its associations to demographic, socioeconomic parameters and glycemic control.
Methods: Patients with type 1 diabetes, aged > 12 years and their
parents were recruited during their regular visits at the Pediatric Diabetes Clinic. A similar group of healthy children, age- and sexmatched served as control group. All participants were asked to fill
out the Greek translated version of the Internet Addiction Test (IAT).
Caregivers of patients with type 1 diabetes were asked to complete a
second questionnaire consisted of questions regarding demographic
and socio-economic data of the family and data concerning disease
management.
Results: Thirty-five patients with a mean decimal age of
14.95 1.90 years and their families participated in the study. Mean
POSTER TOURS
total score of the patients’ IAT questionnaires was significantly lower
compared to the controls (26.26 12.67 versus 39.91 18.55,
P = 0.003). Controls were categorized as exhibiting mild addictive
behavior at a significant higher percentage that controls (31.43% versus 2.86%, P = 0.002). All patients on insulin pump demonstrated
normal Internet Use. Mild addictive behavior was associated with a
lower parental educational level. Finally, IAT scores and HbA1c values
were linearly correlated with an association that was approaching significance (r = 0.315, P = 0.065).
Conclusions: Adolescents with Type 1 diabetes and especially those
on insulin pump exhibit normal Internet use compared to their
healthy peers. Time spend on Internet correlates reversibly with glycemic control.
P166
A triadic approach towards illness perceptions in
youth with type 1 diabetes and their parents:
associations with patient and parent functioning
S. Prikken1, L. Oris1, I. Weets2, P. Moons1,3, K. Luyckx1
1
KU Leuven, Leuven, Belgium, 2Brussels Free University, Brussels,
Belgium, 3Gothenburg University, Gothenburg, Sweden
Objectives: Type 1 diabetes constitutes a challenging illness for both
the patient and its immediate context. Especially parents play a crucial role in illness adaptation and management of adolescent and
emerging adult patients. The present study addressed the combined
role of patient and parental illness perceptions to understand how
type 1 diabetes impacts both patient and parental functioning. Previous research focused mainly on the role of illness perceptions and
patient self-regulation, but a triadic approach investigating how
patient and parental illness perceptions interact in predicting functioning remains forthcoming.
Methods: Selected from the Belgian Diabetes Registry, a total of
330 patients-mothers-fathers triads participated. Mean age of
patients (52% female) was 18.25 (SD = 2.98). Patients and both their
parents completed questionnaires on their own illness perceptions
(Brief IPQ) and functioning (depressive symptoms, life satisfaction).
Additionally, patients reported on their treatment adherence. HbA1c
values were obtained from patients’ medical records.
Results: A series of regression analyses indicated that, although a
person’s own illness perceptions predicted his or her functioning, illness perceptions of other close relatives were also predictive. Further, significant two- and three-way interaction terms indicated that
illness perceptions of different members of the triad interacted in
predicting patient and parental functioning. For instance, with respect
to the illness perception of personal control, treatment adherence
was highest when both patients and mothers scored high on perceived personal control. Likewise, fathers’ life satisfaction was highest
when both fathers and patients scored high on perceived personal
control.
Conclusions: The present study encourages researchers to take the
family as a system into account when examining individual functioning, both of patients with type 1 diabetes and their parents.
P167
Parenting and treatment adherence in type
1 diabetes throughout adolescence and emerging
adulthood
E. Goethals1,2, L. Oris2, S. Prikken2, B. Soenens3, K. Casteels1,2,
N. Van Broeck2, I. Weets4, K. Luyckx2
1
University Hospital Leuven, Leuven, Belgium, 2University of Leuven,
Leuven, Belgium, 3Ghent University, Ghent, Belgium, 4Free University of
Brussels, Brussels, Belgium
Objective: The importance of parenting towards treatment adherence in type 1 diabetes (T1D) has previously been studied, but this
research mainly focused on young patients and on parenting styles.
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Our study examines associations between different parenting dimensions as the building blocks of parenting styles (diabetes monitoring,
responsiveness, psychological control) and treatment adherence
throughout adolescence and emerging adulthood. In contrast to previous research, that focused mainly on mother reports, this study is
multi-informant, including adolescent and emerging adults with T1D
as well as both their mothers and fathers.
Methods: 521 patients (aged 14–25 years) with T1D, 407 mothers,
and 345 fathers were included. Analyses within and across informants examined the associations between parenting dimensions and
treatment adherence (and potential moderation effects in these
associations).
Results: Treatment adherence was consistently and negatively predicted by psychological control (i.e., negative and pressuring parenting) and positively by responsiveness (i.e., supportive and warm
parenting). Diabetes monitoring (i.e., consistent rule setting) was not
uniquely linked to treatment adherence, except when combined with
high levels of responsiveness. Some effects of psychological control
and responsiveness were more pronounced in the older age group.
Conclusions: Researchers and clinicians should remain attentive
towards the potential role of parenting for treatment adherence, even
in emerging adult patients. As similar effects emerge for fathers as
well as for mothers, it is important to involve both in the comprehensive treatment of T1D.
P168
care of children with type 1 diabetes mellitus at
school: a review of attitude of parents in a
developing country
T. Jaja1
1
University of Port Harcourt Teaching Hospital, Rivers State, Port
Harcourt, Nigeria
Background: Optimal glycaemic control is essential in preventing diabetes related complications in children with diabetes. The school is
an important component of care and support to achieve good outcome as children spend a considerable time in school.
Aim and objective: The aim of this study was to review the attitudes
of parents towards care of their children with Type 1 Diabetes Mellitus (DM) at School in a developing country.
Methods: Parents of all children with Type 1 DM seen at the endocrine unit of the University of Port Harcourt Teaching Hospital were
invited to participate. Data were collected using a questionnaire.
Information on biodata, Details of care in school and challenges experienced were documented and HBAic was done for all children.
Results: The Parents of eighteen children and adolescents with Type
1 DM participated in the study. The age range of the children was
between 5 and 17 years, mean age of 12.18 1.7years. Mean duration of DM 3.12 2.4years and mean HBAic was 9.49%
Two parents (11.1%) did not inform the school of child’s condition.
No parent gave a written plan of diabetes care/treatment of hypoglycaemia in school and 4 parents (22.2%) did not make contact with
school when child was in school. No child had a glucometer or took
insulin to school. Five parents (27.8%) adjusted or omitted morning
insulin dose to prevent hypoglycaemias in school. Fifteen (83.3%) of
children were on twice daily insulin injections. Six children(33.3%) are
from high socioeconomic class.
Conclusion: This study demonstrates poor attitude and deficiencies
in care of children with Type 1 DM in school in our region. There is
need for training of parents and presentation of written plans for care
of every child with Type 1 DM in school.
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Poster Tour 22: Epidemiology, Acute and Chronic Complications &
Associated Diseases
P169
Hypertonic saline or mannitol in management of
cerebral oedema due to diabetic ketoacidosis in
children? A review of current advise by paediatric
intensivists of North-West England and North
Wales (NWTS)
R. Mohanty1, V. Holec2, R. Phatak3
1
Blackpool Teaching Hospitals NHS Foundation Trust, Paediatrics,
Blackpool, United Kingdom, 2Alder Hey Children’s Hospital, Liverpool,
United Kingdom, 3Royal Manchester Children’s Hospital, CMUHT,
Intensive Care Unit, Manchester, United Kingdom
Objectives: Cerebral oedema due to DKA has mortality rate of 24%.
Early recognition and effective intervention can prevent neurological
complication and mortality. ISPAD (International Society for Pediatric
and Adolescent Diabetes) and BSPED (British Society for Paediatric
Endocrinology and Diabetes) guidelines suggest to use either hypertonic saline or mannitol to treat cerebral oedema in children with diabetic ketoacidosis (DKA). In this study we intend to evaluate
preference by the intensivists in management of suspected cerebral
oedema in children admitted with Diabetic Ketoacidosis (DKA) in
North-West England.
Methods: A retrospective study was carried out to analyse the management and outcome of patients with Diabetic Ketoacidosis referred
to North West and North Wales Transport Service (NWTS) between
July 2012 and April 2015.
Results: 66 patients (32 boys/34 girls) were included with a median
age of 10.5 years. Most common (53%) reason for referral was neurological symptoms suggestive of possible cerebral oedema (35/66).
10/35 (28%) had CT scan brain but none showed any radiological evidence of raised intracranial pressure. Average initial venous blood pH
was 6.99 and electrolyte imbalance was noted in 31/66 (46%)
patients. Out of 14 patients who received osmotherapy 12children
(85.7%) received 2.7% saline and only 2 children were given mannitol.
Out of 14 children 7 (50%) were transferred to high dependency unit
(HDU) and 7 (50%) were admitted to intensive care unit (ICU). All
7 children in ICU were ventilated as they had low Glasgow Coma
Scale (GCS). 1 child died before osmotherapy was commenced.
Conclusion: Early CT brain is not sensitive enough to inform initiation of osmotherapy in children with suspected cerebral oedema. Our
study showed that hypertonic saline is more frequently recommended by intensivists in North West England and North Wales
compared to mannitol in management of cerebral oedema. Further
study is needed to establish this trend.
P170
Insulin edema related insulin pump initiation: case
report
M. Monteiro1, M. Gomes da Costa1, C.K.R. Feder1, P.V. Freire1,
A.C. Yamada1, J.E.N. Salles1, M.V. Pereira1, L.E. Calliari2
1
Santa Casa Faculty of Medical Sciences, Endocrinology, Sao Paulo,
Brazil, 2Santa Casa Faculty of Medical Sciences, Pediatric Endocrinology
Unit, Sao Paulo, Brazil
Introduction: Insulin edema rarely occurs in patients with Type 1 Diabetes Mellitus (T1D), after the introduction or intensification of treatment. In the majority of cases, this phenomenon is transient. Our
objective was to report a case of a patient with insulin edema after
the initiation of Continuous Subcutaneous Insulin Infusion System
(CSII), in two different moments.
Case report: A 24 year old woman, with T1D since 11 years of age,
was under regular use of Insulin Glargine and Lispro. She was
presenting important glucose instability and variability, with episodes
of hypoglycemia unawareness and severe hypoglycemia, even with a
high mean glucose exposure. Those were the indications for a test
with CSII. Last HbA1c was 13.5% (estimated average glucose:
340 mg/dL), and total daily dose(TDD) was 52,8 Units/day. The
pump set up followed general rules. We noticed a better glycemic
control after the initiation of the pump, as compared with the previous ones. On the first week of pump use, the mean glucose went
down to 185 mg/dL, but she presented significant weight gain, 6 kg/
4 days, together with peri-orbital, feet and ankle edema. Laboratory
tests were normal. Patient was treated with spironolactone 50 mg
/day for 10 days, when edema was resolved. Insulin pump was changed back to multiple doses with insulin analogs for three months,
when insulin pump was re-initiated. Again, patient presented a very
similar edema, only this time furosemide had to be added to spironolactone for two weeks.
Discussion: Generalized edema after CSII system initiation is rare.
Some pathophysiologic explanations have been proposed, like insulin
increase of capillary permeability, anti-natriuretic effect, due to
increase in sodium tubular reabsorption, or increase in counterregulation hormones in response to hypoglycemia. As insulin pump
prescriptions are growing fast, it is important for the pediatric endocrinologists to be aware of this risk and know how to act promptly to
resolve it.
P171
Strategy to reduce delay in referral of children with
new onset diabetes mellitus to specialist paediatric
diabetes teams
J.C. Agwu1, V. Lane2
1
Sandwell and West Birmingham NHS Trust, Paediatrics, West
Bromwich, United Kingdom, 2Sandwell and West Birmingham NHS Trust,
Biochemistry, West Bromwich, United Kingdom
Introduction: Our local 10 year audit (1st Jan 2005 - 31st Dec 2014)
showed that 38.5% (37/96) of children and young people (CYP) presented in DKA at onset of Diabetes Mellitus. There was delayed
referral in 36.5% (35/96). 54.2% (19/35) of children CYP in whom
referral to secondary care was delayed presented in DKA. The commonest reason in our cohort for delay in referral was due to the GP
carrying out further investigations e.g. fasting blood glucose in order
to confirm the diagnosis prior to referral.
Objective: To reduce delay in referral by General Practitioners (GPs),
of children with new onset Diabetes Mellitus, to specialist Paediatric
diabetes teams (PDT).
Method: We introduced an electronic ’popup’ alert (EPA) that
reminds GPs of the national guideline, which recommends same day
referral of all children suspected of having DM to PDT, every time
they want to place an electronic order for blood glucose (BG)on any
child aged less than 18 years. We analysed the number of BG
requests by GPs, and DKA rates, 3 months before (sept -dec 2015)
and 3 months (Jan-mar 2016) after the introduction EPA . We analysed categorical data using Fisher Exact Test.
Results: There has been 19% reduction in requests for BG by GPs in
CYP aged less than 18 years (772 vs 626). Total no. of CYP presenting with DM (various sources of referral) before introduction of EPA
was 11. 5 of these presented in DKA (2 of whom were associated
with delayed referral due to GP undertaking further tests). Total
no. of CYP presenting with DM (various sources of referral) after
introduction of EPA was 15. 5 of these presented in DKA. None of
whom were associated with delayed referral.
Conclusion: There has been a significant reduction (p = 0.02) in the
number of children presenting in DKA associated with GP delaying
101
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referral by carrying out tests to confirm diagnosis prior to referral.
Longer term evaluation will be required to confirm the usefulness of
the EPA though these results are promising.
P172
Prognostic factors and patterns of c-peptide level
for 3 years in type 1 DM children
J.W. Hwang, M.S. Kim, D.-Y. Lee
Chonbuk National University Medical School, Department of Pediatrics,
Jeonju, Korea, Republic of
Objectives: C-peptide is the best measurement of endogenous insulin secretion in patients with diabetes. This study investigated the
relationship between C-peptide and clinical/laboratory parameters,
measured at 6 month intervals for 3 years after diagnosis.
Methods: We retrospectively reviewed the data of 34 children
(n = 19 girls, 15 boys) aged 1 to 19 years (Mean age 9.68 4.56 yrs)
with Type 1 DM. The initial course of Type 1 DM was studied in
2 groups of 27 patients of abrupt progression group with c-peptide
less than 0.6 ng/mL at 36 months (Group A) and 7 patients of slow
progression group with c-peptide equal to or greater than 0.6 ng/mL
at 36 months (Group B). Symptoms were subdivided into 3 groups,
glucosuria only (5.9%), polydipsia, polyuria with weight loss (67.6%),
and DKA (26.5%).
Results: 1) In abrupt progression group (Group A), mean age at diagnosis was younger (A : 8.67 4.28 yrs, B : 13.57 3.55 yrs,
p = 0.009), has lower BMI (A : 16.25 2.48 kg/m2, B:
18.65 3.32 kg/m2, p = 0.041) and severe symptoms (p = 0.013)
compared to slow progression group (Group B). Group A also showed
significant difference in initial pH (A: 7.31 0.15, B: 7.40 0.03,
p = 0.014) and initial c-peptide level (A: 0.64 0.46 ng/mL, B:
0.87 1.08 ng/mL, p = 0.022).
2) There was no significant correlation between sex, family history
of Type 2 DM, HbA1c, pancreatic autoantibodies, thyroid antibodies
and serum insulin at onset between two groups.
3) Simple correlation analyses showed that in group A, 36 month cpeptide level is not significantly correlated with the initial c-peptide
level (γ = 0.376, p = 0.053).
Conclusion: Patients with younger age, lesser BMI, significant symptoms and low initial c-peptide level need an early intensive insulin
therapy for preservation of beta-cell function.
P173
Asymmetric dimethylarginine in children and
adolescents with type 1 diabetes; association with
metabolic control and endothelial dysfunction
B. Ersoy1, N. Eroğlu1, M. Özkol2, E. Onur3
1
Celal Bayar University, Faculty of Medicine, Pediatric Endocrinology,
Manisa, Turkey, 2Celal Bayar University, Faculty of Medicine,
Department of Radiodiagnostic, Manisa, Turkey, 3Celal Bayar University,
Faculty of Medicine, Clinical Biochemstry, Manisa, Turkey
Aim: We aimed to determine changes of Asymmetric dimethylarginine (ADMA) levels in regarding with diabetes duration and relation
with lipid profile, metabolic control and endothelial dysfunction in
children and adolescents with Type 1 Diabetes Mellitus (DM).
Participants and Methods: Eighty eight diabetic children aged 7–25
years were included in this cross-sectional study. In the sera of all
patients, ADMA levels, HbA1c, and lipid profile were assessed.
Carotid Intima Media Thickness (IMT) was measured as an indicator
of subclinical atherosclerosis. The patients were divided into three
groups according to the duration of diabetes as 1 to 5 years (group1),
>5 to 10 years (group 2), and >10 years (group 3).
Results: The mean age of each group showed statistically significant
difference (p < 0.001). ADMA levels were significantly higher in
group 1 compared to groups 2 and 3 (P < 0.05). There was no significant difference in ADMA levels between group 2 and 3 (P > 0.05).
Significant differences were found regarding carotid IMT between
group1 and 3, and group 2 and 3 (p < 0.05). Triglyceride (TG) and
Low Density Lipoprotein Cholesterol (LDL-C) levels were significantly
lower in group 1, compared to group 2 and 3 (p < 0.05). No differences were found between group 2 and 3 (p < 0.05). ADMA levels
showed significant inverse association with age (r = −0.507,
P < 0.001), diabetes duration (r = −0.282, p = 0.008), and LDL-C
(r = −0.283, p = 0.008).
Conclusion: ADMA concentrations decreased with age as well as
duration of diabetes. Patients with diabetes duration of less than
5 years had significantly higher ADMA level. In patients with longer
5 years’ duration, ADMA levels did not show any change with the
increase of duration. There is no association between ADMA and
Carotid IMT as an indicator of subclinical atherosclerosis. Further
studies are needed to clarify the potential association of ADMA with
subclinical atherosclerosis in children and adolescents with
Type 1 DM.
P174
Raising the cut-off value for anti-tissue
transglutaminase antibodies decreased the number
of unnecessary biopsies in children with type
1 diabetes
A. Velthuis1, M. Wessels1, E. van Lochem1, E. Duijndam1, J. Meijer1,
D. Mul2, J. van Alfen-van der Velden3, P. van Setten1
Rijnstate, Arnhem, Netherlands, 2Haga Hospital, The Hague,
Netherlands, 3Radboudumc, Nijmegen, Netherlands
1
Objectives: The aim of our study was to investigate whether the
anti-tissue transglutaminase type 2 IgA antibody serum (TG2A) cutoff value for performing a biopsy to investigate celiac disease (CD) in
children with type 1 diabetes mellitus (T1DM) can be raised. Reason
for this was to overcome unnecessary biopsies, without losing too
much sensitivity.
Methods: Children with T1DM who had both elevated TG2A titers
during regular screening and a duodenal biopsy during the course of
their diabetes were included. The optimal TG2A cut-off value was
determined using receiver operating characteristics (ROC) curve analysis; and compared with the cut-off value used in the ESPGHAN
guidelines in terms of sensitivity, specificity, positive and negative
predictive value. TG2A titers were expressed as the ratio between
the value obtained and the upper limit of normal (ULN). Antiendomysial antibodies (EMA) were used as a confirmatory test.
Results: A total of 63 children were included. The optimal cut-off
value for performing a biopsy proved 11xULN. Raising the cut-off
value from 3xULN to 11xULN changed the sensitivity from 96% to
87%; increased the specificity from 36% to 73%, the positive predictive value from 88% to 94% and the negative predictive value from
67% to 53%. The number of negative biopsies was reduced from
12% to 6%.
Conclusion: Raising the TG2A cut-off value for performing a biopsy
in children with T1DM to 11.5xULN reduces the number of unnecessary biopsies. The subsequent slight loss in sensitivity is in our opinion acceptable.
Disclosure of interest: None Declared.
P175
Current status of incidence and prevalence of type
1 diabetes among children aged less than 15 years
in Japan
Y. Onda1, S. Sugihara2, T. Ogata3, S. Yokoya4, T. Yokoyama5,
N. Tajima6, T1D Study Group
1
Jikei University School of Medicine, Internal Medicine, Tokyo, Japan,
Tokyo Women’s Medical University Medical Center East, Pediatrics,
Tokyo, Japan, 3Hamamatsu University School of Medicine, Pediatrics,
Shizuoka, Japan, 4National Center for Child Health and Development,
2
102
Medical Subspecialties, Tokyo, Japan, 5National Institute of Public
Health, Technology Assessment and Biostatistics, Saitama, Japan, 6Jikei
University School of Medicine, Tokyo, Japan
Objective: A rapid increase in incidence of type 1 diabetes (T1D),
especially among young children, has been reported in Europe. We
evaluated the epidemiology of T1D in Japan to know whether such a
phenomenon is observed in a country with a low risk of T1D.
Methods: A majority of children with T1D are registered with the
government-subsidized Specified Pediatric Chronic Diseases Treatment Research Projects (SPCDTRP). In this study, the incidence and
prevalence of childhood (<15 years old)-onset T1D were estimated
by drawing on the SPCDTRP data. Inclusion criteria for T1D were as
follows:
1) diagnosis of T1D by a physician, but also
2) receiving insulin therapy, and/or
3) GAD antibody positivity.
The data available for 2005 to 2012 from the SPCDTRP were used
to estimate the incidence rate for 2005 to 2010, adjusted to cover
those registered within 3 years of onset, and stratified by sex, age at
onset, and month of onset.
Results: The incidence was 2.3/100,000 person-years (95%CI, 2.22.4) (boys/girls, 1.9[1.8-2.0]/2.5[2.3-2.7]) with that for the age brackets 0–4, 5–9, and 10–14 years being 1.5(1.3-1.7), 2.3(2.1-2.5), and
3.0(2.7-3.3), respectively. The onset of disease was shown to peak at
13 years at 3.2(2.9-3.5), with the peak months of disease onset being
April/May and December. The number of patients with T1D
aged < 15 years was estimated to be 2326(2202–2450) with the
prevalence estimated as 13.5/100,000 persons (12.6-14.4).
Conclusions: Available data demonstrated a very low incidence, with
the onset of disease shown to peak in early adolescence with a
female predominance. These findings were consistent with epidemiological data reported earlier in Japan and showed no increase in incidence, unlike those recently reported in Western and some other
Asian countries. In addition, the incidence of childhood-onset diabetes exhibited an annual bimodal pattern in this study. Further
research is required to determine the case ascertainment rate for the
SPCDTRP cohort.
POSTER TOURS
P176
Falling all-cause mortality from the Yorkshire
register of type 1 diabetes in children and young
adults
T.C. Evans-Cheung, H.J. Bodansky, R.G. Feltbower, R.C. Parslow
University of Leeds, Leeds, United Kingdom
Objectives: The Yorkshire Register of Diabetes in Children and
Young Adults (YRDCYA) previously found excess mortality in individuals with type 1 diabetes (T1D). Updated data examined mortality
risk factors and mortality over time.
Methods: The YRDCYA includes under 15 s (early onset) diagnosed
with T1D in Yorkshire from 1978 and 15 to 29 year olds (late onset)
diagnosed in West Yorkshire from 1991. The YRDCYA was linked to
death certification data from the Office for National Statistics (ONS).
Standardised mortality ratios (SMRs) and survival curves were produced by demographics. SMRs used England and Wales population
death rates by 5-year age group and sex from 1978 to 2014.
Results: There were 233 deaths from 6,209 individuals with 107,492
person-years of follow-up. Overall SMR was 4.3 (95% CI 3.8 - 4.9).
The late onset group had a significant increased rate of death for time
since diagnosis.
[Cumulative proportion of deaths]
SMR for those diagnosed before 1980 with 20 years or more
follow-up time (3.1 (95% CI 1.9 - 5.1)) was significantly higher than
those diagnosed between 1990 to 1994 (0.7 (95% CI 0.3 - 1.4).
Conclusions: Early onset T1D is a significant mortality risk factor.
However, age at death seems more important than diabetes duration,
suggesting that factors associated with later life are the key determinants for risk of death. Decreasing trend in SMRs with later years of
diagnosis provides some evidence that mortality has decreased
over time.
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Poster Tour 23: Monogenic Diabetes
P177
Clinical peculiarities in a large pediatric population
with Wolfram syndrome
S. Passanisi1, F. Lombardo1, C. Ventrici1, A. Gasbarro1, G. Candela1,
G. Salzano1
1
University of Messina, Department of Pediatric, Gynecological,
Microbiological and Biomedical Sciences, Messina, Italy
Wolfram syndrome (WFS) is a rare, autosomal recessive, neurodegenerative and progressive disease. Early onset diabetes mellitus and
bilateral progressive optic atrophy are sensitive and specific criteria
for clinical diagnosis. The leading cause of death is the central respiratory failure resulting from brainstem atrophy.
Methods: We describe clinical features of 14 patients from 6 different families followed in our Center.
Results: Median age of WFS onset was 11.6 years. In each one diabetes mellitus was the first clinical manifestation. Sensorineural hearing impairment was present in 85% patients (median age of onset
13.2 years). Central diabetes insipidus occurred in 92% patients with
a median age of onset of 13.7 years. Other endocrine findings were
hypogonadotrophic hypogonadism (7%) and Hashimoto’s thyroiditis
(14.2%). Abnormalities of urogenital tract were present in 35.7% of
cases, including dilated renal outflow tracts, urinary incontinence and
bladder atony (median age of onset 18 years). Heart diseases were
detected in 14.2% patients with a median age of onset of 13.5 years,
including ventricular septal disease and secundum atrial septal defect
with concomitant valvulopathy. Four of WFS patients (28.5%)
deceased at the median age of 27.4 years, in three patients the cause
of death was central respiratory failure and in one patient was endstage renal failure.
Conclusions: Our data are superimposable with those reported in
the literature in terms of average age of onset, clinical course of the
disease and causes of death. The frequency of deafness and diabetes
insipidus was more elevated in our patients, the incidence of urogenital diseases was lower although in one case led to death one patient.
Moreover, in the present case population we highlight the relative
high frequency of heart disease. On the basis of the paucity of data
reported in the literature, we suggest to consider also the cardiological aspects as expression of WFS according to our data.
P178
SGLT-2 Inhibitor use in an adolescent girl with a
pronounced insulin resistance due to a new
compound heterozygous mutation of the gene
encoding for the insulin receptor
of the gene encoding for the insulin receptor (INSR) through amplification of the exons 1–22 with PCR and consecutive sequencing
showed two not described compound heterozygous mutations. The
unaffected, not consanguine parents were heterozygous for one of
the mutations: father: c.513C > G (p.Tyr171*), mother c.2767G > A
(p.Val923Met), retrospectively.
Results: Insulin treatment was stopped, therapy with metformin was
initiated and the intake of carbs was restricted. Metabolic control
improved for a while, but worsened after 6 months. BMI significantly
increased (BMI-SDS 0.74) with a massive increase of the subcutaneous fat. We initiated the off-label use with an SGLT-2-inhibitor to
reduce glucose levels and consecutively insulin levels: HbA1c 8.5%,
no ketonaemia, weight decrease (BMI-SDS 0.45). Androgen excess is
successfully treated with cyproteronacetat, acanthosis and hirsutism
improved and menstruation restored.
Conclusion: An insulin resistance in young slim diabetic patients
should lead to the examination for a defect in the insulin receptor.
Off-label use of SGLT-2 inhibitors could be a successful treatment
option for patients with a defect in the insulin receptor.
P179
Greater glucose variability during OGTT is
associated with worse clinical markers in cystic
fibrosis
R. Margetts, S. Drew, H. Gordon, C. Peters
Great Ormond Street Hospital, London, United Kingdom
Objectives: To demonstrate the incidence of rebound hypoglycaemia
(RH) in those with normal glucose tolerance (GT) in cystic fibrosis
(CF) and determine whether oscillations in blood glucose (BG) are
related to reduced clinical markers.
Methods: Data from OGTT screening tests was collected from one
paediatric centre over 18 months. 1.75 g/kg glucose (max 75 g) was
administered and glucose concentrations measured at 0, 60, 120 and
180 mins. Results were classified according to WHO diagnostic criteria. In addition, a BG < 4 mmol/l at 180mins was classified as
RH. The difference in peak and trough BG for each test was calculated. Data on BMI and FEV1 was collected at the same time as
the OGTT.
Results: 35 tests were performed. 22 females, age range 3.9 16.4 years (mean 10.8)
Normal
Impaired
Glucose
Indeterminate Tolerance
OGTT (n = 35)
15
8
RH (n = 20)
11 (73%) 6 (75%)
2 (22%)
1 (33%)
Children’s Hospital ’Auf der Bult’, Diabetes Centre for Children and
Adolescents, Hannover, Germany, 2bio.logis, Centre for Genetic
Diagnostics, Frankfurt am Main, Germany
Age (years)*
10.1
11.1
11.5
12.1
FEV1 (% predicted)*
79.4
74.5
77.1
86
BMI (sds)*
−0.26
−0.76
−0.35
0.16
Background: Mutations of the gene encoding for the insulin receptor
are rare. Due to the receptor´s limited function it results in a diabetic
metabolism with marked insulin resistance. A therapy with insulin is
not successful.
Case report: We describe a case of a girl presenting to us at the age
of 14 years with a BMI-SDS of −1.28, multiple daily insulin injection
therapy for 1.5 years, no diabetic associated antibodies, hirsutism,
acanthosis nigricans and secondary amenorrhea, high needs of insulin
(>10units/kg/day) and high glucose values (150-250 mg/dl),
HbA1c 9.4%.
Methods: Excess of Insulin (>286.6μU/ml) and androgens, normal
cortisol; ultrasound, MRI and laboratory findings without signs for
any abdominal, adrenal or genital tumor. Molecular genetic analysis
Difference in peak and 5.3
trough (mmol/L)*
9.2
6.1
7.1
N. Datz1, M. Fath1, T. Biester1, G. Wildhardt2, D. Steinberger2,
S. Heger1, T. Danne1, O. Kordonouri1
1
9
CFRD
3
[Summary of results *given as mean]
RH is more common in those with normal OGTT or those with
indeterminate GT. As GT deteriorates, there is less RH. Glucose variability, as determined by the mean difference between peak and
trough glucose measurements, was highest in the indeterminate GT
group. This group also had the lowest BMI standard deviation scores
and lowest FEV1 (%predicted).
Conclusion: There is a high incidence of RH associated with normal
and indeterminate GT in CF. Clinical markers of CF health were
104
worse in the group with greatest glucose variability during the OGTT.
Glucose oscillation has been proposed as a marker of oxidative stress
and early interventions to prevent fluctuating glucose concentrations
may be beneficial before the onset of CFRD as determined by OGTT.
Continuous glucose monitoring in this group would therefore be a
potentially useful adjunct to screening.
P180
Are cystic fibrosis trust guidelines robust enough
for early identification of CFRD compared to CFF/
ISPAD guidelines?
A. Gangadharan1, C. Berry2, R. Watling2, S. Kerr3, K. Southern4,
S. Senniappan1
1
Alder Hey Children’s Hospital, Department of Paediatric Diabetes &
Endocrinology, Liverpool, United Kingdom, 2Alder Hey Children’s
Hospital, Department of Paediatric Dietetics, Liverpool, United Kingdom,
3
Alder Hey Children’s Hospital, Department of Paediatric Diabetes,
Liverpool, United Kingdom, 4Alder Hey Children’s Hospital, Department
of Paediatric Respiratory Medicine, Liverpool, United Kingdom
Introduction: Nutrition plays a pivotal role in long-term survival of
Cystic Fibrosis (CF) patients and worsening catabolic state affects the
respiratory reserve and premature death. Management of glucose
intolerance with early insulin treatment promotes anabolism and
improves lung function. There is a wide variation in CFRD screening
procedure across continents. The recommended age at start of diabetes screening is 12 years as per CF trust (UK) and 10 years as per
CFF&ISPAD.
Aim: To assess if early screening of glycaemic status helps in early
identification of glucose intolerance in patients with CF and to evaluate the correlation between OGTT and HbA1c.
Methodology: Retrospective data on OGTT, HbA1c, and patient
demographics were collected on all CF patients in a tertiary paediatric
hospital in UK(n = 84, 35 M). Patients were categorised into 3 age
groups [<10, 10 to < 12 & ≥12 years].
Results: [Table 1]
35 CF patients underwent a total of 127 complete OGTT with
median age 13 years (range 3–17.3), median follow up of 4 years
(range 0.8 -11.1).
OGTT: Eleven patients(13%) were diagnosed with CFRD requiring
various forms of insulin therapy including insulin pump therapy. This
includes 3 patients diagnosed with CFRD as a result of the early
OGTT screening between the age of 10 and 12 years(27%). OGTT
was undertaken in children less than 10 years of age if they were
symptomatic and this has identified one CFRD patient at the age of
9.4 years. Five eligible patients(≥10 years of age) did not
undergo OGTT.
HbA1c: Total of 89 HbA1c analyses was undertaken along with
simultaneous OGTT
Conclusions:
1. Application of CFF/ISPAD guideline promotes early diagnosis
of CFRD.
2. OGTT may not be routinely needed in children less than 10 years
of age unless clinical indicated.
3. No correlation between HbA1c and OGTT, thus unreliable for
diagnosis of CFRD.
4. A revised national consensus guideline on CFRD screening in UK
would be very useful for early diagnosis of CFRD.
P181
Role of mutations causing neonatal diabetes in
congenital hyperinsulinism (CHI) in infancy
G. d’Annunzio1, G. Romanisio2, A. Salina3, C. Aloi3, A. Virgone4,
A. Accogli2, N. Minuto1, M.C. Schiaffino2
1
Giannina Gaslini Institute, Pediatric Clinic, Regional Center for Diabetes,
Genoa, Italy, 2Giannina Gaslini Institute, Pediatric Clinic, Genoa, Italy,
3
Giannina Gaslini Institute, Pediatric Clinic, Laboratory of Diabetology,
POSTER TOURS
Genoa, Italy, 4Giannina Gaslini Institute, Division of Cardiovascular
Surgery, Genoa, Italy
CHI refers to a group of inherited disorders caused by inappropriate
high insulin secretion to blood glucose levels, resulting in recurrent
episodes of hypoglycemia. Worldwide, CHI estimate incidence ranges
from 1/35000-40000 to 1/2500 live births, mainly in regions with
high rates of consanguinity.In the pancreatic β-cells the ATP-sensitive
potassium (K + ATP) regulates glucose-stimulated insulin secretion.
K + ATP is composed by 4 ion channels (Kir6.2) and 4 regulatory sulfonylurea receptors (SUR1). The K + ATP channels are also present in
the brain and in other neuroendocrine tissues. Inactivating mutations
in the ABCC8 and KCNJ11 encoding respectively SUR1 and Kir6.2
subunits of the β-cell ATP-sensitive potassium channels (K + ATP) are
the most common causes. Herein we report the case of a 19-monthold male with CHI carrying two different mutations: c.916 C > T; p.
Arg306Cys and c.4433 G > A; p.Gly1478Arg located in exons 6 and
37 of ABCC8 respectively. Despite the neonatal onset of CHI, with
episodes of recurrent hypoglycemia since the first days of life, the
baby didn´t need later a pharmacological treatment to maintain blood
glucose levels within the normal range. Otherwise only dietary measures (enteral feeding of milk enriched with glucose polymers) were
prescribed. Since the paternally-inherited mutation may be linked to
neonatal diabetes mellitus and maternally-inherited mutation has
been reported in cases with mild forms of hyperinsulinism, we might
hypothesize a balance protecting from inappropriate insulin secretion
and subsequent severe hypoglycemic episodes. Moreover, we recommend long term follow-up and periodic oral glucose tolerance test for
early detection of insulin dysregulation, considering the established
glucose impairment reported on the father side.
P182
Insulin receptor gene mutations as a cause of
fasting hypoglycemia in children
D.A.M. Athayde, C. Passone, C. Pinheiro, S.L. Firmino,
M.L.C. Giannella, R. Savoldelli, T.D. Manna, D. Damiani
Universidade de São Paulo (USP), Pediatric Endocrinology, São Paulo,
Brazil
Objective: Rabson Mendehall syndrome (RMS) represents an intermediate form among syndromes related to mutations in the insulin
receptor (INSR) gene. It is characterized by dental anomalies, hyperpigmented skin, hirsutism, macrogenitossomia and severe insulin
resistance (IR). Our objective is to report the clinical and laboratorial
characteristics of two patients with suspected RMS.
Methods:
Case 1. A 6-year-old boy born to unrelated parents, developed hyperpigmentation in areas of skinfolds in his first year of life; one first
cousin had similar physical features. Physical examination showed
cervical, axillary, inguinal and peri-umbilical acanthosis nigricans;
hypertrichosis; dental abnormalities and macropenis.
Case 2. A 2-month- old girl born to unrelated parents, presenting
dysmorphic features, hypotonicity, hypertrichosis, cervical, axillary
and inguinal acanthosis nigricans, developed hypoglycemia since her
fist day of life.
Results: Case 1 presented prolonged fasting hypoglycemia (minimum
43 mg/dL),
few
episodes
of
postprandial
hyperglycemia
(220–234 mg/dL); HbA1c was 5.8%; fasting glucose and insulin collected at the same time were 70 mg/dL and 178.6 mcU/mL, respectively. OGTT showed a peak insulin level of 2287.2 mcU/mL and
glucose of 138 mg/dL. Molecular investigation demonstrated a
homozygous missense mutation in exon 19 of INSR gene, at codon
1135, GCG (alanine) to GTG (valine).
Case 2 presented neonatal hyperinsulinemic hypoglycemia showing
fasting glucose and insulin levels of 41 mg/dL and 186 mcU/mL,
respectively; during a hypoglycemic episode a glucagon test was performed with a peak insulin of 258 mcU/mL and glucose of 20 mg/dL;
HbA1c was 5.2%. Even though there was no response to diazoxide
treatment, the hypoglycemia crisis could be controlled with dietary
management.
105
POSTER TOURS
Conclusion: Despite being a rare genetic disorder, insulin receptor
mutations should be included in differential diagnosis of fasting hypoglycemia in children.
have FOXP3 mutations that lead to less severe disease. We recommend that a clinical suspicion for IPEX be raised in any male patient
with diabetes, particularly if they exhibit signs of immune dysregulation and skin findings.
P183
A novel mutation in a male infant with immune
dysregulation, polyendocrinopathy, enteropathy, Xlinked (IPEX) syndrome
P184
Missense mutation of GLIS3 gene resulting in
neonatal diabetes and congenital hypothyroidism
G. Karagüzel1, M. Abul2, A.H. Cebi3, R. Polat1, F. Orhan2
N. Algazir
1
Tripoli Medical Center, Tripoli, Libya
Karadeniz Technical University, School of Medicine, Pediatric
Endocrinology, Trabzon, Turkey, 2Karadeniz Technical University, School
of Medicine, Pediatric Immunology, Trabzon, Turkey, 3Karadeniz
Technical University, School of Medicine, Clinical Genetics, Trabzon,
Turkey
Background: Immune dysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX) syndrome is an early onset systemic autoimmune
genetic disorder caused by mutation of the forkhead box protein 3 (FOXP3) gene (Xp11.23), a key regulator of immune tolerance. We
report the case of a male infant with IPEX syndrome.
Case report: A 5-month-old male infant was referred to our clinic for
hyperglycemia. He was born at 40 weeks of an uneventful pregnancy.
He is the second child of nonconsanguineous healthy parents. His
elder brother was diagnosed as immune deficiency with hyper- immunoglobulin E and membranoproliferative glomerulonephritis. He was
admitted to our institute for pneumonia at three months. His serum
glucose level was elevated to 340 mg/dl during infection necessitating an insulin drip and the patient was fully recovered in 2 weeks
with HbA1c was 4.8%. His medical history was otherwise unremarkable. On examination; his weight was 7.3 kg (50. p), height 66.5 cm
(50.p), and no dehydration. He had cutaneous lesions compatible with
atopic dermatitis. On laboratory; serum glucose was 400 mg/dL with
normal blood gas, HbA1c 6.6 %, glucosuria, hemoglobin 8.5 gr/dL,
eosinophilia, and elevated immunoglobulin-E. Screening for other
endocrine dysfunctions was negative. He was diagnosed as neonatal
diabetes and treated with insülin. IPEX syndrome was considered
with all findings of the patient and his brother’s medical history.
Sequencing of the FOXP3 gene revealed a novel mutation in the
patient, his brother and his mother.
Conclusions: Our patient had not a severe enteropathy and recurrent
infections as the features of the classic phenotype of IPEX. It is
important to remember that a significant proportion of IPEX patients
Background: Neonatal diabetes is transient and usually resolves
between 6 and 18 months of life. In the remainder of cases, the diabetes is permanent.Mutations in the GLI-similar 3 (GLIS3) gene
encoding the transcription factor GLIS3 are a rare cause of permanent neonatal diabetes and congenital hypothyroidism with eight
affected cases reported to date.We are reporting first missense mutation in GLIS3 resulting in neonatal diabetes and congenital
hypothyroidism.
Objective and hypotheses: To evaluate & present non classical situation for a case of neonatal diabetes. As well as sequence correlation
between neonatal diabetes and hypothyroidism in missens mutation
in genetic studies.
Method: One infant Libyan female 6 weeks old, she was presented
with hypovolemic shock in ketotic state and markedly raised her
blood sugar 1020 mg /dl. Evaluations the patient clinically and
genetic studies was done were found first missens mutation resulting
in her condition.
Results: The homozygous mutation c.1924A > T (p.Ser642Cys), was
identified when the patient was tested for a monogenic etiology by
sequencing a panel of 13 genes associated with neonatal diabetes.
Patient now is at eight months of age with normal developmental
milestones, as well as physical development and requires 0.1-0.2
units/kg/day of basal insulin with HbA1c 6.3%.
Conclusion: This case extends the clinical spectrum associated with
mutations in GLIS3. We are describingthe first case of GLIS3 gene
missense mutation c.1924A > T (p.Ser642Cys) resulted in neonatal
diabetes and congenital hypothyroidism. Mutations in GLIS3 should
be considered in all children with neonatal diabetes without an established cause, irrespective of reported parental relatedness or insulin
requirements.
106
POSTER TOURS
Poster Tour 24: New Insulins and Pharmacologic Agents
P185
A comparative, systematic, meta-analysis of the
safety and efficacy of insulin degludec (IDeg). Does
IDeg confer any advantage over other long-acting
analogues in young patients with type 1 diabetes?
C. Mathews1, K. Gallagher1, C.L. Acerini1,2
1
Addenbrooke’s Hospital, Cambridge, United Kingdom, 2University of
Cambridge, Department of Paediatrics, Cambridge, United Kingdom
Objective: Insulin degludec (IDeg) is an insulin analogue with pharmacokinetic / pharmacodynamic properties that enable once daily
dosing anytime of the day. Several clinical trials have been reported
and IDeg has recently been approved for use in youth with Type 1 diabetes(T1D). However the utility of IDeg in T1D remains unclear.
This study sought to synthesise data from clinical trials to compare
the efficacy and safety of IDeg against other licensed long-acting
insulin analogues.
Methods: A systematic review (May 2016) using OVID, Medline,
EMBASE, CINAHL and SCOPUS databases. Data from randomised,
controlled trials in T1D were subjected to meta-analysis(Review Manager v5.3).Primary outcomes analysed: HbA1c, fasting plasma glucose
(FPG), adverse events (AE), hypoglycaemia rates and insulin dosing
requirements.
Results: Seven trials were identified (1 paediatric (age 1-18 yrs)vs.
detemir; 6 adult(median age 43,range 18-75 yrs)vs. 4 Glargine/2
Detemir). Compared to other long-acting analogues, IDeg showed
non-inferiority for HbA1c reduction(mean difference (MD)0.05%
[95% CI-0.02,0.12]p = NS)but superiority for reductions in FPG(MD:0.82 mmol/L [−1.42,-0.21]p0.008). There were no differences in
combined(RR:0.87 [0.62,1.20]) or severe hypoglycaemia rate(RR:-0.87
[−0.53,-1.44])(p = NS), whereas IDeg was associated with greater
reductions in nocturnal hypos(RR: −0.61[−0.47,-0.80]p = 0.0003),
basal insulin(MD:-0.06U/kg[−0.06, −0.05]p < 0.0001) and bolus insulin dose (MD:-0.01U/kg[−0.01,-0.00]p < 0.0001). There were no differences in AEs (total RR:0.95[0.86,1.06];Severe RR:1.28
[0.96,1.70]p = NS).
Conclusion: Compared to other long acting insulin analogues IDeg is
non-inferior for HbA1c reduction, but superior for lower FPG. IDeg is
associated with lower insulin dosing, reduced nocturnal hypo rate
and has a similar adverse events profile. Further data regarding youth
with T1D is needed but given IDeg’s pharmacological properties
results from adults studies are generalisable to children.
P186
Efficacy and safety of insulin degludec in children
and adolescents with type 1 diabetes
B. Predieri1, P. Bruzzi1, G. Maltoni2, S. Zucchini2, L. Iughetti1
1
University of Modena and Reggio Emilia, Department of Medical and
Surgical Sciences for Mothers, Children and Adults, Modena, Italy, 2S.
Orsola-Malpighi Hospital, Department of Pediatrics, Bologna, Italy
Objectives: Degludec (IDeg; Tresiba®) is a novel basal insulin
with an ultra-long, flat and stable action profile. In adults, it was
demonstrated to provide more glucose-lowering effects and
lower rates of hypoglycemia respect to glargine (IGlar). To date
studies on childhoods´ IDeg use are scarce. Aim of this study
was to assess the efficacy and the safety of IDeg in children
and adolescents with type 1 diabetes (T1DM) previously treated
with IGlar.
Methods: Twenty children and adolescents with T1DM (15.1 4.0
yrs; 9 males; 7 prepubertal; T1DM duration 7.2 3.7 yrs; IGlar treatment at least 1 year) were recruited in the study and shifted to IDeg
once daily. Anthropometric (BMI-SDS), metabolic [HbA1c, FPG, and
severe hypoglycaemia rates], and insulin dose [IGlar or IDeg plus
short-acting or regular] were collected at baseline (T0, during IGlar
treatment), 3 months (T1), and 6 months (T2) after IDeg was started.
Data were analysed according to pubertal status.
Results: BMI-SDS did not change on IDeg both in prepubertal and
in pubertal patients. Despite HbA1c values were not significantly
improved during IDeg treatment (ΔHbA1c T0-T1 -0.3%, p = 0.1;
T0-T2 -0.1%, p = 0.6), FPG was significantly decreased at T1
(−18.6 34.1 mg/dl, p = 0.05). No episode of severe hypoglycaemia was reported on IDeg. We found a significant reduction in
doses of both basal insulin (IGlar vs. IDeg: 21.8 8.9
vs. 19.4 7.8 IU/day, p = 0.003) and short-acting or regular mealtime insulin (T0 vs. T2 0.56 0.13 vs. 0.50 0.15 IU/kg/
day, p = 0.02).
Conclusions: In our patients, IDeg seems effective to improve the
glycemic control reducing FPG even at lower basal insulin doses
compared to IGlar. Moreover, it allowed the reduction of the dose
of mealtime insulin. No episode of acute complication was
reported suggesting how IDeg may be consider safe also in
childhood.
P187
Comparison of daily insulin dose in continuous
subcutaneous insulin infusion and multiple daily
injection therapies for children with type 1 diabetes
mellitus depending on severity of metabolic
disorder at disease onset
E. Evsyukova1, I. Kolomina1
1
Z.A. Bashlyaevoy Children’s Hospital, Moscow, Russian Federation
Objective: To analyze advantages of continuous subcutaneous insulin infusion (CSII) over the multiple daily injection (MDI) by giving children with type 1 diabetes mellitus multiple injections at disease
onset.
Methods: Participants of the study were 93 children with type
1 diabetes mellitus at disease onset and disease duration of
14–21 days since the date of initial diagnosis. Glycated hemoglobin (HbA1c) and acid–base balance were measured in all patients,
glycemic control was carried out 9 times per day. A nonparametric Mann–Whitney test criterion was used for statistics
processing.
Results: The patients were divided in two groups in accordance with
the generally accepted standards of ketosis and diabetic ketoacidosis
diagnostics: group 1 (n = 57, average age 9,7 3,4, average HbA1c
level of 9,5 1,5%) - ketosis, group 2 (n = 36, average age
9,16 4,1, average HbA1c level of 11,57 1,62%) - ketoacidosis.
The study has shown that the average daily dose of insulin in the
first group amounted to 0,37 0,19 U/kg, in the second group to
0,51 0,21 U/kg (p = 0,003).
In the first group 19 children have received CSII at an average daily
dose of 0,39 0,18 U/kg and 38 patients were treated with MDI
with an average daily dose of 0,36 0,2 U/kg (p = 0,57).
In the second group 12 patients have received CSII at an
average daily dose of 0,45 0,13 U/kg and 24 patients were
treated with MDI with an average daily dose of 0,54 0,23
U/kg (p = 0,29).
Conclusion: The daily dose of insulin for children with type 1 diabetes
mellitus at disease onset depends on the severity of the metabolic
disorder at the beginning of the therapy. CSII may be more effective
in cases of more significant metabolic disorders.
107
POSTER TOURS
P188
Dapagliflozin, an SGLT2 Inhibitor, induces a
transient decrease on BMI and insulin dose in
female adolescents with Type 1 Diabetes and
clinical hyperandrogenism
R. Roman1,2, N. Valdivia1, S. Ruiz2
1
University of Antofagasta, Faculty of Medicine and Odontology,
Antofagasta, Chile, 2Antofagasta Regional Hospital, Pediatric
Endocrinology Unit, Antofagasta, Chile
Dapagliflozin, an insulin-independent sodium-glucose cotransporter
2 inhibitor (SGLT2-I), increases glucosuria and reduces hyperglycemia
in subjects with T2D. The objective was to assess the effect of Dapagliflozin on body weight in 3 overweight female adolescents with
T1D, acne, hypertrichosis and normal androgen levels. Dapagliflozin
(10 mg per day) was prescribed during 12 months and the insulin
dose was adjusted. Patients were 15 2 years old, 3 1 years post
menarche and had attained near final height.
P189
The incidence of hyperglycemia and ketosis with
insulin degludec-based treatment compared with
insulin detemir in pediatric patients with type
1 diabetes: an analysis of data from two
randomized trials
N. Thalange1, L. Deeb2, G. Klingensmith3, D. Franco4, R. Hanas5,6,
L. Bardtrum7, P. Reiter7, T. Danne8
1
Norfolk & Norwich University Hospital, Jenny Lind Children’s Hospital,
Norwich, United Kingdom, 2Florida State University College of Medicine,
Tallahassee, United States, 3Barbara Davis Center for Childhood
Diabetes, Aurora, United States, 4CPCLIN, Sao Paulo, Brazil,
5
Gothenburg University, Sahlgrenska Academy, Uddevalla, Sweden, 6NU
Hospital Group, Dept of Pediatrics, Uddevalla, Sweden, 7Novo Nordisk
A/S, Søborg, Denmark, 8Children’s Hospital ’Auf der Bult’, Dept of
General Paediatrics, Hannover, Germany
Time (month)
Weight (kg)
BMI (kg/m2)
BMI (SDS)
HbA1c (%)
Insulin (U/day)
Glucose (mg/Dl)
Glucose (SD)
0
66,7
25,2
1,42
8,1
58
191
92
6
60,4
22,7
0,75
8,1
36
175
85
12
64,2
24,2
0,9
8,1
51
177
74
[Results shown as mean]
Capillary Beta-hydroxybutyrate was low or undetectable (range
0.0- 0.5) and none of the patients showed electrolyte disturbances or
urinary tract infections. Polydipsia, polyuria and dry mouth were
reported. One patient exhibited hand tremor but refused to discontinue the SGLT2-I. After 11,6 months on Dapaglifozin, one girl who
had showed a progressive reduction of Hba1c (8.3% to 7.5%) and
IMC SDS (0,85 to −0,05) developed an euglycemic diabetic ketoacidosis and treatment was stopped. After 6 months, all subjects reduce
their body weight (3.9; 6.7 and 8 kg respectively) and 2 girls exhibited
a reduction in body acne. After 12 months, two subjects exhibited a
partial rebound on IMC SDS. Interestingly blood glucose levels and
fluctuation were reduced but HbA1c did not improved in 2 out of
3 subjects. Insulin dose and body weight were reduced after 6 months
on Dapagliflozin without metabolic deterioration in 3 adolescents
with T1D; whereas a partial rebound on both parameters was seen
after 12 months on treatment. Adverse drug side effects as euglycemic ketoacidosis and hand tremor may appear. Randomized controlled trials are needed. Our findings provide hope that SGLT2
inhibition might be an effective adjuvant to insulin treatment in overweight adolescents with T1D.
Objectives: To assess the incidence of hyperglycemia and episodes
of ketosis in two phase 3b trials investigating insulin degludec (IDeg;
NN1250-3561 [Study 1]) and insulin degludec/insulin aspart
(IDegAsp; NN5401-3816 [Study 2]), which both have a long duration
of action due to the IDeg component, versus insulin detemir (IDet) in
pediatric patients with type 1 diabetes.
Methods: Patients aged 1–18 years were randomized to IDeg OD or
IDet OD or BID for 26 weeks in Study 1 and IDegAsp OD or IDet
OD or BID for 16 weeks in Study 2. All treatment arms received IAsp
as mealtime insulin. In Study 1, hyperglycemia was recorded if plasma
glucose (PG) was >11.1 mmol/L (200 mg/dL); in Study 2, hyperglycemia was recorded if PG was >14.0 mmol/L (250 mg/dL) where
patient looked/felt ill. In both trials, capillary blood ketones were to
be measured if PG was >14.0 mmol/L.
Results: Due to the different criteria for recording hyperglycemia,
there was a difference in the rate of hyperglycemic episodes between
the trials (Table 1). Lower rates of ketosis (self-measured ketones
>1.5 mmol/L) were observed with IDeg than IDet, reaching statistical
significance in Study 1 (Table 1). In both studies, lower rates of ketosis per patient year of exposure (PYE) were observed with IDeg than
IDet for ketone levels of >0.6, >1.5 and >3.0 mmol/L (Table 1).
Number of episodes per PYE
Trial arm (n)
Hyperglycemia†
Episodes of ketones
>0.6 mmol/L
Episodes of ketones
>1.5 mmol/L
Episodes of ketones
>3.0 mmol/L
Study 1
IDeg + IAsp
(n = 174)
364.3
3.46
0.51
0.02
(26 weeks)
IDet + IAsp
(n = 175)
368.3
6.90
1.02
0.19
Rate ratio (95% Cl) for IDeg vs IDet (FAS)
0.99 (0.84;
1.15)
NA
0.36 (0.17; 0.76)*
NA
Study 2
IDegAsp + IAsp
(n = 181)
10.94
0.37
0.11
0.04
(16 weeks)
IDet + IAsp
(n = 179)
8.33
0.76
0.24
0.07
1.08 (0.64;
1.81)
NA
0.44 (0.11; 1.74)
NA
Rate ratio (95% Cl) for
IDegAsp vs IDet (FAS)
*
p < 0.05. †Hyperglycemia: espisodes with PG >11.1 mmol/L (200 mg/dL) (study 1); PG >14.0 mmol/L (250 mg/dL) where patient looked/felt ill (Study
2). FAS, full analysis set; IDeg, insulin degludec; IDgeAsp, insulin degludec/insulin aspart; IDet, insulin detemir; NA, not available; PG, plasma glucose;
PYE, patient years of exposure.
108
POSTER TOURS
Conclusions: These data demonstrate the potential of IDeg in preventing hyperglycemia and ketosis in children and adolescents with
type 1 diabetes.
[Table]
P190
Ultra long-acting degludec versus long-acting
insulin glargine in children and teenagers with type
1 diabetes
A. Bosco1, R. Cardani2, A. Moretti1, A. Trettene1, A. Salvatoni1,2
2
1
University of Insubria, DSCM-Pediatric Unit, Varese, Italy, ASSTSettelaghi, Mother & Child Department - Pediatric Unit, Varese, Italy
Objectives: Unstable metabolic control and frequent hypoglycemic
events are the main indications of switching from long-acting insulin
glargine to ultra long-acting insulin degludec. The aim of the present
study is to evaluate the efficacy of such a switch in children and
adolescents.
Methods: We enrolled retrospectively 58 children and adolescents
with type 1 diabetes divided into two groups matched for age, sex
and metabolic control. Group A was switched from glargine to degludec while group B continued treatment with glargine. We compared
HbA1c, percent of BG detections below 60 mg/dl, mean and SD of
home blood glucose monitoring (HBGM), HBGI and LBGI during the
three months before and after switching from one to the other insulin in group A and during the corresponding period in group B. Data
are reported as median (IQR). Chi square and Mann–Whitney test
were used for statistical analysis.
Results: During the three months after switching the percentage of
patients who improved the HbA1c was higher in group A then in
group B. We didn’t find any statistical significant difference between
the two groups for any parameter taken into account. In particular
group A didn’t showed any statistically significant reduction of hypoglycemic events after switching (see table).
Conclusions: According to our preliminary results the transition from
long-acting insulin glargine to insulin ultra long-acting degludec in
pediatric patients with T1DM does not seem to be able to significantly improve the metabolic control and reduce the risk of
hypoglycemia.
[Results]
P191
The effect of adding metformin to insulin therapy
for type 1 diabetes mellitus children: a systematic
review and meta-analysis
R. Al Khalifah1, A. Alnhdi2, H. Alghar2, M. Alanazi2, I.D. Florez3,4
King Saud University, Pediatrics, Riyadh, Saudi Arabia, 2King Saud
University, Riyadh, Saudi Arabia, 3Universidad de Antioquia, Pediatrics,
Antioquia, Colombia, 4McMaster University, Clinical Epidemiology and
Biostatistics, Hamilton, Canada
1
Background: Although its prescription is off-label in children
with T1DM, metformin has been used to improve features of insulin
resistance. We aimed to synthesize the evidence of metformin effectiveness in addition to insulin in T1DM children in improving metabolic outcomes, and features of insulin resistance.
Methods: We performed a systematic review and meta-analysis of
randomized controlled trials evaluating the effectiveness of metformin
addition to insulin therapy compared to placebo in T1DM children age
6–19 years. We performed literature searches through Ovid Midline,
Ovid Embase, and Cochrane Central Register of Controlled Trials
(CENTRAL) from the database inception date to February 15, 2016,
and grey literature search. Two reviewers screened titles and abstracts
independently, assessed full text eligibility, and extracted the data. We
performed meta-analysis using fixed effects model and reported effect
estimates with 95% confidence interval (95%CI). Quality of the evidence was assessed with GRADE Approach.
Results: We screened 727 studies, and included 6 RCTs with
324 patients. These had low risk of bias design and included adolescents (mean age 15 years). The meta-analysis showed that the addition
of metformin compared to placebo resulted in similar HbA1C(mmol/
mol)(mean difference [MD] = −0.04, 95%CI,-0.27, 0.19), BMI(kg/m2)
(MD = −0.13 95%CI,-0.65, 0.40), severe hypoglycaemia (OR = 3.82,
95%CI, 0.73, 19.90), and DKA(OR = 1.94, 95%CI,0.43,8.80). However,
metformin decreased total insulin daily dose(TIDD) (unit/kg/day)
(MD = −0.16, 95%CI,-0.21,-0.11), and reduced BMI z-score
(MD = −0.11, 95%CI −0.21, −0.01) . No trial reported health related
quality of life scores. The evidence quality was moderate to low.
Conclusions: Current evidence does not support use of metformin in
T1DM adolescents to improve metabolic outcomes. However, Metformin may provide modest reduction in TIDD and BMI z-score.
PROSPERO registration:CRD42016035914.
HBA1c basal and after switch [n(%);ΔHbA1c]
% of hypoglycemic events (%BG < 60 mg/dl)
Improved
Unchanged
Worse
Basal
After switch
Group A
16(55); 0.4(0.5)
4(14)
9(31); 0.6(0.8)
3.5(5.9)
3.1(5.0)
Group B
9(31); 0.4(0.6)
7(24)
13(45); 0.4(0.4)
4.6(6.4)
3.5(3.9)
p
NS
NS
109
POSTER TOURS
Poster Tour 25: Psychosocial Issues
P193
Gambling with their health: a pilot study examining
risks that adolescents take with their diabetes
management
C. Gonynor1, Y. Rojas1, B. Anderson1, D. Schwartz1, R. Wasserman1
1
Baylor College of Medicine and Texas Children’s Hospital, Psychology,
Houston, United States
Objective: Because general risky behavior (e.g., reckless driving,
binge drinking) peaks in adolescence, adolescents may also take risks
with their diabetes care (e.g., going 24 hours without insulin, feeling
blood glucose might be low and not checking). These types of diabetes-specific risk-taking behaviors have not been previously researched.
The aim of the current study was to describe youths’ experiences
with more commonly occurring diabetes-specific risk-taking
behaviors.
Method: Thirty adolescents with T1D (age 15–19, 60% female, M
A1c = 8.7 1.4%) reported on how often they engaged in 38 behaviors that place them at risk for adverse events or poor glycemic control, using the newly developed Diabetes-Specific Risk-Taking
Inventory (DSRI, α = .92). Semi-structured interviews were conducted
with 4 different youth (age 17–19, 1 female and 3 males). The interviews were transcribed and themes were determined with qualitative
thematic analysis.
Result: Using a cut-off median score of 3, 15 diabetes-specific risktaking behaviors were identified as occurring at least every few
months, for at least 50% of the sample. Thematic analysis focused on
youth responses to these 15 most frequently occurring behaviors.
The overall theme of “reducing burden” (reducing the amount of
effort or time spent on diabetes management tasks) was derived from
the qualitative data. For example, adolescents spoke about ignoring
pump alarms in the middle of night to continue sleeping and trusting
physical symptoms of hypoglycemia rather than checking blood
glucose.
Conclusion: For the most commonly occurring diabetes-specific risktaking behaviors, adolescents risk poor health outcomes in order to
lighten the load of diabetes management. Understanding what risks
adolescents take with their diabetes management and why they take
them may help inform clinical intervention to decrease risk-taking
and prevent adverse health outcomes.
P194
The impact of secondary caregivers (SCs) on
parental burden in the management of type
1 diabetes (T1D) in children < 8 years old
A. Whitehouse1, P. Commissariat1, M. Hilliard2, K. Harrington1,
K. Miller3, M. Mantravadi4, M. Van Name5, B. Anderson2,
W. Tamborlane5, L. DiMeglio4, L. Laffel1
1
Joslin Diabetes Center, Boston, United States, 2Baylor College of
Medicine, Houston, United States, 3Jaeb Center for Health Research,
Tampa, United States, 4Indiana University School of Medicine,
Indianapolis, United States, 5Yale School of Medicine, New Haven,
United States
Objectives: Care of T1D in children < 8 y/o places burden upon parents who are the primary caregivers; non-parent SCs can help parents
with care, potentially reducing burden while adding to parental worry.
Understanding parental perceptions of SCs can help improve support
for families of young children with T1D.
Methods: Semi-structured qualitative interviews were conducted
with parents (85% mothers) of 79 youth aged 1 to < 8 y/o with
T1D for ≥6 months (mean age 5.2 1.5y, T1D duration 2.4 1.3y,
77% white, A1c 7.9 0.9%, 66% pump-treated). Interview transcripts were coded and evaluated using content analysis to derive
central themes. Parents also completed surveys on healthcare
needs.
Results: Parents cited constant vigilance as a major burden and
endorsed SCs as a potential means to alleviate burden associated
with T1D management. Three themes emerged: 1) difficulty finding
SCs willing to provide T1D care, particularly for youth using injections
without diabetes technologies (pumps, CGM); 2) difficulty trusting
SCs with their child’s care due to worries about SCs’ T1D knowledge
and ability to identify or treat fluctuating BGs; 3) intentionally raising
the child’s target BG range when in the care of SCs in order to reduce
parental worry about the SCs’ ability to identify and treat hypoglycemia in a timely way. Notably, 89% of parents endorsed needing help
within the previous 6 months to educate school/childcare personnel.
Conclusions: While SCs may help care for young children with T1D,
these findings suggest that parents have concerns about their young
child’s safety with SCs and may need assistance in training SCs.
Structured SC education in T1D care of young children may help
reduce parental worries and enhance parents’ confidence in SCs’ ability to manage T1D. Use of diabetes technologies may also facilitate
management by SCs. In turn, glycemic control may improve if SC
education mitigates the parental desire to increase the child’s target
BG range while with SCs.
P195
Quality of life in type 1 diabetes and coeliac
disease: role of the gluten-free diet
A. Pham-Short1,2, K.C. Donaghue1,2, G. Ambler1,2, S. Garnett1,2,
M.E. Craig1,2,3
1
The Childrens Hospital at Westmead, Institute of Endocrinology and
Diabetes, Sydney, Australia, 2University of Sydney, Discipline of
Paediatrics and Child Health, Sydney, Australia, 3University of New
South Wales, School of Women’s and Child Health, Sydney, Australia
Objective: To examine quality of life (QoL), glycemic control and gluten free diet (GFD) adherence in youth with type 1 diabetes (T1D)
and biopsy confirmed coeliac disease (CD) vs T1D only.
Methods: Case–control study of 35 youth with T1D and 35 with
T1D + CD matched for age, T1D duration, gender and A1C. QoL was
assessed in youth and parents using the PedsQL Generic Core Scale,
PedsQL Diabetes Module and the General Well Being Scale; those
with T1D + CD also completed the CD-specific CDDUX questionnaire and parents completed the PedsQL Family Impact Scale. Questionnaires were scored from 0–100, higher scores indicate better
QoL or well-being. Scores were compared between T1D vs T1D +
CD using Mann–Whitney U tests, with subgroup analyses by GFD
adherence vs non-adherence and CSII vs MDI in those with
T1D + CD.
Results: Overall mean age was 13.6 3.0 years, T1D duration
7.6 3.1 years, female gender 56% and CSII use 70%, with no differences between T1D + CD vs T1D. CD duration was 4.6 2.7
years, diagnosed at mean age 9.1 3.5 years. Based on dietitian
review and celiac titers, 69% were classified as GFD non-adherent.
Youth with T1D + CD reported similar generic and diabetes-specific
QoL to T1D only. GFD non-adherent vs adherent youth reported
lower diabetes-specific QoL (mean score 58 vs 75, p = 0.003) and
lower general well-being (57 vs 76, p = 0.02), as did their parents
(50 vs 72, p = 0.006), while A1C was higher (9.6 vs 8.0% / 81 vs
64 mmol/mol, p = 0.02). Youth with T1D + CD using CSII vs MDI
reported similar generic and diabetes-specific QoL and A1C (8.6 vs
8.2% / 70 vs 66 mmol/mol, p = 0.44), but were unhappier having to
follow a lifelong diet (59 vs 29, p = 0.007).
Conclusions: While overall QoL is not worse in youth with T1D +
CD, those who do not adhere to the GFD have lower QoL and
worse glycemic control. Novel strategies are required to understand
and improve adherence in youth living with both conditions.
110
POSTER TOURS
P197
Identity formation in youth with type 1 diabetes
M. Verschueren1, L. Oris1, L. Claes1, P. Moons1,2, I. Weets3,
K. Luyckx1
1
KU Leuven, Leuven, Belgium, 2Gothenburg University, Gothenburg,
Sweden, 3Brussels Free University, Brussels, Belgium
Introduction: Adolescents and emerging adults with type 1 diabetes
(T1D) are confronted with illness-related stressors that may hinder
important developmental tasks. As T1D may challenge the ability to
become autonomous and to construct a personal identity, the present
study investigated personal identity formation in these patients, and
how it is related to psychosocial and diabetes-specific functioning.
Methods: A total of 431 patients with T1D (aged 14–26; 53.1%
female) and community controls (matched 1:1 on age and gender)
reported on identity, well-being, diabetes-specific problems, treatment adherence, and illness perceptions. HbA1c-values were
obtained from the treating physician.
Results: Using cluster-analysis on both adaptive and maladaptive
identity processes, six identity types or statuses were identified in
line with community research (achievement, foreclosure, moratorium,
troubled diffusion, carefree diffusion, and undifferentiated), with
patients and controls being equally distributed. Whereas achievement
and foreclosure constitute more adaptive identity statuses characterized by strong identity commitments, especially troubled diffusion is
a maladaptive identity state characterized by identity rumination and
a lack of firm choices. Using analyses of variance, patients in foreclosure and achievement (both characterized by high identity commitments) presented with the most adaptive psychosocial and diabetes
functioning. In contrast, patients in troubled diffusion and, to a lesser
extent, moratorium (both characterized by a maladaptive or ruminative type of exploration) showed the least adaptive scores on wellbeing, diabetes-specific problems, treatment adherence, and illnessperceptions.
Conclusion: The present study underscores the importance of assessing identity issues in youth with T1D making the challenging transition to adulthood. Hence, identity comprises an important clinical
factor to consider in diabetes counseling and treatment.
P198
Treatment adherence in children with type
1 diabetes: the role of patient and parental
executive functioning
E. Goethals1,2, K. Luyckx1, K. Casteels1,2, J. Lemiere1,2, D. Van
Liefferinge2, J. Laridaen3, N. Van Broeck2
University Hospital Leuven, Leuven, Belgium, 2University of Leuven,
Leuven, Belgium, 3Ghent University, Ghent, Belgium
1
Objective: Managing type 1 diabetes(T1D) requires the ability to
make complex and critical decisions regarding treatment, to execute
complex tasks accurately and to make adjustments when problems
arise.This requires effective neuropsychological competencies of
patients and their families, especially in the domain of executive
functioning (EF). EF refers to a set of skills necessary for independent,
purposeful, goal-directed activity (e.g., the ability to self-monitor,plan,
solve problems,set priorities). Research on this matter in T1D is
scarce and has focused mainly on EF in young patients, leaving the
role of parental EF unaddressed.This multi-informant study examined
associations and interactions between child and parental EF and
treatment adherence in T1D.
Methods: 284 patients with T1D (6–18 years old) were included.
229 mothers and 163 fathers parents filled out questionnaires on
child and parental EF and on treatment adherence. Of the 11–18
year olds, 136 young patients filled out self-reports as well. Analyses
within and across informants examined the associations between
patient and parental EF and treatment adherence (and potential moderation effects in these associations).
Results: Overall, especially child EF was consistently and clearly
associated with treatment adherence (between and across informants). Moreover, there was a consistent interaction effect between
child and parental EF in the prediction of treatment adherence. For
instance, child EF had an effect on treatment adherence especially
when parental EF was good.
Conclusions: This multi-informant study adds to current knowledge
about treatment adherence by implementing not only child but also
parental EF. As the present study demonstrates the significant role of
child as well as parental EF, researchers and clinicians should remain
attentive towards the role of neuropsychological concepts such as EF
in the domain of T1D. Implementation in clinical practice seems necessary and meaningful.
P199
Turkish version of the diabetes eating problem
survey-revised on adolescents with type 1 diabetes
mellitus
Y. Atik Altinok1, S. Ozen1, S. Darcan1, D. Goksen Simsek1
1
Ege University, Department of Pediatric Endocrinology and Diabetes,
Izmir, Turkey
Aim: To examine the reliability and validity of the Turkish version of
Diabetes Eating Problem Survey-Revised (DEPS-R) for adolescent
with Type 1 Diabetes (T1D).
Methods: DEPS-R is a 16-item self-report questionnaire to measure
general and diabetes-specific DEBs.The factorial structure of the
Turkish version of DEPS-R was examined by confirmatory factor
analysis (CFA) and the internal consistency was tested using Cronbach’s / coefficient.
Results: Table 1 illustrates characteristics of the study participants.
DEPS-R correlated positively with age,BMI-SDS, HbA1c, no correlation was found with diabetes duration.
[Characteristics of Study Participiants]
The Cronbach / coefficients for the Turkish version of DEPS-R
were 0.856, 0.858 and 0.857 for the entire sample, females and
males respectively.Three components were identified, explaining
52.4% of the total variation.Factor 1 was the most dominant
factor,explaining 34.3% of the variance.Factors 2 and 3 explained
Female
Male
Total
n
98
77
175
Age(years)
14.0(9.0-18.0)
14.0(9.0-18.0)
14.0(9.0-18.0)
HbA1c(%)
8.1(5.5-15.0)
8.1(5.9-13.3)
8.1(5.5-15.0)
Diabetes duration(month)
71(12–188)
60(12–210)
76(12–210)
DEPS-R score
11.5(0–55)
11.0(0–55)
11.0(0–55)
BMI-SDS
0.16 1.27*
−0.11 1.24*
0.04 1.26*
BMI-SDS Insulin pump therapy, %
25.5
33.8
29
P Value
Þ
0.411
Þ
0.303
Þ
0.247
Þ
0.263
0.140**
ÞÞ
0.233
Data are medians (min-max),unless otherwise indicated. BMI:Body Mass Index,SDS:Standard Deviation Score,DEPS-R:
Diabetes Eating Problem SurveyÞ
Revised.P values refer to the significance of the difference between males and females. *Mean SD Mann Whitney U test**Independent sample t
ÞÞ
test, Chi-Square test
POSTER TOURS
9.2% and 8.8% of the variance,respectively.Although our model identified three factors,it is difficult at this point to establish obvious subscales related to these three factors.F1 appears to address
maladaptive eating habits, F2 the concerns about weight and
thinness,and F3 the approach of maintaining high blood glucose
values to lose weight.After the suitability of data for factor analysis
was assessed,CFA was performed on the 16 items of the DEPS-R.
Compliance was determined between the main factors and
subscales(RMSEA = 0.076).
Conclusion: Short,self-report measure designed to screen DEB will
be useful for clinicians.
P200
Understanding barriers to self-management among
Latino adolescents with type 2 diabetes
N. Chang1
1
Children’s Hospital Los Angeles, Endocrinology & Metabolism, Los
Angeles, United States
Type 2 diabetes mellitus (T2DM) is a growing problem among Latino
adolescents. An even bigger problem is the lack of adherence to selfmanagement of the disease in this population. Little is known about
what adolescents perceive as barriers to their diabetes care. This
111
study will elicit descriptions of diabetes self-management strategies
and decision-making used by Latino adolescents and will develop an
explanatory framework of T2DM self-management among these
youth. This study used grounded theory in a qualitative design to
explore and understand the barriers and facilitators to effective diabetes self-management from the perspective of Latino adolescents
with T2DM. Twenty eight children and adolescents ages 14–20 participated in focus groups or individual interviews. We found barriers
and facilitators to diabetes care. The management of diabetes has
multiple levels of influence that are affected by intrapersonal, interpersonal, community and societal factors. One of the major findings
in this qualitative data is the impact that “Lack of diagnosis acceptance” has as a barrier to positive diabetes self-management behaviors. Diabetes management during adolescence is challenging due to
many physical, psychological and cognitive changes. In order to avoid
diabetes related complications and lifelong consequences to the
health of these individuals, it is necessary to understand how to overcome the barriers to diabetes self-management. The research findings
of this study will help guide the development of culturally and age
appropriate interventions to address the psychological needs of these
adolescents and help them to accept the diagnosis of T2DM. Acceptance of the diagnosis by the adolescent and the acceptance of the
parental responsibilities in diabetes care are essential to improve selfmanagement adherence and consequently improve metabolic control
within Latino adolescents.
112
POSTER TOURS
Poster Tour 26: Latebreakers
P201
Assessment of environmental factors and the risk
of type 1 diabetes in children in Minia Governorate,
Egypt; case–control study
B. Ali1, M. Elfoly1, E. Ramadan2, R. Bersom1
1
Minia University/Faculty of Medicine, Pediatric Department, Minia,
Egypt, 2Minia University/Faculty of Medicine, Community, Minia, Egypt
Introducion: Type 1 diabetes results from an interaction of genetic
and environmental factors that triggers the autoimmune destruction
of insulin-producing pancreatic beta-cells. Discovering those genetic
and environmental risk factors and determining how they interact to
cause disease are key steps toward being able to identify individuals
who areat risk for T1DM and accurately assess their specific level
of risk.
The aim of the work: was to determine the environmental risk factors of type 1 diabetes mellitus among children in Minia governorate.
Subjects and Methods: Our study was carried out on 220 child aged
from 2–16 years old were classified into 110 diabetic patients and
110 control group, age and sex matched.A special questionnaire was
designed for the purpose of the study.It included:Through history
taking ( present history, family history ,perinatal , natal and postnatal
history, feeding history , vaccination history and history of early childhood illness).Full clinical examination.
Results: The results of this study showed that there were many environmental factors which play a very important role in precipitation of
T1DM among children, those factors are ; maternal factors such as ;
age,gestational diabetes and patient´s factors such as early neonatal
illness(RDS and prematurity), short duration of breast feeding, early
introduction of cow milk and gluten, lack of vitamin D supplementation, early childhood viral infection especially mumps and allergies.
Conclusion: Exposure to environmental risk factors in genetically
predisposed persons during pregnancy, neonatal period and early
childhood are thought to play an important role in triggering the
immune process leading to the development of T1DM.
P202
Clinical characteristics and mortality rate in
pediatric diabetic ketoacidosis
Y.J. Kim1, M.S. Kim2, D.-Y. Lee2
1
Chonbuk National University Hospital, Jeonju-Si, Korea, Republic of,
Chonbuk National University Medical School, Jeonju-Si, Korea,
Republic of
2
Objectives: Diabetic ketoacidosis (DKA) is a serious complication of
acute pediatric type 1 diabetes mellitus (T1DM). This study aimed to
determine the risk factors and clinical aspects of DKA.
Methods: Children hospitalized for DKA between January 2004 and
December 2014 were included. Cases were classified as mild, moderate, or severe according to clinical and laboratory results collected
during that time period. Statistical significance was defined
as P < 0.05.
Results: Fifty-nine DKA cases (pH ≤ 7.3) were confirmed in
43 patients. The average age was 11.98 4.40 years (range, 1.319.9 years). Thirty-one patients had previously experienced DKA.
DKA was most frequent in moderate cases (21 cases, 35.6%), followed by severe (19 cases, 32.2%) and mild cases (19 cases, 32.2%).
Clinical manifestation did not differ; however, severe cases exhibited
more aggravated metabolism such as hyperglycemia, elevated corrected serum sodium, and effective serum osmolality. Female patients
experienced severe and moderate cases more frequently (P = 0.041).
Hemoglobin A1c levels did not differ between initial and recurrent
cases. Two female patients (11.2 and 13.4 years) died with symptoms
of brain edema. The mortality rate was 3.39% (2/59). Only blood
sugar level differed significantly between surviving and non-surviving
cases (P = 0.022).
Conclusion: In this study, no statistically significant differences were
identified between surviving and non-surviving cases other than
blood sugar levels. However, female patients should be carefully diagnosed and treated. Proper blood sugar level maintenance and continuous education are needed, especially in summer, even for previously
diagnosed and insulin-treated T1DM patients.
P203
Hospitalization risk in children and adolescents with
or without type 1 diabetes from Germany: an
analysis of statutory health insurance data on
12 million subjects
B. Bohn1,2, A. Schwandt1,2, P. Ihle3, A. Icks2,4,5, J. Rosenbauer2,6,
B. Karges2,7,8, R.W. Holl1,2
1
University of Ulm, Institute of Epidemiology and Medical Biometry,
ZIBMT, Ulm, Germany, 2German Center for Diabetes Research (DZD),
Munich-Neuherberg, Germany, 3University of Cologne, PMV Research
Group at the Department of Child and Adolescent Psychiatry and
Psychotherapy, Cologne, Germany, 4Heinrich-Heine-University
Düsseldorf, Faculty of Medicine, Institute of Health Services Research
and Health Economics, Düsseldorf, Germany, 5Paul Langerhans Group of
Health Services Research and Health Economics, German Diabetes
Center, Leibniz Center at University of Düsseldorf, Düsseldorf, Germany,
6
Leibniz Center for Diabetes Research at University of Düsseldorf,
Institute for Biometrics and Epidemiology, German Diabetes Center,
Düsseldorf, Germany, 7RWTH Aachen University, Division of
Endocrinology and Diabetes, Medical Faculty, Aachen, Germany,
8
Bethlehem Hospital, Department of Pediatrics, Stolberg, Germany
Objective: To compare the hospital admission risk in children and
adolescents with type 1 diabetes (T1D) with that of the general pediatric population from Germany.
Methods: Data were provided by the German information system
for health care data which contains information on all patients with a
statutory health insurance (DaTraV/DIMDI). Data from the year 2011
were used. Children and adolescents (0- ≤ 19 years of age;
n = 12,030,242) were included in this analysis. To identify subjects
with T1D, the ICD-coded diagnosis from the inpatient and outpatient
sectors, and insulin use based on ATC-code were applied. Demographic characteristics were compared between subjects with
(n = 26,444) or without T1D (12,003,798). Unadjusted odds ratios
(OR) with 95% confidence interval (95%-CI) were used to compare
the hospitalization risk for patients with or without T1D. The study
population was stratified by age-groups (0- ≤ 5; >5- ≤10; >10- ≤15,
and >15- ≤ 19 years). A p-value < 0.01 was considered significant.
Data processing and statistics were implemented with SQL.
Results: The mean age ( SD) of the general pediatric population
was lower compared to that of children with T1D (10.4 5.5
vs. 13.2 4.3; p < 0.0001). Slightly more girls were documented in
children without T1D (48.7% vs. 47.3%; p < 0.0001). In all agegroups, the hospitalization risk in children and adolescents with T1D
was higher compared to that of their counterparts. The highest risk
was observed in >5- ≤ 10 year olds (OR 8.1; 95%-CI: 7.7 to 8.5), followed by patients >10- ≤ 15 (OR 7.4; 95%-CI: 7.1 to 7.7) and
patients ≤5 years of age (OR 5.3; 95%-CI: 4.8 to 5.7). Compared to
the general pediatric population, the lowest risk was indicated in
patients >15- ≤ 19 years of age (OR 4.0; 95%-CI: 3.9 to 4.2).
Conclusions: Children and adolescents with T1D from Germany had
a 4 to 8 times higher hospitalization risk compared to the general
pediatric population. High rates of elective hospital admission may
contribute to these results.
113
POSTER TOURS
P204
Management of childhood diabetes in Morocco:
descriptive study of the current situation in public
centers
F.Z. Mouzouni1, S. Abourazzak2, F. Jennane3, A. Iferghas1, Z. Imane4
1
Ministry of Health/Morocco, Direction of Epidemiology and Disease
Control, Rabat, Morocco, 2Hassan II University Hospital, Sidi Mohammed
Ben Abdellah University, Department of Pediatrics, Fez, Morocco, 3Ibn
Rochd University Hospital, Mohammed VI University, Department of
Pediatrics, Casablanca, Morocco, 4Ibn Sina University Hospital,
Mohammed V University, Department of Pediatrics, Rabat, Morocco
Objectives: Childhood diabetes represents a public health issue in
Morocco, with an estimated 15 000 patients. In 2013, Ministry of
Health (MoH) signed a partnership with Sanofi to create dedicated
centers and to model its care management. First step was to evaluate
the current situation in public centers.
Methods: This was an observational, multi-centric, cross-sectional
study conducted in 2014. The steering committee, composed of T1D
medical experts, epidemiologists and representatives of public health
departments, validated a standardized questionnaire including: Management Care, Human Resources, Medicines and Education, Information System. The study was implemented in 30 centers including
3 university hospitals, representing 11 regions of the Kingdom (70%).
A descriptive analysis was performed using Epi info 3.5.3.
Results: 4140 patients were monitored in the 30 centers. 87% of
them were treated in University Hospitals. In these 3 centers, 90% of
patients were under 18 years old. In the other centers, 85% of the
patients were over 18. In terms of human resources, only 3 centers
have a multidisciplinary team with pediatrician, nurse and dietician.
Teams don’t receive regular trainings.
80% of used insulin used are human insulins in vials delivered by
the MoH.
Educational sessions are organized in 85% of the structures; only
31% of them have a dedicated education room. 68% of the centers
have no standardized diabetes educational program.
All have a data base, but only 50% of them generate data analysis,
mainly due to a lack of human resources and/or a lack of training.
Conclusion: There is clearly a need to improve staff training, and
implement standardized treatment regimen and education program.
MoH and steering committee have decided to initiate a standardized
program for childhood diabetes with the support of Sanofi. A training
program for health care professionals and patient education tools will
be implemented in three pilot centers between 2016 and 2017.
P205
A study of type 1 diabetes mellitus from South
India
M. Ayyagari1
1
Diabetic Child Society, Visakhapatnam, India
Objective: Diabetes in children is increasing and data is sparse and
resources are poor in many parts of the country. The aim of this study
is to describe the clinical profile and follow up of Type 1 Diabetes in
young attending the Diabetic Child Society over the last 1.5 years.
Material and Methods: The diabetic child society aims to support
needy children with diabetes and improve health care of diabetes in
the young. A total of 218 subjects with diabetes onset below the age
of 25 years are enrolled and screened for glycemic control, complications , comorbidities and self managment issues are addressed.
Results: Males (100) and females (118) with mean age of 17.5 years
and mean duration of diabetes of 7.2 year are the subjects of the
study. 16% had A1c < 7.5%, 46% had A1c between 7.5 -9% and 38%
had A1c >9%.Ocular complications were seen in 12% and include
NPDR , PDR , Cataract , Glaucoma and Optic atrophy . .Diabetic Kidney Disease (DKD) is seen in 9%of the subjects. Ocular and renal
complications are associated with long duration of diabetes and
higher A1c. Episodes of Diabetic Ketoacidosis (DKA) are seen in 7%
and Mortality is 1.8%.
The co-morbidities are: Hypothyroidism (12%), Epilepsy (2.3%),
PCOS (2.3%). Syndromes are: DIDMOAD (5), Down’s syndrome (1),
Turner’s syndrome (1), SHORT (2). 10% have family history of Type
1 diabetes among siblings. Frequency of SMBG revealed that only
58% monitor regularly and barriers to insulin therapy exist.
Conclusion: The diabetic child society aims to support improve
health care of Type 1 diabetes in young. The higher A1c, complications and frequent hospitalizations are due to non-adherence to therapy due to lack of awareness,, low socioeconomic status, illiteracy,
lack of parental and psychosocial support. SMBG iand insulin are
underused despite free supply. The society is endeavouring to
address these issues and being nascent still would take time to reach
optimum goals and hopes to attain in future.
P206
A study of insulin injection practices among
patients attending OPD of a tertiary care hospital in
Davangere, Karnataka, India
A. Nadig1, P.S. Balu2, R. Valaulikar2
1
J J M Medical College, Internal Medicine, Davangere, India, 2J J M
Medical College, Community Medicine, Davangere, India
Objectives: 1. To assess practices concerning insulin-injection among
patients taking insulin
2. To identify the correlates of each incorrect insulin injection practice among patients taking insulin
Methods:
Source of data: As majority of diabetes patients get treatment in the
medicine OPDs, this will be the source of collecting data. Permission
will be obtained from the Medical Director to carry out this study in
the OPD
Sampling procedure: As the proportion of patients incorrectly adopting various components of insulin injection practice varies across
studies, an estimated proportion of 50% is adopted for the purpose
of calculating the highest required sample size. With a power of 80%
and 95% confidence interval and considering an absolute precision of
10%, the sample size comes to 96. Considering a non-response rate
of 10%, it is calculated to be 106.
Study subjects: Type-1 or Type-2 diabetes patients on insulin
therapy
Study design: A cross sectional descriptive study.
Study period: 2months between 1-08-2015 to 30-09-2015
Statistical analysis: Descriptive analysis of the data will be done
using means, proportions and percentages. The association between
variables of interest will be done using both bivariate (Chi-square and
Fisher exact test) and multivariate tests.
Results: Nearly 3% of patients reported always injecting into lipohypertrophic lesions and 26% inject into them sometimes. Of the 65%
of patients using cloudy insulins , 35% did not remix it before use.
Conclusions: Correct choice of type of insulin, dose and adherence
to insulin treatment is known to control blood sugars effectively, correct injection practices is equally effective in the control of hyperglycemia. As patients under insulin therapy are required to take
repeated injections, the techniques that patients adopt for storing,
mixing and injecting this drug, play an important role in patient’s
response to insulin therapy, if done wrongly are known to be associated with a poor glycemic control.
P207
Complication spectrum of DKA seen in a pediatric
intensive care unit in a developing country
K.N. Humayun, Q. Abbas, S. Arbab, A. Haq
1
Aga Khan University, Pediatrics and Child Health, Karachi, Pakistan
Background: Diabetic ketoacidosis (DKA) remains one of the most
common endocrinological emergencies. Limited data is available on
the spectrum of acute complications of DKA in children from developing countries.
114
Objective: To describe spectrum of acute complications and outcome of children admitted in the Pediatric Intensive Care Unit (PICU)
with DKA.
Methods: Retrospective review of the medical records of all children
admitted with the diagnosis of DKA in our PICU from January 2010
to August 2015 was done. Data was collected on a structured proforma and descriptive statistics were applied.
Results: Total 37 children were admitted with complicated DKA
(1.9% of total PICU admission). There was an increase in admissions
with complicated DKA from 1.8% in 2010 to 3.4% in 2015. Mean
age was 8.1 4.6 years and 70% were females (26/37). Mean Prism
III score was 9.4 6, mean GCS on presentation was 11 3.8 and
mean low pH was 7.00 0.15. 13/37 children (35%) needed inotropic support, 11/37 (30%) required mechanical ventilation while
only 1 patient required renal replacement therapy. 2 patients (5.4 %)
died during their PICU stay.
Conclusions: Cerebral edema, shock and AKI with electrolyte
abnormalities are the most common complications of DKA in
children.
Keywords: Children, severe DKA, complications, PICU
POSTER TOURS
P208
Introduction of an intensive outpatient education
programme is acceptable to parents of children, and
young people with newly diagnosed type
1 diabetes
M. Kershaw1, R. Krone1, L. Drummond1, R. Dias1, T. Barrett1,2
1
Birmingham Children’s Hospital, Endocrinology and Diabetes,
Birmingham, United Kingdom, 2University of Birmingham, Birmingham,
United Kingdom
Objectives: Many successful European centres provide intensive education as 2 week inpatient admissions for newly diagnosed type 1 diabetes. Prolonged inpatient stay is resource intensive and disrupts the
family unit. Our centre aimed to determine the feasibility of delivering
an intensive education programme in an ambulatory care setting.
Methods: The curriculum, introduced in October 2013, comprised
20 hours face to face education by paediatric diabetes nurses, doctors, dietitians, psychologist and social/family support worker
(SW/FSW) over 6 weeks. Sessions were scheduled around lunch.
Home or diabetes unit visits were provided, as required, for injection
support. Families with children diagnosed between October 2014
and November 2015 were provided with an anonymous questionnaire to evaluate programme satisfaction and highlight challenges.
Results: There were 54 newly diagnosed in the study period, all of
whom participated in the programme. Overall programme attendance
rates were high (91%). Questionnaires were completed by 14 (26%)
families. 11(79%) were completed by a parent (1 with interpreter). 92100% of families agreed or strongly agreed sessions delivered by
PDSN, Drs or Dietitians were helpful. Sessions rated ambivalent by 1738% were SW/FSW or psychology delivered sessions, complications
and hyperglycaemia. Families report they could attend and reschedule
appointments as required. One family reported appointment times
caused difficulty collecting siblings from school. One family raised parking issues. One found the course provided more information than they
could manage, others found the pace appropriate.
Conclusion: An intensive education programme can be successfully
delivered on an ambulatory basis, despite barriers of inner city location,
limited parking and a population comprising high prevalence of low
socioeconomic status and ethnic minorities. Strategies to address
issues highlighted by families are in place to improve accessibility to all.
115
POSTER TOURS
Poster Tour 27: President’s Choice
P209
Telemedicine for care of youth with type
1 diabetes: two year follow up
R.P. Wadwa1, N. Nguyen1, C. Sullivan1, R. Slover1, J.F. Thomas2
1
University of Colorado Denver, Barbara Davis Center for Childhood
Diabetes, Aurora, United States, 2Children’s Hospital Colorado, Aurora,
United States
Objective: In the western United States, patients with type 1 diabetes (T1D) living in rural areas may have limited access to pediatric
endocrinologists. Our clinic has provided clinical care for youth with
T1D distant from our center using telemedicine since 2012. In this
study, we examined 2-year follow up data to examine changes in
hemoglobin A1c (A1c) with use of telemedicine.
Methods: Telemedicine clinics include pediatric endocrinologists in
Aurora, Colorado, USA videoconferencing with patients at hospital
diabetes centers in Casper and Cheyenne, Wyoming, USA (172 and
454 km from the clinic). We analyzed data from 26 pediatric T1D
patients with at least 2 years (≥22 months) of follow up after initial
use of telemedicine for diabetes care.
Results: Pediatric T1D patients seen at telemedicine sites in Casper
(50%) and Cheyenne (50%), Wyoming were 77% male, had mean age
11.1 4.0 years and T1D duration 4.6 3.8 years at the initial telemedicine visit. Of the 26 patients with 2-year follow up, 50% were
on insulin pumps at baseline. Mean A1c did not change from initial
telemedicine visit (A1c 9.2 1.5%) to the 2 year follow up visit (A1c
9.3 1.6%, p = 0.75). However, glycemic control varied greatly in
this cohort (A1c range 7.1-13.7% at 2-yr follow up) with most
patients (92%) not achieving A1c targets (<7.5% per ISPAD guidelines). More than half (54%) had no increase in A1c at follow
up. Change in A1c over the 2-year time period was not significantly
associated with age, T1D duration or insulin pump use but was
inversely correlated to A1c when starting telemedicine (r = −
0.40, p = 0.04).
Conclusions: Telemedicine provides increased access to subspecialist
diabetes care for pediatric T1D patients while maintaining glycemic
control for most and lowering A1c for those with higher A1c levels at
baseline. Further evaluation is needed to determine the effects of
clinical care utilizing telemedicine on long term glycemic control in
pediatric T1D patients.
P210
Flash glucose monitoring improves perception and
frequency of glucose monitoring leading to
improved glucose control
N. Helm1,2, T. De Mendonca Lindström1, S. Forsman1, A. Ohlsson1,
P. Adolfsson1
1
2
Kungsbacka Pediatric Outpatient Clinic, Kungsbacka, Sweden,
Sahlgrenska University, Gothenburg, Sweden
Objectives: The purpose of our study was to evaluate attitude to
flash glucose monitoring (FGM), the pattern of glucose monitoring
and glycemic control among children with type 1 diabetes.
Methods: The study included 37 patients (21 boys,16 girls, age
7–18) from the pediatric outpatient clinic at Hallands Hospital Kungsbacka, Sweden, January 1, 2015-April 31, 2016. 18 patients used
insulin pump. Each patient had a startup visit, and two follow-up visits. The glucose measuring frequency, average glucose value, glucose
variability and frequency of hypoglycemia over the last 14 days were
registered during each visit. HbA1c was measured at first and last
visit. The patients valued their experience of glucose measurements
and their ability to achieve a good glycemic control during each visit,
and motivated any continued FGM use during the last visit (1–3
months after FGM start). Statistical analyses with Wilcoxon signed
rank tests were performed.
Results: Patients (n = 13) with HbA1c > =58 at start of follow-up
showed a statistically significant improvement in HbA1c between
visit 1 (median 64, mean 70) and visit 3 (median 59, mean 63)
(p = 0.006). Glucose measuring frequency increased statistically significantly between visit 1 (median 5.0, mean 7.2), and 3 (median 11.5,
mean 12.6) (p < 0.001). The self-perceived experience of glucose
measurements improved statistically significantly between visit
1 (median 5.1, mean 5.2), and 3 (median 9.1, mean 9.0)(p < 0.001).
Also the self-perceived ability to achieve a good glycemic control
improved between visit 1 (median 5.2, mean 5.2), and 3 (median 7.9,
mean 7.9)(p < 0.001).
Conclusions: Children with typ 1 diabetes who used the FGM system could improve their HbA1c levels, this was most evident among
children that started with a higher HbA1c. All children increased their
glucose measuring frequency, reported an improved self-perceived
experience of glucose measurements and had a positive attitude
to FGM.
P211
Time for prandial insulin injections in children and
adolescents with diabetes mellitus type 1: real life
practice
E. Titovich1, T. Kuraeva1
1
Endocrinology Research Center, The Institute of Pediatric
Endocrinology, Moscow, Russian Federation
Aim: Guidelines recommend injecting prandial insulins pre-meal.
However, pre-meal injections can be perceived inconvenient due to
the variable appetite or lifestyle. The objective of survey was to
assess the timing of injection of prandial insulin in real patient
practice.
Design and Methods: 536 caregivers of children and adolescents
with diabetes mellitus type 1 (T1D) were interviewed face to face in
18 Russian cities.
Results: 25% percent of patients inject prandial insulin post-meal
more than 5 times a week (group 1). Appetite in general, including
dosing insulin based on actual food intake is the primary motivation.
Median declared timing of injection is 15 min after the start of the
meal. Another 24,3% of patients inject post-meal 1–4 times a week
(group 2). While appetite and timing uncertainty of the meal intake
play a significant role, the primary factor for injecting post-meal is a
low pre-meal glucose level. Finally, 50,7% always inject pre-meal
(group 3), strictly following doctors’ advice. There was no significant
difference in mean HbA1c between groups, respectively 8,4/8,1/
8,4% (group 1 / 2 / 3). About 28% from group 1 had severe hypoglycemia or coma in anamnesis (p˂0,05 vs 10%- group 2; 12%-group 3),
what can explain post-meal injections. Also in group 1 the frequency
of measurements of glucose level during the day was higher than in
other groups, that could be a result of experienced hypoglycemia in
the past.
Conclusion: A quarter of patients with T1D in the pediatric environment regularly injects prandial insulins post-meal, mostly due the willingness to dose insulin based on actual food intake rather than dose
insulin based on expected meals. This underpins a need for more
practical patient education taking into account their practical situations as well as prandial insulins with faster onset of action.
116
P212
mHealth in management of type 1 diabetes: a
systematic review of the published clinical trials
(METTLE)
S. Kulkarni1, N. Wadhwa2, R. Deshpande3, S. Siddiqui4, M. Padsalge5,
K. Samudra6, S. Shah7, T. Lathia8, T. Godbole9, C. Kulkarni1,
J. Deshpande3
Diabetes, Heart and Child Care Center, Navi Mumbai, India, 2AUW
Global, Mumbai, India, 3Ashirwad Hospital, Nalasopara, Thane, India,
4
Siddiqui Nursing Home, Mumbra, Thane, India, 5Diabecare- Speciality
Diabetes Centre, Navi Mumbai, India, 6Diabetes Care Clinic, New Panvel,
Navi Mumbai, India, 7Apollo Sugar Clinics, Mumbai, India, 8Fortis
Hiranandani Hospital, Vashi, Navi Mumbai, India, 9Harmony Health Hub,
Nasik, India
1
Objectives: We evaluated the evidence based perspectives for the
utility of mHealth technology to address the challenges for the management of T1DM.
Methodology: We conducted a systematic review of the clinical trials
evaluating impact of mHealth technologies for the outcomes in
T1DM, across the pubmed and Cochrane library by using specific
MeSH, boolean operators Type 1 Diabetes AND mHealth, Apps, Adolescent, sensor, wearable, telemed, technology NOT type 2 Diabetes,
conducted for a minimum period of one month.
Results: Cumulatively, 1367 pts were evaluated in 20 clinical trials,
mean no of patients 68 50, Min 10 Max 180 (95% CI 45, 92)
(p < 0.0001). Mean duration of trial 25.6 weeks 14.27 (95% CI
18.92, 32.28) (p < 0.0001). Cumulative duration was 512 weeks, (Min
1 month- Max 1 year) Diverse evidence has evolved over 15 years,
with 11 publications in initial 10 years, 9 in last 5 years (2011–2015).
The established technologies utilised for evaluation include Dexcom
G4™ PLATINUM CGM, mySentry system (Medtronic Inc.), sensor for
physical activity integrated into a mobile phone (DiaTrace), web
based tool to support the diabetes care Glucobeeb (Gb), VIE-DIAB,
telemedical support program.
Conclusions: The systematic review evidence indicates slow evolution of the technological interface from simple telehealth models to
the latest complex enablers being the mobile apps and sensor wearable technology based interventions. There is an urgent need to evaluate in trial, connected technologies including smartphone, sensors
and wearable technologies to enable an evidence based evolving digital ecosystem that would be primarily data driven and link patients
and care givers to enable precise and frequent management. We propose to evaluate in future trials one or more outcomes evaluated by
the mHealth systems as a 3 C model- Classical (HbA1c and Glycaemic
change), Critical (nocturnal hypoglycaemia) and Care centric (quality
of life, adjustment of insulin dosage, behavioural health).
P213
Effectiveness of SmartGuard technology in
prevention of nocturnal hypoglycemia after
prolonged physical activity
L. Petruzelkova1, K. Pickova1, B. Obermannova1
1
University Hospital Motol and 2nd Faculty of Medicine, Charles
University, Prague, Czech Republic
Objectives: Preventing nocturnal hypoglycaemia after prolonged
physical activity using sensor-augmented pump therapy (SAP) with
predictive low-glucose management (PLGM) has not been well studied. We conducted a paediatric diabetes camp study to determine
whether SAP with PLGM could reduce the frequency of nocturnal
hypoglycaemia after prolonged physical activity more effectively than
SAP together with a carbohydrate intake algorithm.
Method: During a week´s sport camp, 20 children (11.7 2 years
old) with T1D were managed by SAP therapy, 7 with and 13 without
PLGM. The settings of CGM/PLGM were customised but standard
across the group. A carbohydrate intake algorithm was used, with
both glycaemia level and trend as inputs. The incidence, severity,
POSTER TOURS
duration of hypoglycaemia and carbohydrate intake according to our
algorithm were documented and compared.
Results: The PLGM system was activated in 74% of nights (1.24
times per night on average). No difference was found between SAP
and PLGM groups in mean overnight glucose curves and mean morning glucose (7.9 3 vs. 7.5 3 mmol/l). The SAP group consumed
significantly more carbohydrates for hypoglycaemia prevention and
treatment, 10 8 gS and 3.5 0 gS (P < 0.0001) for SAP and SAPPLGM respectively. There was no difference in the severity of hypoglycaemia; however the SAP group spent significantly longer time in
hypoglycaemia (64 25 min vs 38 13 min, P < 0.05). We
observed different peak periods for hypoglycaemia during nights
(10 to 12 PM in PLGM group, 3 to 7 AM in SAP group, P < 0.05).
Conclusion: With PLGM, euglycaemia after prolonged physical activity was largely maintained with minimal carbohydrate intake.
P214
Soluble lectin-like oxidized low density lipoprotein
receptor-1 as a biochemical marker for diabetic
vasculopathy in type 1 diabetes mellitus
M. El Samahi1, A. Adly1, E. Ismail2
1
Ain Shams University, Pediatrics, Cairo, Egypt, 2Ain Shams University,
Clinical Pathology, Cairo, Egypt
Background: Oxidized low-density lipoprotein (OxLDL) acts through
the interaction with lectin-like OxLDL receptor-1 (LOX-1), expressed
differentially on the surface of the cells of the arterial wall and
inflammatory circulating cells involved in the atherosclerotic process
and endothelial dysfunction.
Aim: We assessed serum soluble LOX-1 (sLOX-1) in children and
adolescents with type 1 diabetes mellitus as a potential marker for
diabetic vascular complications in relation to glycemic control, inflammation and carotid intima media thickness (CIMT).
Methods: Eighty patients with type 1 diabetes were divided into
2 groups according to the presence of micro-vascular complications
and compared with 40 healthy controls. High-sensitivity C-reactive
protein (hs-CRP), hemoglobin A1c (HbA1c), urinary albumin creatinine
ratio (UACR), serum sLOX-1 levels. CIMT was assessed using Doppler
ultrasound scanner.
Results: CIMT and serum sLOX-1 levels were significantly increased
in patients compared with controls and in patients with microvascular complications compared with those without (p < 0.001).
Serum sLOX-1 was higher in patients with microalbuminuria than
normoalbuminuric group (p < 0.001) and in patients with peripheral
neuropathy than those without. The cutoff value of serum sLOX-1 at
125 pg/mL could differentiate patients with and without microvascular complications with a sensitivity of 82.1% and specificity of
100%. Multiple regression linear analysis showed that HbA1c, hsCRP and CIMT were independently related to sLOX-1 levels in type
1 diabetic patients. Logistic regression analysis showed that HbA1c,
total cholesterol, UACR, hs-CRP, CIMT and sLOX-1 are independently related to the presence of micro-vascular complications.
Conclusion: sLOX-1 could be a reliable biomarker for microvascular
complications in type 1 diabetes. The relation between sLOX-1 and
CIMT reflects a state of subclinical atherosclerosis and a link between
diabetic micro- and macroangiopathy.
P215
Obesity and body mass index standard deviation
score in children with type 1 diabetes in the Nordic
countries
N. Birkebaek1, R. Bjarnason2, L. Christensen3, A.K. Drivvoll4,
L. Hanberger5, A. Johansen6, U. Samuelsson7, T. Skrivarhaug4,
J. Svensson8, A. Thorsson9, K. Åkesson10
1
Aarhus University Hospital, Skejby, Department of Pediatrics, Aarhus,
Denmark, 2Landspitali University Hospital, Hringbraut, and Faculty of
Medicine, University of Iceland, Department of Pediatrics, Reykjavik,
POSTER TOURS
Iceland, 3Aarhus University Hospital, Department of Clinical
Epidemiology, Aarhus, Denmark, 4Oslo University Hospital, Division of
Pediatric and Adolescent Medicine, Oslo, Norway, 5Linkøping University,
Department Medicine and Health Sciences, Division of Nursing,
Linkøbing, Sweden, 6Rigshospitalet, Department of Growth and
Reproduction, Copenhagen, Denmark, 7Linkøbing University Hospital,
Department of Pediatric, Linkøbing, Sweden, 8Herlev Hospital and
Faculty of Health and Medical Science, University of Copenhagen,
Department of Pediatric, Copenhagen, Denmark, 9Landspitali University
Hospital, Hringbraut, Department of Pediatrics, Reykjavik, Iceland,
10
Jønkøbing Hospital, Department of Pediatrics, Jønkøbing, Sweden
Objectives: Intensified insulin therapy to optimize metabolic control
reduces risk of late complications as retinopathy, nephropathy and
neuropathy. However, intensive insulin therapy may increase body
mass index, which in itself is a risk factor for micro- and macrovascular complications. The objectives of the study were to describe the
prevalence of obesity in children with T1D in the Nordic countries,
Denmark, Iceland, Norway and Sweden, and to report possible differences in body mass index standard deviation score (BMISDS)
between the countries. Furthermore, to uncover possible predictors
for the increased BMISDS in children with T1D.
Methods: The study population consisted of all children less than
15 years, with a T1D duration of more than one year and registered
in the national childhood diabetes databases in the Nordic countries
in the year 2012. Data completeness was almost 100%. The Swedish
population-based longitudinal values from birth to 18 years of age for
height and weight were used as reference for calculating BMISDS.
Results: There were 7212 (48% females) children included in the
study. Mean (SD) age was 10.0(2.3) years and mean diabetes duration
was 4.0(3.1) years. The percentages of children with obesity defined
as a BMIDS ≥ 1.645 (≥95th percentile) were increased and different
between countries 14–31 % (P < 0.01), lowest in Denmark and highest in Iceland. Mean BMISDS was above the mean of the reference
population in all four countries, Denmark: 0.6, Iceland: 0.99, Norway:
0.71, Sweden: 0.66 (P < 0.01). The prevalence of obesity was higher
in boys than girls (P < 0.01).
Conclusion: The average BMI in children with T1D in the Nordic
countries is above the mean of the reference population with regional
differences. The high prevalence of obesity in the Nordic childhood
T1D populations is worrying, and in the future weight should also be
a focus area in diabetes care in children.
117
P216
Prevalence of cardiovascular risk factors in
adolescents and young adults with type 1 diabetes
and comorbid autoimmune disease in comparison
to T1DM patients with early vascular complications
ska-Olszewska1, B. Klonowska2, D. Charemska2,
B. Głowin
ski1,
ska2, A. Banach2, A. Kącka2, A. Szynkarczuk2, W. Łuczyn
J. Jabłon
A. Bossowski1, E. Jarocka-Cyrta2
1
Medical University of Białystok, Department of Pediatrics,
Endocrinology, Diabetology with Cardiology Division, Bialystok, Poland,
2
Medical Faculty of Warmia and Mazury University, Pediatric
Department No 6, Olsztyn, Poland
Objectives: Cardiovascular disease (CVD), frequent and fatal complication in the course of type diabetes mellitus (T1DM) has autoimmune origin. Some autoimmune diseases, like rheumatoid arthritis,
celiac or Hashimoto diseases were found to be associated with
increased CVD risk. The possible association between T1DM comorbid with other autoimmune disease and CV risk has not been studied.
The aim of the study was to assess the level and prevalence of classical cardiovascular risk factors in adolescents and young adults with
T1DM with comorbid Hashimoto (H) or celiac (C) disease and to compare with T1DM without any additional diseases and with T1DM
with early microvascular complications (MC).
Methods: Ninety T1DM patients, aged mean 17 yrs (10–27 yrs),
with at least 5 yrs of the disease history (30 with only diabetes,
20 with H, 20 with C and 20 with MC) were studied. We assessed
weight, BMI, blood pressure, lipids, metabolic control (last HbA1c and
mean from the whole disease duration) together with prevalence of
overweight/obesity (OB), hypertension (HT), lipid abnormalities
(LA) and suboptimal metabolic control (SMC).
Results: The frequency of OB was 33% in the whole T1DM group,
with the 50% in the H (Chi2 = 3.8, p < 0.05) and 40% in the MC
group. HT occurred in 45% in whole T1DM, with 75% in MC
(Chi2 = 9.7, p = 0.01). Lipid abnormalities were present in 34% of all
studied, with 45% in the MC group. HbA1c > 7.5% was present 80%
in the whole group, with 90% (Chi2 = 5.3, p = 0.02) in H, and 100%
(Chi2 = 10.5, p = 0.001) in MC group.
Conclusions: Young T1DM with Hashimoto disease occur to have
increased prevalence of CVD risk factors. Celiac disease presents
with the lower frequence of additional CVD abnormalities. The group
with recognized MC appeared to have the most adverse CVD factor
profile.
118
POSTER TOURS
ePoster session
P217
Diabetes and paramyotonia congenita: previously
unreported clinical association?
M.M. Gomes1, V. Fernandes2, S. Carvalho1, S. Martins1, O. Marques2,
A. Antunes1
Hospital de Braga, Pediatrics, Braga, Portugal, 2Hospital de Braga,
Endocrinology, Braga, Portugal
1
Background: Paramyotonia congenita (PMC) is an uncommon, autosomal dominant disorder, caused by mutations in the sodiumchannels (SCN4A) that affects the skeletal muscle cells. PMC begins
in infancy with sustained muscle stiffness mainly in the face, neck
and limbs. Type 1 diabetes (T1D) is the most common type of diabetes in adolescence. Type 2 diabetes (T2D), Monogenic Diabetes and
secondary forms rarely occur. In the literature there is no report
about the association of these diseases.
Case: 15-year-old male, with 1-month evolution of polyuria and polydipsia. It was made a presumptive diagnosis of T1D: glucose
286 mg/dL, HbA1c 9.7%, no ketosis or acidosis and negative autoimmunity. Multiple daily insulin injections therapy was started with
low needs of fast-acting insulin.
Eight days later, the adolescent began with muscle stiffness, dysphagia and dysarthria. Examination showed myotonia and hypertonia
of the limbs, face and neck. Creatine kinase and myoglobin were
slightly elevated and electromyography revealed myotonic
discharges.
He was the second child of non-consanguineous parents, born full
term at vaginal delivery with a birth weight of 4160 g (90th percentile). Both grandmothers had T2D. His father was posteriorly diagnosed with PMC with known SCN4A gene mutation. His paternal
aunt had an unknown form of myotonia. Thereafter a diagnosis of
PMC was done in this adolescent.
One-year later, he kept requiring low doses of fast-acting insulin,
the same dose of long-acting insulin and HbA1c 6.7%. We tried to
suspend insulin but hyperglycemia recurred. At that time, insulin and
c-peptide were normal. A short trial with glimepiride (2 mg/day)
revealed no sustained response. Good metabolic control was
achieved with long-acting insulin and metformin (HbA1c 6.5%).
Discussion: We question the association between PMC and diabetes
(could it be a common disturbance in sodium-channels?). We also
want to discuss the etiology of this type of diabetes.
P218
Difficulties in therapy titration in a patient with
type 1 diabetes mellitus and Addison disease
G. Stipancic1, M. Pozgaj Sepec1, L. La Grasta Sabolic1
1
University Hospital Centre Sestre Milosrdnice, University Department of
Pediatrics, Pediatric Diabetes Unit, Zagreb, Croatia
Introduction: The association of type 1 diabetes (T1D), autoimmune
thyroid disease and Addison disease, known as autoimmune poliglandular syndrome type 2 (APS type 2), rarely starts in childhood
and adolescence. The development of adrenal insufficiency often presents a diagnostic problem; but sometimes difficulties in titration of
T1D therapy persist after the diagnosis of APS type 2 is confirmed.
Case report: our patient was diagnosed with T1D at the age of 6.5 y
(2003), initially in a severe DKA. The metabolic control of the disease
was permanently poor and resulted in 5episodes of severe DKA. In
2006 she developed chronic lymphocytic thyroiditis and in 2010 substitution therapy with L-tyroxin was started. In December 2014, at
the age of 17y and 6 mo, she came to the Outpatient Clinic with clasical symptoms of adrenal insufficiency that was confirmed with lab
tests(ACTH 195.7pmol/L, plasma cortisol < 8 nmol/l, PRA 303 ng/L,
aldosterone < 2 pmol/l). Substitution therapy with hydrocortisone
and fludrocortisone was started. After 6 mo insulin therapy was continued via SCII but frequent hypoglycemias and high level of ACTH
(316,4pmol/l) persisted. CGMS and simultaneous measurments of
plasma cortisol levels every 2-4 h during 24 h revealed decreased
levels of plasma cortisol at least 2 h before next hydrocortisone dose
and were consistent with the time of frequent hypoglycemias as a
result of a shorter hydrocortisone activity. Thereupon hydrocortisone
replacement therapy was applied every 6 hours to better mimic the
physiological daily cortisol profile. The aim was to reduce the number
of hypoglycaemias and the oscillations of blood sugar levels.
Conclusion: Frequent hypoglycemias in a patient with T1D should
rise the suspicion of a developing adrenal insufficiency. When the
diagnosis is made, hydrocortisone therapy implementation can be
compromised by the noncompliance of the patient but also different
responses to the treatment that is especially present in adolescence.
P219
Influence of simple obesity on respiratory disorders
in children
A. Swiercz1, M. Szalecki1,2, H. Dmenska3
1
Children’s Memorial Health Institute, Department of Endocrynology and
Diabetology, Warsaw, Poland, 2Jan Kochanowski University, Faculty of
Health Sciences, Kielce, Poland, 3Children’s Memorial Health Institute,
Pulmonological Policlinic, Warsaw, Poland
Objectives: In recent years, obesity has become the leading health
problem worldwide, overtaking AIDS and malnutrition. Similarly,
asthma appears one of the dominating diseases in child population of
developed countries. Numerous observations show that obese children more often suffer respiratory disorders, with sleep apnoea syndrome among them. However, characteristics of obesity influence on
respiratory disorders is not well known. The aim of the study is evaluation of influence of simple obesity on selected parameters of specific types of respiratory disorders (obturation, restriction, sleep
apnoea).
Material and Methods: Investigated group consisted of 30 patients
with simple obesity. There were 20 girls of mean age of 14.33 years
and 10 boys of mean age of 14.05 years. Mean body weight was
86.3 kg (68–107) and 87.5 kg (65–135), respectively.
We evaluated the effect of occurence and grade of simple obesity
on type and intensity of respiratory sleep disorders, estimated by
polysomnography, and on selected spirometric parameters (FEV1,
FVC, FEV1/FVC, MEF50).
Results: Mean number of apnoea per sleep hour (apnoea index - AI),
was 8.32 9.69 in whole group, 8.98 11.73 in girls and 6,99 2
in boys. Mean number of hypopnoea per sleep hour (hypopnoea
index - HI) was 5.95 4.59, 5.87 5.11 and 6.13 3.31, respectively. Mean cumulative apnoea - hypopnoea index (AHI) was
14.27 12.48 in entire group, 14.85 15.11 in girls and
13.12 2.86 in boys. We demonstrated that patients with greater
BMI have higher AI, number of obturative apnoea and higher number
and longer time of desaturation. There were no significant influence
of obeesity on lungs function, measured by spirometric parameters
(FEV1, FVC, FEV1/FVC, MEF50).
Conclusions: Simple obesity is linked with sleep apnoea syndrome in
children, and greater obesity is connected with more severe respiratory disturbances. Simple obesity does not affect lung lungs function,
measured by spirometric parameters.
P220
Type 1 diabetes and epilepsy: the role of GADA
T.A. Timpanaro1, F. Greco2, D. Lopresti2, S. Passanisi2, A. Lorubbio3,
L. Fusco3, S. Cianfarani3, M. Cappa3, R. Schiaffini3
119
POSTER TOURS
1
Policlinico G. Rodolico Catania, Biancavilla, Italy, 2Policlinico
G. Rodolico Catania, Catania, Italy, 3Bambino Gesù, Roma, Italy
Introduction: Over the last years there has been an increasing interest in the potential association between type 1 diabetes mellitus
(T1DM) and epilepsy.
The exact underlying mechanisms and cause-effect relationship are
not well defined.
The possible mechanisms are: GAD-Abs, which have been associated in 80% of patients with new diagnosis of T1DM and in a large
variety of neurologic conditions; metabolic conditions such as hypoglycemia, hyperglycemia and DKA, common problems in diabetic
patients; genetic predisposition and the presence of brain lesions.
Methods: 775 T1DM patients followed by Diabetes Unit- Bambino
Gesù Children’s Hospital were enrolled in a retrospective study.
We evaluated age at diagnosis, duration of diabetes, daily insulin
dose, metabolic control assessed by HbA1c, severe hypoglycemic episodes, titres of antiGADab, EEG abnormalities, antiepileptic drugs and
relative drug resistance.
Exclusion criteria were duration of diabetes < 1 year, perinatal diseases, syndromes and brain lesions.
Results: A total of 31 patients (0,4%),18 female and 13 male, with
the mean age of 6,2 years were affected by T1DM and epilepsy. The
onset of diabetes preceded epilepsy in 30 patients.
23 patients presented focal epilepsy (temporal lobe epilepsy) and
8 presented generalized epilepsy 7 patients showed resistance to
antiepileptic drugs.
No correlation could be demonstrated for duration of diabetes,
mean daily insulin dose, metabolic control and HbA1 values.
Serum antiGADab titres was 7.5 8,42 IU in T1DM patients without epilepsy; 15.4 13 IU in T1DM and epilepsy patients, in drug
resistance was 29 IU 19.
Conclusion: High titres of antiGADab are significantly associated to
the development of epilepsy (p < 0,01) and ,antiepileptic drug
resistance(p < 0,05).
P221
Effect of serotonin modulating pharmacotherapies
on Body Mass Index and dysglycaemia among
children and adolescents: systematic review and
network meta analysis
R. Al Khalifah1,2,3, N.E. De Long4, I.D. Florez2,5, J. Sierra5, J. Orlando
Contreras5, B. Sadeghirad2,6, L. Mbuagbaw2,7,8, K.M. Morrison3
King Saud University, Pediatrics, Riyadh, Saudi Arabia, 2McMaster
University, Clinical Epidemiology and Biostatistics, Hamilton, Canada,
3
McMaster University, Pedeatrics, Hamilton, Canada, 4McMaster
University, Obstetrics and Gynecology, Hamilton, Canada, 5Universidad
de Antioquia, Pediatrics, Medellín, Colombia, 6Kerman University of
Medical Sciences, Neuroscience Research Centre, Kerman, Iran, Islamic
Republic of, 7Father Sean O’Sullivan Research Centre, St. Joseph’s
Healthcare, Biostatistics Unit, Hamilton, Canada, 8Yaoundé Central
Hospital, Centre for Development of Best Practices in Health (CDBPH),
Yaoundé, Cameroon
1
Introduction: Currently there is limited consensus on the role of
Serotonin-modulating medications (SMM) on weight gain and dysglycaemia among children with mental health diseases. We aimed to
synthesize available evidence on the effects serotonin-modulating
medications on body mass index (BMI), weight, and glycaemic
control.
Methods and analysis: We conducted a systematic review and network meta-analysis (NMA) of randomized controlled trials (RCTs)
evaluating the use of SMM in the treatment of children with mental
health conditions, aged 2–17 years. The outcome measures are
BMI(kg/m2, and z-score), weight, and dysglycaemia (prediabetes and
diabetes). We performed literature searches through Ovid Medline,
Ovid Embase, PsycINFO, and gray literature resources. Two
reviewers independently screened titles and abstracts, assessed the
eligibility using full texts, extracted information from eligible trials and
assessed the risk of bias and quality of the evidence.
Results: We identified 949 study records, and included 62 RCTs that
met the eligibility criteria, comparing Clozapine, Atomoxetine, Risperidone, Citalopram, Duloxetine, Amphetamine, Olanzapine, Ziprasidone,
Aripiprazole, Quetiapine, Molindone, Venlafaxine, Paliperidone
against Placebo or each other. The trials included patients who are 317years old and diagnosed with schizophrenia, schizo-affective disorder, Attention-deficit/hyperactivity disorder, depression, bipolar
affective disorder, mania,Tourette syndrome, autism spectrum disorder, conduct disorders, or severe disruptive behaviour disorder. The
treatment duration was 3–32 weeks. The NMA results (comparative
safety) will be presented.
Conclusions: This NMA will be the first to assess SMM and their
effects on weight and glycaemic control in pediatrics. We anticipate
our results will help physicians and patients make more informed
choices while considering the metabolic side effect profile.
PROSPERO registration:CRD42015024367.
P222
The importance of liver ultarsound scores in
nonalcoholic fatty liver disease in Egyptian obese
children and adolescent
O. Omar1, M. Abd El Fattah1, A. Mahfouz1, R. Abo Elwafa2
1
Alexandria University, Pediatrics, Alexandria, Egypt, 2Alexandria
University, Clinical Pathology, Alexandria, Egypt
Objective: To assess the correlation between the liver ultrasound
scores with degree of obesity and biochemical abnormalities in obese
children and adolescent.
Methods: Forty obese children and adoloscent aged 5–18 years
were enroled in the study. Lipid profile and liver function tests were
done, Insulin resistance was calculated using Homeostasis model
assessment (Homa-IR) and quantitative insulin sensitivity check index
(QUICKI), Trans-abdominal ultrasonography (US) findings were scored
according to Liver echotexture, Echo penetration and visibility of diaphragm and clarity of liver blood vessel structures, Scores ranged
from 0 to 9 points. The child was considered to have mild, moderate
and severe fatty liver change if the overall score was 1–3, 4–6 and
7–9 respectively.
Results: Fatty liver was detected in 67.5 % among obese children by
US, There was a significant positive correlation between ultasound
score with waist circumference (WC), triglycerides, HDL, ALT and
fasting glucose.
Conclusions: The bedside US is a powerful and useful diagnostic tool
in the detection of NAFLD. Measurements of WC is important as
indicator of central adiposity and are practical tools to identify a subgroup of obese children at greater risk of NAFLD.
P223
Prevalence of celiac disease in a children group
with type I diabetes
C. Girard1, C. Morin1, M. Talvard1, Z. Ajaltouni1, A. De Percin1, J.-P.
Olives1, C. Le Tallec1,2
1
CHU Hôpital des Enfants, Toulouse, France, 2Association Enfance
Adolescence Diabète, Toulouse, France
Objective: Celiac disease is an immune-mediated systemic disorder
that occurs in genetically predisposed individuals after exposure to
gluten ingestion. The pathophysiology of the disease is well elicited
by the direct sensitization of the small intestine to gluten, causing villous atrophy and resulting in various clinical presentations. Patients
with Diabetes Mellitus type I (DM type I) have been considered at
high-risk for developing celiac disease.
The purpose of our study was to determine the prevalence of
celiac disease among children who are followed in our unit for DM
type I. The diagnosis of celiac disease was made based on the new
European recommendations (ESPGHAN 2012), that aim to simplify
celiac diagnosis and consider patients with celiac disease when both,
the serological (anti-transglutaminase and anti-endomysium) and the
120
genetic study (HLA DQ2 and/or DQ8) are positive, thus requiring less
intestinal biopsies.
Methods: Epidemiologic descriptive study included 750 DM type I
patients with age ranging from 11 months to 18 years old, followed
in the period between June 2014 and June 2016. The patients were
included in the study either at the time of DM type I diagnosis or
during a follow up consultation.
Results: Celiac disease was confirmed in 28 out of 750 patients with
DM type I based on the ESPGHAN recommendations, with a prevalence of 4%. If we consider the patients who required intestinal biopsies as positive for celiac disease, the prevalence can increase up to
4,7 %. We also found that patients with positive HLA DQ2 and/or
DQ8 genes are 2,4 time more frequent (95%) compared to general
population.
Conclusion: DM type 1 patients have an increased risk for celiac disease. Screening is recommended for all patients even if they appear
asymptomatic. Importantly, in genetically predisposed patients (HLA
DQ2/DQ8), repeated screening seems necessary.
P224
Precocious puberty in a boy with type 1 diabetes
mellitus, hypothalamic teratoma, right forearam
hypoplasia, carrier of galactosemia
A. Swiercz1, M. Wysocka-Mincewicz1, E. Moszczynska1,
M. Szalecki1,2
1
Children’s Memorial Health Institute, Department of Endocrynology and
Diabetology, Warsaw, Poland, 2Jan Kochanowski University, Faculty of
Health Sciences, Kielce, Poland
Objectives: Precocious Puberty (PP) is defined as pubescence before
the age of 8 (girls) and 9 (boys) years. There are two main types:
GnRH-dependent (called central or true), and GnRH-independent PP
(peripheral, pseudo PP). In significant part of cases of central PP in
boys, focal changes of the brain - tumors or developmental anomalies
- are discovered. Patomechanism of the PP in these cases is unclear.
It is considered that it can be effect of compression or other damage
of neural pathway that inhibits GnRH-secreting neurons. Tumors
localised in posterior hypothalamus or at the base of third ventricle,
commonly causing PP, are hamartoma, germinoma and teratoma.
Methods: A case analysis.
Results: 10 years old boy, carrier of galactosemia with right forearm
hypoplasia, suffering type 1 diabetes mellitus since the age of 8 years,
treated with insulin pump, in whom since the age of 8 years and
8 months, symptoms of PP were observed - growth acceleration,
acne, pubarche, testicles enlargement and distict smell of sweat. On
the basis of steroid profile and LH-RH test, GnRH-depednded PP was
diagnosed. Brain MRI revealed tumor in hypothalamus and pituitary
stalk, appeared to be teratoma. There were no indications for surgery.
In control MRI after 6 months, the image was as previous. Therapy
with long-acting GnRH analogue was introduced. Child is in follow-up
of our policlinic.
Conclusions: 1. Manifestation of PP symptoms in a child should be
always thoroughly investigated.
2. In patients with true PP, one should quest for focal changes in
central nervous system.
The change in glycemic profile and insulin use in child with T1DM
can be one of the first signs of other diseases, including endocrine.
P225
The prevalence of celiac disease in patients with
type 1 diabetes - assessment of the 3-year
prospective study
A. Groszek1, M. Szalecki1,2, M. Wysocka1, M. Wajda-Cuszlag1,
B. Oralewska3, E. Konopka4, I. Trojanowska4, J. Bierła4,
B. Cukrowska4
1
The Children’s Memorial Health Institute, Clinic of Endocrinology and
Diabetology, Warsaw, Poland, 2Medicine and Health Sciences Faculty
POSTER TOURS
UJK, Kielce, Poland, 3The Children’s Memorial Health Institute,
Department of Gastroenterology, Hepatology and Nutrition Disorders,
Warsaw, Poland, 4The Children’s Memorial Health Institute, Department
of Pathology, Warsaw, Poland
Objectives: Patients with type 1 diabetes (T1D) are at increased risk
for developing celiac disease (CD). The aim of this study was to evaluate the prevalence of CD in children with T1D in a 3-year-long prospective study.
Methods: The study included 472 patients aged 8 months to 18 years
(246 girls and 226 boys) who were patients of the Department of
Endocrinology and Diabetology Children´s Memorial Health Institute
in 2012–2014. In all the patients at the start of the study a serological screening of CD was performed, which included an assessment of
concentration of antibodies against tissue transglutaminase (tTG-IgA)
and/or deamidated gliadin peptides (IgG-DGP) - in case of a deficit of
total IgA. Patients with positive antibodies underwent a biopsy of the
small intestine to evaluate it histopathologically. CD was diagnosed in
children with characteristic histological changes evaluated in a
Marsh-Oberhuber scale as at least Marsh II.
Results: In the group of 472 children CD was diagnosed in 33 cases
(6.7%), while in 8 cases, the CD was diagnosed before. Repeated
serological tests during the period of 1–3 years were performed in
278 patients (58.9% of children included in the study). In all the
patients with elevated levels of antibodies tTG-IgA or DPG-IgG CD
was histologically confirmed. CD was more frequent in girls (n = 20,
8.13%) than in boys (n = 13, 5.75%). In the first phase of the study
CD was diagnosed in 13 children (4.45%). Repeated serological tests
detected CD in further 12 patients (4.3%): respectively after one year
in 7, after 2 years in 2 and after 3 years in 3 patients.
Conclusions: It has been confirmed that patients with DMT1 are at
higher risk for developing CD and should be regularly, optimally once
a year, tested for CD using serological analysis (tTG-IgA and IgGDPG). A longer observation of patients with DMT1 will determine
how long should the screening be continued.
P226
Wolcott-Rallison syndrome (WRS) first case report
in Pakistan
M. Ibrahim
National Institute of Child Health, Endocrinology, Karachi, Pakistan
Case report: 3 months old female infant presented to us with fever,
vomiting and polyuria for one week duration. She is product of consanguineous marriage and seventh issue of first cousin parents. Her
three siblings had history of diabetes diagnosed during infancy and all
expired with complications of diabetes and severe infections. Her
father was also diabetic. Our patient had developed respiratory distress and uncontrolled blood sugar. She had history of previous multiple admissions and work up at primary care center and tertiary care
center where she was managed for fever and recurrent urinary tract
infection. She is immunized up to date according to EPI. She was
born by normal vaginal delivery and pregnancy was also uneventful.
Birth weight was 3 kg. She was on mother feed. On examination, the
patient was febrile, dehydrated and no dysmorphism. Her FOC
41 cm (−2SDS), Length 70 cm (−1.83SDS) and weight was 6.2 Kg
(−4.2SDS). Systemic examination was unremarkable during admission
and her blood sugar was persistently high with HbA1c 14.8%. Skeletal survey findings: both hands had few carpals bones which were
small in size for age and irregular in shape. Coxa vera deformity was
seen in pelvic x-ray. There was flattening of proximal metaphysis of
right femur. Skull, spine and long bones appeared normal. Liver function test, renal function test and echocardiography were normal.
Findings: Both hands had few carpals bones which were small in size
for age and irregular in shape. Coxa vera deformity was seen in pelvic
x-ray. There was flattening of proximal metaphysis of right femur.
Skull, spine long bones appeared normal.
Conclusion: The genetic etiology could be determined in cases of
Neonatal Diabetes Mellitus, their genetic analysis for mutations
should be sent in all cases.
121
POSTER TOURS
P227
Prevalence of celiac disease in type 1 diabetes
mellitus in children and adolescents attending
diabetic clinic at National Institute of Child Health
Belarusian children are impossible to explain only by non optimal
iodine status or life style/nutrition habits. A restoration of active
country wide monitoring programs is required to elucidate the etiology of widespread thyroid dysfunction and metabolic disorders in the
aspect of endocrine disruptor influence.
R. Baloch
National Institute of Child Health, Public Health, Karachi, Pakistan
Background: The association of celiac disease and type 1 diabetes
mellitus is known worldwide due to shared immunological background, since celiac disease could present in diabetic patients with
Nonspecific symptoms or asymptomatically, periodic serological
screening is necessary for early Diagnosis.
Objectives: To estimate the prevalence of celiac disease in children
with type 1 Diabetes.
Patients and Methods: A total of 660 children with type 1 diabetes
attending the National Institute of Child Health; 334 boys, 314 girls
with mean age of 9.5 year 4.7 and mean duration of diabetes
3.5years 2.5, from Feb 2014 to May 2015. 233 children were
screened for celiac disease tissue transglutaminase (tTG) antibodies
IgA,IgG through Kit method in which cut off values were < 1.2.
Anthropometry done, plotted on chart.
Results: Anti tissue transglutaminase antibody were positive in total
41 patients, more in girls 24 (60%) and boys 17 mean age in girls
were 8.3 3 mean age and boys were 6.6 3, making the prevalence of celiac disease 17.59%, only 2 patient have serology value
more than 100 times. The classical presentation of the disease was
lacking in most patients, but they presented with abdominal distention, diarrhea short stature, rectal prolapse. In most cases Celiac disease was diagnosed within the first year of the diagnosis of diabetes.
Conclusion: Annual autoantibody screening is recommended, for
early diagnosis and management of patients with diabetes type 1.
Keywords: Diabetes
mellitus,
celiac
disease,
anti-tissue
transglutaminase
P228
Metabolic disorders, prediabetes and thyroid
dysfunction in Belarusian children
M. Lushchyk1, Y. Vainilovich1, N. Dudzik1, A. Tuzova1, V. Sivuda2,
V. Drozd1, L. Danilova3
1
Belarusian Medical Academy of Postgraduate Education, Thyroid
Disease Research, Minsk, Belarus, 2Brest Regional Endocrine Dispensary,
Brest, Belarus, 3Belarusian Medical Academy of Postgraduate Education,
Endocrinology Department, Minsk, Belarus
Possible role of thyroid subclinical dysfunction in development of
metabolic disorders and development of prediabetes is discussed in
clinical endocrinology during last years. Thyroid diseases are widespread in Belarus. Republic of Belarus belongs to European countries
with predominantly light and moderate chronic iodine deficiency. The
State Program of iodine prophylaxis with iodinated salt started
15 years ago. According to the results of screening in Brest and
Minsk regions - the situation is changing. The median levels of iodine
excretion in Stolin (Brest region) in 2002 yr were less 50.0 μg/L in
school children, in Minsk region - less 100.0 μg/L. In 2015 yr. the
median levels of iodine excretion in children of Brest region reached
105.5 μg/L, of Minsk - 145.6 μg/L. An analysis of the dietary questionnaire data showed that population during last 5 years are still not
using iodinated salt. Levels of nitrate consumption (with food or
drinking water) especially in rural regions are often exceeding recommended levels. Impact of different endocrine disruptors in genesis of
thyroid and metabolic disorders is also highly possible.
The incidence of subclinical hypothyroidism and thyroid nodules is
increasing in children and young adults during last 30 years. According to active screening in school children of Brest and Minsk regions
during 2010–2015 yrs. subclinical and clinical hypothyroidism, metabolic syndrome and prediabetes, type 2 diabetes and thyroid nodules
showed up to be not a rare disorder. Negative tendencies in the prevalence of subclinical hypothyroidism, association with overweight or
obesity, metabolic disorders, prediabetes or type 2 diabetes in
P229
Autoimmune hepatitis in a boy with newlydiagnosed type 1 diabetes
L. Groele, A. Szypowska
Medical University of Warsaw, Department of Paediatrics, Warsaw,
Poland
Objectives: Type 1 diabetes increases risk of other autoimmune diseases. Autoimmune hepatitis (AIH) is relatively seldom concomitant disease. It is estimated 0,1-1,9 AIH incidences per 100 thousand Caucasian
habitants. The course varies from asymptomatic to very severe leading
in a short time to liver failure. Untreated AIH leads to structural and
functional damage, and finally to cirrhosis. The diagnosis is established
on the basis of abnormal laboratory parameters (elevated levels of transaminases, GGT, gamma-globulin, IgG autoantibodies), finally confirmed
by the typical infiltration of mononuclear cells and necrosis in liver
biopsy. Patients with AIH are treated with steroids and azathioprine.
We describe a boy with diagnosed type 1 diabetes and AIH at the
same time.
Methods: A 6-year old boy was admitted to hospital because of polydipsia, polyuria, weight loss, and hyperglycemia in laboratory studies.
In a familiar interview father of the boy is suffering from multiple
sclerosis. At admission, the patient was in a good general condition,
slightly dehydrated. In laboratory scores hyperglycemia, glycosuria,
elevated HbA1c, anti-GAD, decreased levels of c-peptide were noted.
Subcutaneous functional insulin therapy was applied.
Due to hyper transaminasemia, additional tests were performed
and elevated levels of GGT, IgG, gamma-globulin found. Infectious
and toxic background, as well as nephrolithiasis bile duct were
excluded. The boy was transferred to the hepatology clinic where
based on the increased level of autoantibodies and liver biopsy diagnosed AIH and encorton and azatioprine treatment applied.
Results: Increased insulin requirements was noted over time of
immunosuppressive therapy from 0,7 IU/kg/day to 1,5 IU /kg/ day,
and the daily basal profile changed.
Conclusion: AIH can coexist with type 1 diabetes in children.
The use of immunosuppressive therapy containing steroid therapy
increases insulin requirement and changes the daily basal profile.
P230
Challenges in the diagnosis of hypoglycemia: Hirata
disease vs. factitious hypoglycemia
D.A.M. Athayde1, S. Ito1, T. Jeronimo1, C. Passone1, R. Savoldelli1,
T.D. Manna1, D. Damiani1
1
Universidade de São Paulo (USP), Pediatric Endocrinology, São Paulo,
Brazil
Objective: Insulin autoimmune syndrome (IAS or Hirata Disease) is
rare among children. Non-ketotic hyperinsulinemic hypoglycemia
with the presence of insulin auto-antibody (IAA) is the condition to
diagnose the syndrome. Our objective was to report clinical and laboratory characteristics of a patient diagnosed with IAS.
Methods: A 6-year-old boy started to present seizures since
7 months of age, which were treated with anticonvulsants until the
age of five, when hypoglycemia was evidenced. During a hospital
admission, the laboratory work-up revealed blood glucose and insulin
levels of 21 mg/dL (1.16 mmol/L) and 34.7 μU/mL, respectively;
other critical sample tests and abdominal MRI were normal. There
was no improvement with diazoxide, somatostatin, hydrochlorothiazide and glucagon treatment. To rule out exogenous insulin administration, an inpatient investigation took place without his mother
presence.
122
Results: At admission, a fasting blood glucose and insulin levels were
26 mg/dL (1.44 mmol/L) and 686.7 μU/mL, without any physical
signs of insulin resistance. Extended OGTT were performed twice,
with blood glucose levels ranging from 21 to 112 mg/dL (1.166.2 mmol/L), insulin levels from 407 to 1000 μU/mL and C-peptide
levels from 1.5 to 5.2 ng/mL. Positive insulin antibody (IAA) > 500
U/ml and a negative plasma assay for sulfonylureas were obtained.
The chromatography study demonstrated high molecular weight insulin, which means that almost all measured insulin was aggregated
with the antibody. After IAS diagnosis was established, dietary and
physical activity recommendations were prescribed and less hypoglycemic episodes were observed.
Conclusions: To exclude factitious hypoglycemia, four hospitalizations and the separation from the mother were required to prove that
she was not injecting insulin inadvertently to her child and autoimmune hypoglycemia diagnosis was established due to the complementary laboratory work-up.
P231
Improving screening for celiac disease in patients
with new-onset type 1 diabetes
C. Ikomi1, C. Alexander2, D. Mallon3, V. Anderson1, M. Jolly2, J. Gahl1,
D. Dykes3, B. Davis2, S. Ellsworth2, S. Corathers1, N. Crimmins1
1
Cincinnati Children’s Hospital Medical Center, Endocrinology,
Cincinnati, United States, 2Cincinnati Children’s Hospital Medical Center,
Anderson Center for Health Systems Excellence, Cincinnati, United
States, 3Cincinnati Children’s Hospital Medical Center, Gastroenterology,
Cincinnati, United States
Background: The prevalence of celiac disease (CD) in those with
Type 1 Diabetes (T1D) is 5 to 7 times greater than the general population. Variations in clinical practice exist regarding initiation and frequency of CD screening in T1D. Even if asymptomatic, undiagnosed
CD is a risk for long-term health consequences.
Objective: Reliably identify CD among patients with T1D, starting at
diagnosis.
Methodology: Informed by existing evidence, Quality Improvement
(QI) methodology was used to develop consensus and implementation of a clinical care algorithm for CD screening at new onset T1D
and surveillance of established patients. The algorithm was piloted
and iterative tests performed to improve reliability. Selected care processes including % new onset T1D patients screened for CD are
tracked.
Results: Following implementation of the algorithm in November
2015, 66 (78%) of 84 eligible patients were screened for CD at diagnosis of T1D. Three patients with abnormal TTG IgA levels ≥20 were
identified and referred to gastroenterology. Screening for CD at diagnosis of T1D increased from a baseline of < 5% to >90% within the
last 6 months.
[Celiac screening at diagnosis of T1D]
POSTER TOURS
Conclusion: This study demonstrates successful adoption of a standard screening protocol for CD in patients with T1D which includes
screening at diagnosis. Future plans include evaluation of the impact
of screening for CD at the time of T1D diagnosis to advance
evidence-based guidelines.
P232
Mammary status in adolescent girls with diabetes
mellitus I (a cases history)
O. Gumeniuk1,2, Y. Chernenkov1
1
Saratov State Medical University, Saratov, Russian Federation, 2Saratov
Hospital 5, Saratov, Russian Federation
The complications of diabetes mellitus type I (DMTI) are more common and more severe in patients who have poor-controlled blood
sugar levels and associated with elevated levels of circulating fatty
acids and hyperglycaemia.
Objectives: To study the mammary status, frequency and peculiarities of breasts diseases in adolescent girls with DMTI.
Methods: The study included 5 adolescent girls (aged 16–18 yrs)
with DMTI with long poor-controlled blood sugar levels. Girls were
subjected to the clinical examination, ultrasound examination of the
breast. The nonparametric method of correlation analysis by Spirmen
was studied.
Results: The investigation shows the indi-vidual level of HbAc% was
>8% in all girls. Two girls had delayed physical and sex development
and breast hypoplasia. The dysplasia of mammary glands (mastopathy) and cyclic mastalgia were diagnosed in all patients (rs = 1). In
one adolescent girl was diagnosed cyst mastopathy, in four girls was
diagnosed adenosis mastopathy.
Conclusions: This study has shown that breast disorders have been
diagnosed in all adolescent girls with poor-controlled DMTI. Mammary status showed a positive correlation with HbAC1 levels. The
DMTI in adolescents is indication for mammary observation.
P233
Necrobiosis lipoidica diabeticorum: a case report
G. Karagüzel1, R. Polat1, S. Yaylı2
1
Karadeniz Technical University, School of Medicine, Pediatric
Endocrinology, Trabzon, Turkey, 2Karadeniz Technical University, School
of Medicine, Dermatology, Trabzon, Turkey
Introduction: Necrobiosis lipoidica diabeticorum (NLD) is a rare
chronic granulomatous dermatitis. There are very few reported cases
of NLD in children and adolescents. We report a case of a girl
with NLD.
Case report: A 17-year old girl with type 1 diabetes presented with
lesions on the lower extremities. She had type 1 diabetes since she
was 9 years old. Microalbuminuria was detected 3 years ago. Her
medical history was otherwise unremarkable. Until the age of 13 she
maintained an adequate glucose control with HbA1c < 8%. Thereafter her glucose control progressively worsened with a HbA1c of 10%.
Her physical examination revealed well-demarcated erytematous
lesions of which central portions were yellow on both lower legs. We
diagnosed NLD and consulted with a dermatologist. A skin biopsy
was not performed, because the lesions were typically for NLD and
topical tacrolimus treatment was given.
Conclusions: Diagnosis of NLD is mainly clinical as in our patient. It
has been suggested that NLD is one of the possible manifestations of
microangiopathy. Whether or not poor glucose control is associated
with the development of NLD remains controversial. Differential
diagnosis include erithema nodosum, lupus panniculitis, granuloma
annulare, sarcoidosis and amiloidosis. Necribiosis lipoidica might also
be a primary disease of collogen. Rarely , squamous cell carcinoma
may develop in areas of necribiosis lipoidica.
123
POSTER TOURS
P234
Acute sinus vein thrombosis as a complication of
diabetic ketoacidosis in a pediatric patient with first
manifestation of type 1 diabetes mellitus
S. Fernandez Rodriguez1, I. Schulze-Neick1, K.F. Schettler1,
S. Bechtold-Dalla Pozza2, H. Schmidt2, C. Weissenbacher2,
A. Peraud3, N.A. Haas1, B. Heineking1
1
Campus Grosshadern of the Ludwig-Maximilians-University, Pediatric
Cardiology and Pediatric Intensive Care, Munich, Germany, 2Dr. von
Hauner Children`s Hospital, Ludwig-Maximilians University, Pediatric
Diabetology and Endocrinology, Munich, Germany, 3Campus
Grosshadern of the Ludwig-Maximilians University, Department of
Neurosurgery, Munich, Germany
Introduction: The diabetic ketoacidosis (DKA) is the most common
cause of death in children with type 1 diabetes mellitus and the allcause mortality of the DKA is 0,15-0,33 %, mostly (57-87%) caused
by brain edema. The occurrence of a cerebral sinus vein thrombosis
(CSVT) in this situation is a rarity and the outcome of the patients
depends on rapid diagnosis and treatment.
Case description: We report the case of a 13-year old boy with
acute exacerbation of inflammatory bowel disease for which he
underwent immunosuppressive therapy with prednisolone and a
four-day antibiotic treatment. He developed acute somnolence,
hyperglycaemia (blood glucose max. 575 mg/dl, 31,9 mmol/l) and
moderate ketoacidosis (pH min. 7,20) in the course of this first type
1 diabetes manifestation (HbA1c 12,6%, 114,2 mmol/mol). Despite
adequate therapy, clinical worsening towards Glasgow-Coma-Scale
(GCS) 5 and recurrent focal and generalised seizures occured. A CT
and MRI showed intracranial masses of unknown origin. Because of
persisting seizures and increasing neurological deficits we performed
a MRI this time including angiography, which thus revealed severe
CSVT. In spite of these findings the patient was able to improve significantly with systemic heparinisation over the course of the following 3 weeks.
Discussion: CSVT in the context of a DKA is an extremely rare complication in pediatric patients and difficult to diagnose. In our case the
manifestation of the type 1 diabetes occurred while he was treated
for acute exacerbation of inflammatory bowel disease. Etiological
DKA and persistent diarrhea caused a dehydration and intravascular
exsiccosis and promoted the occurrence of a thrombosis. The presence of coagulopathy was excluded.
Conclusion: Although cerebral sinus vein thrombosis is a rare complication of a diabetic ketoacidosis, it must be considered in patients
who do not respond to adequate treatment for brain edema. The outcome depends on rapid diagnosis and treatment.
P235
Events of severe hypoglycemia is associated with a
progressive increase in hemoglobin A1c among
children with type 1 diabetes - a study from the
Danish Childhood Diabetes Registry
K. Pilgaard1, J. Svensson2, K. Holst2, J. Johannesen2, A. Johansen3,
M. Madsen4, K. Kristensen5, S. Fredheim2, S. Pörksen6, T. Hertel7,
N. Birkebæk5
1
Nordsjællands Hospital, Childrens Department, Hillerød, Denmark,
Herlev University Hospital, Copenhagen, Herlev, Denmark,
3
Rigshospitalet, Copenhagen, Denmark, 4Aalborg University Hospital,
Aalborg, Denmark, 5Aarhus University Hospital, Aarhus, Denmark,
2
6
Roskilde Hospital, Roskilde, Denmark, 7Odense University Hospital,
Odense, Denmark
Objectives: Fear of hypoglycaemia is associated with reduced quality
of life and may have implications on life-style and/or diabetes regulatory behavior. The aim of this study was to investigate if severe
hypoglycaemia is followed by a deterioration in metabolic control
among children with type 1 diabetes.
Methods: A national population based study obtained from the Danish Childhood Diabetes Registry comprising data from 2010–15.
Severe hypoglycemia was defined according to the 2014 ISPAD
guidelines. A mixed model was applied and data were adjusted for
age, gender, duration of diabetes and ethnicity.
Results: In the period 2010–15 the register comprised a total of
4,274 children (50.6 % boys). Mean (SD) age was 12.5 (4.0) years and
duration of diabetes 5.42 (3.9) years. There were 629 (14.7%) children experiencing at least 1 severe event; 336 children experienced
1 event of severe hypoglycaemia, 148 had 2 events and 145 had ≥ 3
events. Mean hemoglobin A1c in those experiencing a hypoglycaemic
event were 68.5 (13.8) mmol/mol whereas those who never experienced severe hypoglycaemia were 63.9 (15.0) mmol/mol. Hemoglobin A1c deteriorated progressively following 1, 2 and ≥ 3 events of
severe hypoglycaemia by mean (SD) 1.29 (1.05); 2.04 (1.15) and 2.56
(0.97) mmol/mol (p < 0.01). There was an increase in pump users
after a hypoglycemic event rising from 42% to above 60%.
Conclusion: Events of severe hypoglycemia is followed by a progressive increase in hemoglobin A1c among Danish children with type
1 diabetes.
P236
HbA1c levels at diagnosis of type 1 diabetes are
related to age and to degree of ketoacidosis
G. Massa1, P. Declercq2, R. Zeevaert1
1
Jessa Ziekenhuis, Pediatric Endocrinology and Diabetology, Hasselt,
Belgium, 2Jessa Ziekenhuis, Clinical Laboratory, Hasselt, Belgium
Background and Objective: The serum HbA1c level reflects the
average measurement of the blood glucose levels during the preceding 2–3 months. Higher serum HbA1c levels at the diagnosis of type
1 diabetes (T1D) may represent delayed diagnosis. In the present
study we evaluated whether the serum levels HbA1c levels at diagnosis of T1D were related to age and to the degree of ketoacidosis.
Methods: We retrospectively studied HbA1c, blood glucose and
bicarbonate levels at diagnosis of 127 children (60 girls) consecutively
diagnosed with T1D between January 1, 2005 and December
31, 2015. HbA1c was measured by ion exchange chromatography
and plasma glucose by the glucose oxidase method. Degree of ketoacidosis was determined by serum bicarbonate level. Patients with
bicarbonate < 15 mmol/l were diagnosed as having diabetic ketoacidosis. Patients were divided into 3 age groups: group 1: age 0.6 5.9 yrs (n = 28); group 2: age 6.0 - 11.9 yrs (n = 54), group 3: age
12.0 - 17.0 yrs (n = 45). Results are expressed as mean SD (range).
Results: The table compares biochemical data between the 3 age
groups.
[Biochemical data]
30 patients (24%) were in ketoacidosis at diagnosis. HbA1c levels
were slightly higher in patients with ketoacidosis (12.4 2.4% vs
11.4 2.0%; p = 0.035). Multiple linear regression analysis revealed
that HbA1c levels were positively related to age (t = +6.621;
p < 0.001) and inversely to bicarbonate levels (t = −4.539 ;
p < 0.001).
Group 1
Group 2
Group 3
Glycemia (mg/dl)
503 224 (118–1139)
506 179 (193–1025)
488 206 (180–1014)
P value
Bicarbonate (mmol/l)
17.4 5.7 (4.5-24.0)
19.4 5.1 (3.8-27.3)
19.5 6.4 (5.6-27.5)
0.247
HbA1c (%)
9.9 1.2 (7.4-12.2)
12.0 2.0 (8.4-17.0)
12.4 2.2 (8.8-17.5)
<0.001
0.890
124
Conclusions: Although glucose levels at diagnosis were not different
between the age groups HbA1c levels were higher in the older children suggesting delayed diagnosis. Only 24% of the patients presented with ketoacidosis. HbA1c levels were inversely related to
bicarbonate levels suggesting a more dangerous situation due to
delayed diagnosis.
P237
Hospital experience in the management of pediatric
diabetic ketoacidosis: retrospective study
(2000–2015)
F. Ruas1, F. Mota1, M. Ferreira1, A. Luís1, G. Laranjo1, J. Campos1
1
Serviço de Pediatria do Centro Hospitalar Tondela-Viseu, EPE, Viseu,
Portugal
Objectives: Our purpose was to investigate the clinical and laboratory aspects of children and adolescents admitted for diabetic ketoacidosis (DKA).
Methods: Medical records of 53 children and adolescents treated for
DKA at a Portuguese urban hospital from 2000 to 2015 were
reviewed. Following data were collected: age and gender, severity,
type and rate of initial fluids, insulin infusion rate, glycaemia, pH and
time to pH normalization, bicarbonate, serum sodium, serum potassium, serum phosphate, complications and duration of hospital stay.
Data analysis was performed using SPSS Statistics 20®.
Results: Average age was 9.9 4.8 years. 62.3% were females. DKA
was severe in the majority of cases (43.4%). At admission, average
serum glycaemia was 542.4 179.5 mg/dL, corrected sodium
134.8 5.4 mmol/L, potassium 4.9 0.7 mmol/L and phosphate
5.1 1.5 mmol/L. Initial fluid replacement was 0.9% saline in 75.5%
of cases and average rate was 6.4 5.5 ml/kg/h. A rate of >10 ml/
kg/h was used in severe cases (p = 0.04). Insulin perfusion rate was
0.1U/kg/h in 58.5% of cases and a rate of 0.05U/kg/h was used in
mild DKA (p = 0.001). Average time to pH normalization (>7.30) was
10 3.4 hours and was significantly higher in severe DKA
(p > 0.001), independently of type and rate of initial fluids (p = 0.14).
We found a significant variation of pH, serum glycaemia, and sodium
at 4, 8 and 12 hours after admission; serum potassium increased at
4 and 8 hours but significantly decreased at 12 hours; serum phosphate significantly decreased at 4, 8 and 12 hours. Hypokalemia
occurred in 7 cases (15.1%). No cases of cerebral edema were
reported. Duration of hospital stay was in average 10.6 8.2 days
and no deaths occurred.
Conclusions: Most cases of DKA were severe. Initial fluid therapy
and insulin perfusion options were in accordance to generally
accepted guidelines and we verified a successful correction of acidosis and hyperglycaemia with no complications.
P238
Risk factors for cerebral edema in children and
adolescents with diabetic ketoacidosis
N. Yaneva1, M. Konstantinova2, D. Iliev1
1
Medical University of Sofia, Pediatric Intensive Care Unit, University
Pediatric Hospital, Sofia, Bulgaria, 2Medical University of Sofia,
Department for Diabetes, Clinic for Endocrinology, Diabetes and
Metabolism, University Pediatric Hospital, Sofia, Bulgaria
Objectives: Cerebral edema (CE) is a rare life-threatening complication of Diabetic ketoacidosis (DKA) in children. We analyzed the biochemical and therapeutic risk factors for CE in DKA.
Methods: A retrospective review of 256 children, hospitalized for
DKA between February 2003 and March 2015. The demographic
characteristics, biochemical variables and therapeutic interventions
were compared between the patients with and without CE.
Results: Cerebral edema was observed in 22 (8.6%) of the 256 subjects studied. One of the patients (5%) had died and 2 (9 %) had survived with neurologic consequences. Cerebral edema was
POSTER TOURS
significantly associated with severe DKA: lower initial pH (p < 0,001)
and bicarbonate (p < 0,001), higher initial blood glucose (p = 0,003),
urea level (p = 0,036) and baseline serum osmolality (p = 0,036). During the treatment of DKA low serum phosphate level was found significantly associated with CE (p = 0,027). We also found significant
dependence between the development of CE and the initiation of
treatment for DKA in another facility before the hospitalization in our
hospital (p = 0.010), bicarbonate application (p < 0,001), higher fluid
volume infused initially (p = 0,005) and delayed potassium substitution (p = 0,003).
Conclusions: Severe ketoacidosis, hyperglycaemia and dehydration
at presentation and low serum phosphate during treatment are significantly related to cerebral edema formation in children with DKA.
The initial severe acidosis and hyperglycaemia probably cause brain
injury that progresses to cerebral edema in the course of developing
hypophosphatemia and cerebral hypervolemia.
P239
Acute decompensations of T1DM children in the
emergency unit
M. Ferrer1, S. Feo1, L. Lahilla1, M. López Ubeda1, R. Rubio1, G. Lou1
1
Miguel Servet Children’s Hospital, Pediatric Diabetes Unit, Zaragoza,
Spain
Objectives: To analyse acute decompensations in T1D children
attended in an emergency unit of a tertiary hospital. To review the
epidemiologic characteristics, severity and main causes of acute complications in these patients and the therapeutic procedures.
Methods: Review of episodes of acute decompensation in T1D
patients younger than 16 years treated in the emergency unit from
March 2013 to July 2015.We excluded T1D patients with some
known intercurrent illness. Analysis of clinical and analytical variables.
Comparison of these data with those corresponding to the previous
two years.
Results: 38 episodes(50% female) corresponding to 28 patients, 10%
of T1D children controlled in our Hospital. Average age was
8,8 years(2–16). T1D average duration was 3 years (1 month9 years). Last year’s average HbA1C was 8,1% before decompensation. The most frequent reasons for the visit were vomiting(44,7%),
hypoglycaemia(26,3%),
hyperglycemia(15,7%)
and
convulsion
(13,1%).52% required observation in the emergency unit and 31,5%
needed hospitalization. 5 patients presented DKA (ketoacidosis)
(1 mild, 2 moderate and 2 severe).The severe cases staid in intensive
care unit. Regarding the treatment,2 patients carried insulin pumps
and 92,8% were treated with multiple insulin injections. We observed
a reduction of 47,2% in the number of episodes in respect of the two
previous years.
Conclusions: A small number of our T1D patients require attention
in emergency due to acute complications. Compared to the previous
years, diabetes decompensation rate is lowering as well as time spent
under observation in emergency room. Decompensations can be prevented and treated at home if phone communication with the diabetic team is available. It is very important to prevent hypoglycemic
episodes, especially in toddlers and patients with unaware hypoglycemias. Continuous glucose monitoring systems are useful tools to
avoid them, so they are specially recommended in patients at risk.
P240
Risk factors for severe hypoglycemia in children
and adolescents with type 1 diabetes
D. Bekkat Berkani1, N. Cherif1, H. Maouch1, L. Oukrif1, F.Z. Zemiri1,
K.S. Bouk’hil1, W. Messadi1, A. Bensenouci1
1
CHU Benimessous, Alger, Algeria
Objective: The aim of our study was to determine the risk factors for
severe hypoglycemia in a population of children and adolescents
with T1D.
125
POSTER TOURS
Methods: We performed a retrospective study (2005–2015) on
300 patients with a mean of 9.6 4.2 years (range 2 to 16 years).
Data were collected from the specialized counseling records where a
questionnaire on possible acute metabolic accidents is filled systematically at every visit. Severe hypoglycemia is defined as blood glucose < 70 mg / dL with disorders of consciousness (confusion,
seizure and coma). Age, sex, duration of diabetes, level of education
of parents, glycated haemoglobin (HbA1c), insulin regimen, number of
glucose control per day, causes, treatment and recurrence of hypoglycemia were recorded.
Results: Overall incidence of hypoglycemia was 2.3 events per
100 patient / year. Confusion was the most common clinical sign
(60%). Hypoglycemia was often unexplained (55%). Other causes
were found: vomiting, intense physical activity, travel, less food consumption, error in injection, less blood glucose control. HbA1c was
between 7.5% and 8% in 53% of cases. Treatment of hypoglycemia
was given in a hospital setting in 40% of cases. Use of glucagon at
home was low (17%). Recurrence of hypoglycemic episodes was
34%. Neither glycemic control nor duration of diabetes nor level of
education of parents seem to play a role in the occurrence of hypoglycemia. Factors related to severe hypoglycemia are school age
between 5 and 10 years (40%) and insulin regimen with two injections of human insulin (66.7%).
Conclusions: Frequency of severe hypoglycemia is relatively low in
our population of diabetic children. It is not associated with lower
HbA1c or intensive insulin therapy. It seems to be mainly related to
the management of diabetes. Prevention must go through an assessment and improvement of our therapeutic education program given
to diabetic children and their families.
P241
Extremely severe ketoacidosis with multiple organ
failure at onset of diabetes type 1 in 17-month girl
- a case report
G. Deja1, M. Daab2, P. Wieczorek2, H. Kaminska1, P. Jarosz-Chobot1
1
Medical University of Silesia, Dept. of Children Diabetology, Katowice,
Poland, 2Upper Silesian Child Health Centre, Katowice, Poland
Introduction: Complications of severe DKA are relatively rare pretty rarely multiple organ failure can be observed. We present the
case report of extremely severe DKA in 17-month girl with cardiorespiratory, kidney and liver failure and intestinal ischemia with
perforation.
Case report: Parents came with 17-month girl to the hospital
because of weakness, vomiting and fever - the child was wrongly
diagnosed with pharyngitis. After 2 days they came back with unconscious child. A girl diagnosed with DKA (glucose 2259 mg/dL,
pH 7.1; BE −21.1 mmol/L) was moved to ICU.
On admission the condition was described as very heavy - in shock,
extremely dehydrated. Laboratory tests confirmed DKA and
hiperosmolar-hyperglycemic state (Na 167 mmol/l, eff. osmolality:
404 mOsm /kg). As a treatment parenteral fluid, insulin iv, pressor
amines and antibiotics were used. Despite intensive treatment, the
further complications were observed - child required intubation and
respiratory support. Next the development of multiple organ failure
with the dominant image of liver and renal failure was observed (ALT:
2174 U/L, ASPT:3759 U/L, cr.:2,95 mg/dl). Moreover, due to intestinal perforation, bowel resection and jejunostomy were necessary.
The child was presenting permanent unstable glucose levels (80400 mg/dl), treated with 20-40% of glucose iv and insulin iv. Insulin
requirements were dynamically variable depending on liver and kidney function. After a month´s stay in the ICU and improvement of
general condition, child was transferred to the Dept.of Children Diabetology to introduce subcutaneous insulin therapy and parent’s education. Finally the girl with complete normalization parameters of
liver, renal and the relatively stable glucose was discharged home
after 3 weeks.
Conclusion: Extremely severe DKA with multiple organ failure as
mentioned above probably results from the coincidence of some
adverse factors as: rapid dehydration in small child, delayed/wrong
diagnosis and young age of parents.
P241
High incidence of diabetic ketoacidosis at diagnosis
of type 1 diabetes among Polish children aged
10–12 and up to 5 years of age: a multicenter study
A. Ramotowska1, A. Szypowska1, K. Dżygało1, M. WysockaMincewicz2, A. Mazur3, L. Lisowicz3, I. Ben-Skowronek4,
J. Sieniawska4, B. Klonowska5, D. Charemska5, J. Nawrotek6,
I. Jałowiec6, A. Bossowski7, M. Jamiołkowska7, B. Pyrżak8,
ska8, M. Szalecki2,9
I. Rogozin
1
Department of Paediatrics, Medical University of Warsaw, Warsaw,
Poland, 2Department of Endocrinology and Diabetology, Children’s
Memorial Health Institute, Warsaw, Poland, 3II Department of
Paediatrics, Paediatric Endocrinology and Diabetes, Medical Faculty
University of Rzeszow, Rzeszow, Poland, 4Department of Paediatric
Endocrinology and Diabetology, Medical University of Lublin, Lublin,
Poland, 5Department of Clinical Pediatrics. Faculty of Medical Sciences,
University of Warmia and Mazury in Olsztyn, Provincial Specialist
Chilldren’s Hospital, Olsztyn, Poland, 6Endocrinology and Diabetology
Ward, General District Hospital, Kielce, Poland, 7Department of
Pediatrics, Endocrinology, Diabetology with a Cardiology Division,
Medical University in Białystok, Bialystok, Poland, 8Department of
Pediatric and Endocrinology, Medical University of Warsaw, Warsaw,
Poland, 9Faculty of Health Sciences, UJK, Kielce, Poland
Objectives: Despite its characteristic symptoms diabetes is still diagnosed late causing the development of diabetic ketoacidosis (DKA).
The aim of this retrospective cohort study was to estimate the incidence of DKA and factors associated with the development of acidosis at diabetes recognition in Polish children aged 0–17 between
2010 and 2014 year.
Methods: The study population consisted of 2100 children with
newly diagnosed T1D in the years 2010–2014 in 7 hospitals in eastern and central Poland. The population living in these areas accounts
for 35% of the Polish population. DKA was defined according ISPAD
Guidelines, as a capillary pH < 7.3. The analysed data included age,
sex, diabetes recognition, pH, HbA1c, fasting C-peptide, BMI-SDS.
Results: DKA was observed in 28.6% of children. There were two
peaks in DKA occurrence: in children < 5 years of age (33.9%) and
aged 10–12 (34%). The highest incidence of DKA was noted in children aged 0–2 (48.4%). In the group with DKA, moderate and severe
DKA occurred in 46.7% of children. Girls and children < 2years of
age were more prone to severe DKA. The multiple logistic regression
analysis showed the following factors associated with DKA: age
(p = 0.002), fasting C-peptide (p = 0.0001), HbA1c (p = 0.0001), no
family history of T1D (p = 0.0001) and BMI-SDS (p = 0.0001).
Conclusion: The incidence of DKA is high and remained unchanged
over the last 5 years. Increasing the awareness of symptoms of DKA
is
recommended
among
children < 5
years
of
age
(especially < 2 years of age) and aged 10–12. Children < 2 years of
age and girls were at the highest risk of severe DKA.
P243
Management and outcomes in paediatric
ketoacidosis - West Midlands experience
A. Kumaran, A. Prashar, M. Kershaw
Birmingham Children’s Hospital, Paediatric Endocrinology and Diabetes,
Birmingham, United Kingdom
Objective: Well defined national guidelines exist for the management
of diabetic ketoacidosis (DKA). Adherence to these protocols are crucial to improve regional patient care outcomes. We aimed to assess
adherence and the frequency of DKA complications associated with
the network adopted BSPED 2009 guidelines.
126
Methods: Prospective audit of DKA management in paediatric units
within the West Midlands region in United Kingdom was performed
from 1st April 2015 - 3rd August 2015.
Results: Data was available for 29 patients (17 females) with a mean
age 12.2 years (range 1–18 years). Mean duration of diabetes 5.5 years
(SD 4.3 years, range 2–13 years). 49% were newly diagnosed Type
1 diabetes of whom 42% reported a delay in diagnosis (2–10 days).
73% experienced moderate or severe DKA. Children with mild DKA
had higher ketone levels at presentation. Fluid boluses were given to
50% and 72% of children with mild and moderate DKA respectively.
Contrary to guidance 2 patients received insulin infusion prematurely,
and experienced rapid shift in blood glucose. Of those commenced on
0.05u/kg/hr, all increased their rates by 2–9 hours. Mean duration of
acidosis was significantly longer in children commenced on 0.05 u/kg/
hr vs those commenced on 0.1 u/kg/hr (mean 21 hrs vs 12.3 hrs,
p = 0.001). Hypokalaemia occurred in 17%, all newly diagnosed, (n = 5
) and hypoglycaemia in 38% (n = 11). Hypoglycaemia was associated
with inappropriate fluid change in 14% of patients.
Conclusion: This audit highlights a low threshold for bolus administration relating to severity of DKA, related to 2009 guidelines, and
variations in insulin introduction. Rates of hypoglycaemia and hypokalaemia were high, raising awareness across the region. Recent
didactic NICE guidance on fluid management in DKA is anticipated to
reduce these complications, as well as the new primary care referral
pathway. Prospective regional audit and outcome comparison with
the new NICE guidance, and referral pathway is underway.
P244
Sever hypertrigliceridemia in the course of
ketoacidosis in a patient with newly diagnosed type
1 diabetes mellitus
śka1, P. Wieczorek2, G. Deja1,
E. Skala-Zamorowska1, H. Kamin
W. Mlynarski3, P. Jarosz-Chobot1
1
Medical University of Silesia, Dept. of Children Diabetology, Katowice,
Poland, 2Medical University of Silesia, Uppersilesian Child’s Health
Centre, Emergency Department, Katowice, Poland, 3Medical University
of Lodz, Department of Paediatrics, Oncology, Haematology and
Diabetology, Lodz, Poland
Introduction: Mild hypertrigliceridemia is a common complication
found in poorly treated diabetes. Prevelance of mild hypertrigliceridemiais found in about 50% patients with diabetic ketoacidosis (DKA).
Severe hypertrigliceridemia (TG > 22,4 mmol/l [>1959 mg/dl]) is a
rare complication found in 1% patients with T1DM.
Aim: A case report of 2-year-old-girl in which clinical picture of type
1 diabetes mellitus was accompanied by DKA and severe
hypertrigliceridemia.
Case report: A 2-year-old-girl was admitted to the Emergency
Department with DKA (pH-7,1, HCO3− 8,8 mmol/l, BE −21,1 mmol/
l), glucose level of 556 mg/dl, hiperlipidemia (TG 11470 mg/dl
[131,1 mmol/l]). After recover from DKA she was discharge from
Intensive Care Unit and trasfered to Departmet of Children Diabetology. At our departmet she was continued an intravenous fluid and an
intravenous infusions of insulin. The breestfeding was reduced. After
3 days of intensive intravenous infusions of insulin she was transitioned to subcutaneous insulin (insulin pump: DD 3,8 (IU), basal
1,2 IU). At the time of diagnosis antibodies associated with type 1 diabetes were strongly positive (anti-GAD 375,79 U/ml, IA-2 451,5
U/ml). The administered treatment result in nearly normal glycemic
values. Beacause of long lasting lipd disturbances we decided to
determine if diabetic lipaemia was caused by loss of function mutations in LPL. Genetic test revealed no mutations in genes
affecting LPL.
Conclusions: Diabetic lipaemia can be caused not only by profound
insulin deficiency. Additional factor which should be taking into consideration in very young children is breast-feeding, which is associated with increased mean toatal cholesterol (TC) and LDL levels.
Morover, sever hypertrigliceridemia may result in mutations in genes
encoding lipoprotein lipase (LPL).
POSTER TOURS
P245
Identifying barriers to the timely diagnosis of type
1 diabetes in young people in the primary care
(community) setting
C. Suo1, K. Wilson2, C. Acerini3
West Suffolk Hospital, Bury St Edmunds, United Kingdom, 2East of
England Children and Young People’s Diabetes Network, Cambridge,
United Kingdom, 3University of Cambridge, Paediatrics Department,
Cambridge, United Kingdom
1
Objectives: In the UK, the majority of young people presenting for
the first time with signs and symptoms of type 1 diabetes (T1D) are
initially seen by their primary care doctor (general practitioner, or
GP). Mis- or delayed diagnosis is not uncommon, and increases the
risk of diabetic ketoacidosis-related morbidity. This study sought to
identify the specific challenges faced by GPs in this setting in order
to develop effective care pathways and recommendations for improving the timely diagnosis of T1D.
Methods: An online survey questionnaire was distributed to all GPs
within a geographically defined health administration area in the
UK. Questions included: demographics; training experiences and clinical knowledge on the diagnosis of childhood T1D; referral pathways;
and equipment access.
Results: 551 GPs were directly approached. 63 responded (11.4%)
and were representative of GPs in England in terms of prior experience. 38 (63%) responders had diagnosed T1D in a child before.
Once T1D was suspected, 87% and 100% indicated they would perform urinalysis and a finger prick blood test respectively on the day
of presentation. However, 38%, 19%, and 27% also chose to test
for venous blood glucose, fasting blood glucose and HbA1C respectively to confirm their diagnosis. All responders would arrange
urgent referral to hospital or call the local children’s diabetes team
for advice. All respondents had access to a glucometer, however
use was not routinely considered in the ’sick child’ with 23% using
it less than once a year. 43% rated their previous T1D training as
’barely adequate’ or ’inadequate’, and 82% indicated that further
training was required.
Conclusions: Our study provides evidence that more training/education on childhood T1D in primary care is needed. Whilst there was
appropriate use of urinalysis and finger prick blood testing, education
is required to raise the awareness for T1D and avoid unnecessary
tests so as to prevent delay in diagnosis.
P246
GAD autoantibodies long after clinical onset in
T1D: search for heterogeneity and better
classification
Q.J. ten Kate1, H.J. Aanstoot1, E. Birnie1,2, M. de Vries1, H.J. Veeze1,
D. Mul1
1
Diabeter, Center for Pediatric and Adolescent Diabetes Care and
Research, Rotterdam, Netherlands, 2University Medical Center
Groningen, Genetics, Groningen, Netherlands
Antibodies to GAD65 (GADA) are not always measured at clinical
onset of type 1 diabetes (T1D) while they could help to identify its
autoimmune nature. We determined the prevalence of autoantibody
positivity to GADA in type 1 diabetes (T1D) patients later in the disease course, and investigated correlations between persisting GADA
positivity (GADA persistence) and various clinical and biological markers of associated diseases.
This retrospective study used clinical and laboratory data of
990 patients (at time of measurement: median age [IQR] 16.7 [9.1]
years, ≥6 months duration of diabetes) attending our clinic. GADA
was measured by ELISA (DASP/IDS proficiency program). Differences
between GADA persisters (GAD titre ≥6 IU/ml) and GADA negatives
were assessed by Students t test or Mann Whitney U test. Correlations with clinical parameters and complication markers were tested
with linear regression.
127
POSTER TOURS
After a median [IQR] time since onset of 7.8 [9.5] years, from all
tested patients, 58.8% (582/990) had persistent GADA levels (GADA
≥6 IU/ml) which was significantly associated to female sex and obesity (p = 0.001 and 0.042). In addition, initial HbA1C was higher in
GADA persisters (p = 0.044). Parameters that correlated with GADA
level (multivariable analysis) were sex, age, age of onset, triglycerides
and disease duration. Predictors for GADA status were sex, age of
onset, age, TSH, triglycerides and variation in HbA1c (expressed
as SD).
With 58% of patients showing GADA long after onset, this test can
be applied later in the course of diabetes to corroborate the autoimmune nature and can thus help classify diabetes . Despite significant
differences in clinical parameters between GADA positives and
GADA negatives, demonstrating marked heterogeneity in T1D, their
clinical relevance remains to be established. It is yet unknown why so
many patients possess persistent autoimmunity against GAD.
P247
Emergency advice for families of children with
diabetes - the story of a helpline
S. Grosser1, V. Alexander1
1
NHS Tayside, Tayside Children’s Hospital, Dundee, United Kingdom
Objective: To describe the changes in out-of-hours emergency
advice to families of children with diabetes over the last 15 years, the
reasons for change and impact on hospital attendance.
The local emergency clinical helpline for children with diabetes
(DiabNet) was discontinued in August 2015. We have looked at its
service and how it informed the support we deliver today, especially
out of hours advice provided currently by paediatric registrars.
Background: DiabNet was established in 2000 as a collaboration
between three Scottish Health Boards. This helpline was staffed by
Paediatric Diabetes Specialist Nurses using shared protocols and
guidelines and was initially open 24 hours a day, 7 days a week. Over
the years, it evolved to offer a more tailored service, as changes in
diabetes management led to families being better equipped to manage most situations.
Consequently, Diabnet helpline was discontinued. Families now
contact the paediatric registrar on-call for emergency advice. To support this change, registrars were trained using interactive teaching
sessions, flow charts on the intranet and a call proforma to ensure a
standard approach. Completed forms are used for audit and training
purposes.
Results: There are 223 children with Type 1 diabetes in NHS Tayside. There were approximately 120 calls to the helpline per year.
32 calls were made in NHS Tayside 2014–15 (<1/week). 35 out of
hours calls were logged in the 8 months since withdrawal of the DiabNet helpline, 3 of which resulted in admission.
Conclusion: Recommendations from NICE in 2015 suggest that
24 hour emergency advice be available to families of children with
type 1 diabetes from “their diabetes team”. Few units would be able
to support this and paediatric trainees have limited exposure to childhood diabetes. With our current approach, early results suggest that
safe and effective advice can be provided by medical trainees with
no increased rate of hospital attendance.
P248
Variations in the relationship between glucose and
HbA1c may contribute to clinic and country
differences in HbA1c
A. Rydin1, M. Ekström1, K. Lundquist1, R. Hanas1,2
1
2
NU Hospital Group, Dept. of Pediatrics, Uddevalla, Sweden,
Gothenburg University, Sahlgrenska Academy, Gothenburg, Sweden
Objectives: In many countries there is a large range between clinics
in mean HbA1c. Our aim was to investigate if this range is influenced
by variation of the relationship between mean glucose levels and
HbA1c.
Methods: Mean glucose over 7, 14 and 30 days was collected with
blood glucose (BG) tests, Continuous Glucose Monitoring (CGM) and
Flash Libre (FGM). Patients were included if over 1 month > 8 BG
tests/day or CGM/FGM >30% of the day was registered. We calculated the Hemoglobin Glycation Index (HGI) for each patient
(HGI = the difference between observed HbA1c and that calculated
from the regression equation of the clinic).
Results: 59 patients with type 1 diabetes were included: age
11.6 4.0 years, diabetes duration 4.6 2.9 years and HbA1c
52.2 10.3 mmol/mol (6.9 0.9%). 2 patients were of non-Swedish
origin. Correlations between glucose over 30 days and HbA1c was:
BG: r = 0.75, CGM: r = 0.70 and Libre: r = 0.93; all p < 0.001. The
relationship between mean glucose levels, CGM (n = 25) or FGM
(n = 20) when available, otherwise BG (n = 14), and HbA1c in a linear
regression equation was: HbA1c (mmol/mol) =11.94 + (4.58 x glucose [mmol/l]), r = 0.82, p < 0.001. HGI ranged from −13.9 to
+6.3 mmol/mol. When comparing thirds (table), there was a rather
small difference in measured HbA1c compared to Soros 2010.
Conclusions: There seems to be a smaller difference in the variation
of mean glucose levels and HbA1c in our clinic with a very homogenous ethnic background. However, Swedish children seem to get
lower HbA1c for the same BG levels compared to populations with
mixed ethnicity. This can affect HbA1c comparisons between clinics
and countries. Comparing percentage of patients below target HbA1c
may be a better measure than mean HbA1c.
Low HGI
Moderate HGI
High HGI
Glucose, mmol/l
9.0
7.8
9.1
Glucose, mg/dl
162
141
164
HbA1c, mmol/mol
48.0
50.2
57.1
HbA1c, %
6.5
6.7
7.4
[Comparison of HGI levels]
P249
Findings from a pre-clinic questionnaire given prior
consultation at an NHS paediatric diabetes
outpatient service in England - the patient’s
perspective: a survey of patient/carer experience of
a paediatric diabetes outpatient service
S. Ahmed1, C. Ihe1
1
Maidstone and Tunbridge Wells Hospital, Pembury, United Kingdom
Objectives: To assess
1. What patients really want from their clinic visits.
2. Patient experience of a consultation focused by a pre-clinic
questionnaire.
Methods: A prospective survey conducted between Feb-Mar 2016
in the Paediatric diabetes out-patient clinic. Pre-clinic questionnaires
were handed out to patients/carers prior to clinic appointment
enquiring about their general health, diabetes control and expectations from the clinic. Clinic consultation was tailored according to
individual patient’s responses. A Post-clinic questionnaire was completed by patients/carers to assess their experience of clinic.
Results: 50 questionnaires were shared with 85% response. Mean
HbA1c was 68 mmol/mol (36-130 mmol/mol). Patients reported satisfaction with their general health(80%), home life (84%) and diet
(80%) but were less satisfied with their mood (57%), school (66%) and
social life (77%). They expressed desire to discuss Insulin doses
(23%), hyper/hypoglycaemias (18%), exercise (14%), travel (9%),
school/exams (9%), mood (9%), carbohydrate counting (7%), social life
128
(4.5%) and other (6% CGMS, pump cannula change). 32% reported
issues in diabetes control.
They expressed desire to see a doctor (23%), diabetes nurse (11%),
psychologist (11%), podiatrist (9%) and dietician (7%). 18% needed to
see >1 member of diabetes team. 4.4% wanted to speak to a member
of diabetes team on their own.
Post consult questionnaire showed >93% of patients were able to
discuss everything and meet a particular member of diabetes team.
80% preferred a “One stop diabetes clinic” with all members of the
MDT together besides the psychologist. 83% felt pre-clinic questionnaire was useful in making their clinic consultation patient/carer
centred.
Conclusions: Pre clinic questionnaire should be considered as a useful tool in understanding patient expectations of a clinic visit. Our
experience shows that patient’s expectation of visit can be efficiently
blended with their clinician’s improving patient’s overall satisfaction.
POSTER TOURS
He developed hyperglycemia during the first cycle of steroid therapy. His BMI 31.8 kg/m2,severe acanthosis nigricans,high insulin
level and normal HbA1C 5.6%. Insulin therapy was started (0.5unit/
kg/day) for 3 weeks. Insulin dose decreased significantly till discontinued, while still on prednisone. The diagnosis of dysglycemia induced
by steroid in an obese patient was entertained. Metformin was
started. After the 2nd cycle of steroid, he developed severe mucositis
that required TPN with glucose infusion rate 2-3 mg/kg/min. Hyperglycemia worsened with blood glucose average 400 mg/dL that
required insulin therapy with increased Insulin requirements up to
1.5unit/kg/day. However, the patient had persistent severe
hyperglycemia.
A possibility of insulin induced insulin resistance was raised and
gradual decrease in insulin dose and spacing of rapid insulin applied.
Blood glucose showed dramatic drop and in 5 days he was receiving
basal insulin 0.2 unit/kg/day and no rapid insulin. CGMS was done all
through taht period which confirmed the suggested possibility.
P250
Variation in 24 hour basal insulin requirements with
age in children and young people (CYP) with type
1 diabetes mellitus (T1DM)
L. Potts1, F. Brown1, C. Peters2, P. Hindmarsh1
1
University College London Hospitals, London, United Kingdom, 2Great
Ormond Street Hospital, Endocrinology, London, United Kingdom
Objectives: To study changes in insulin basal rates as a proxy for
insulin sensitivity in CYP with well controlled T1DM (mean HbA1c
7.3%, range 5.2-8.5).
Methods: Insulin pump settings (total daily dose (TDD), sensitivity
ratio) from 227 (110 M) CYP with T1DM aged 2–19.5 years were
related to age, sex and body mass index (BMI).
Results: There were no differences between the sexes for age, BMI,
sensitivity, TDD/kg or glycosylated haemoglobin (HbA1c). HbA1c did
not change across the age range and was not influenced by insulin
dose or % basal insulin delivery. Sensitivity ratio was inversely related
with age (r = −0.75; P < 0.001) and partly with BMI with no effect of
sex. The percentage basal insulin increased with age: 0.6% /year. The
highest basal rates were between 18.00-24.00 h (0.7 (SD 0.5) Units/
h) and between 06.00-12.00 h (0.6 (SD 0.5) Units/h) compared to the
other times (P = 0.004) with the time frames 00.00-06.00 h and
06.00-12.00 h showing the greatest increases with age.
Conclusions: Insulin requirements change with age in part related to
changes in Growth Hormone secretion. Little is known of the impact
of age on the circadian variation in insulin secretion. These data suggest that there is a circadian variation in insulin sensitivity as
reflected in basal insulin delivery rates. The change in insulin sensitivity decreases with age across the whole study population and is not
influenced by sex and only partly by BMI. Although Growth Hormone
has been implicated in the pubertal alterations these data would suggest that other factors, either intrinsic or extrinsic, may influence
insulin sensitivity through childhood and adolescence.
P251
Insulin- induced insulin resistance in a 12 year old
boy with Leukemia on steroid therapy: continuous
glucose monitoring system can have a role
A. Elawwa1,2, A. Soliman1,2, N. Al Aaraj1, F. Al Yafei1, N. El Sayed1,
E. Mosaad1, M. El Gamal1, Z. Mohammadi1, F. Umar1
1
Hamad Medical Corporation, Pediatric Endocrine & Diabetes
Department, Doha, Qatar, 2Faculty of Medicine, Alexandria University,
Pediatric Department, Alexandria, Egypt
Introduction: Somogyi described patients with hyperglycemia despite
being on high doses of insulin.
Case
presentation: A
13
year
old
boy,Down
syndrome,hypothyroidism and newly diagnosed acute lymphocytic
leukemia.
[CGMS before, during & after insulin dose reduction]
Conclusion: Reduction of the insulin dose rather than increase might
be the key step in the normalization of the blood glucose level when
insulin induced insulin resistance is suspected. CGMS can help its
detection.
P252
Kindergarten diabetes care for the toddlers with
type 1 diabetes (T1D) according to parents views
Y. Bazdarska1,2, R. Stoicheva1, N. Vuleva3, V. Iotova1,2
UMHAT ’St. Marina’, First Pediatric Clinic, Varna, Bulgaria, 2Medical
University of Varna, Varna, Bulgaria, 3Municipality Varna, Expert in
Department of Health, Varna, Bulgaria
1
Background: In the last decades there is a clear trend of increasing
incidence of T1D in developing countries and the age group under
6 years. Parents of patients from that particular age group often complain of inadequate support and diabetes care during kindergarten
time. We present a pilot study for diabetes management at kindergartens in our municipality. Our aim was to understand the parents’attitude towards diabetes care in the kindergarten.
Methods: Parents of all patients under 7 years of age who attend
kindergarten were invited to participate. We collected only parents’
opinion for provided support specific to diabetes through a specially
developed questionnaire. A 76.5% of total number of approached
parents accepted to participate.
Results: In total, 13 parents were interviewed (12 mothers), mean
age 36.3 4.06 years, 11 (84.6%) university graduates. Mean age of
their children is 5.75 1.5 years, mean duration of T1D 2.52 1.9
y., and BMI is appropriate for age and sex. All of children use insulin
analogs, 7 (53.8%) are on pump therapy. Mean HbA1c is
129
POSTER TOURS
7.55% 0.74. In 46% families were offered to transfer their child to
other kindergarten by kindergartens staff because of the difficulty of
diabetes care. Most of the parents are taking care for children during
kindergarten time (76.9%); 69% of parents measure blood glucose
between 2–3 times/day and inject insulin in the kindergarten; 30% of
children attend half day, and 23% are with their mother in kindergarten during the whole day. Of all parents, 77% (10) estimate diabetes
care and support as inadequate. Their recommendations are “to open
a specialized diabetes group/kindergarten (50%)”, “education of kindergarten staff (100%)”, etc.
Conclusion: The study demonstrates lack of support to the youngest
children with diabetes in our municipality. Specially developed
approach to kindergarten based care with broad stakeholders support
is urgently needed.
communication style; information giving / sharing and constancy
of support.
Our study provides evidence that youth with T1D deem consistency of care, providing timely and relevant information and being listened to and treated like an adult as indicators of rewarding and
engaging transitional diabetes care. The voice and opinions of young
people with T1D should be used to develop care pathways that
reflect their specific needs and requirements.
P254
High remission rate in children with type1 diabetes
in Sweden but minor differences in age
U. Söderström1,2, J. Åman1,3, U. Samuelsson4
1
P253
Identifying the barriers to effective diabetes
’transitional care’. A qualitative study of patient
satisfaction and experiences of transition
K.R.H.M. Wilson1, J. Ashford2, P. Olsen3, S. Slegtenhorst4,
R. Williams2, C.L. Acerini5
1
East of England Children and Young People’s Diabetes Network,
Cambridge, United Kingdom, 2Cambridge University Hospitals NHS
Foundation Trust, Department of Paediatrics, Cambridge, United
Kingdom, 3West Suffolk Hospital, Department of Paediatrics, Bury St
Edmunds, United Kingdom, 4Cambridge University Hospitals NHS
Foundation Trust, Department of Dietetics, Cambridge, United Kingdom,
5
University of Cambridge, Department of Paediatrics, Cambridge, United
Kingdom
Onset
Örebro University, School of Health and Medicine, Örebro, Sweden,
Childrens Hospital Sörmland, Pediatrics, Eskilstuna, Sweden, 3Örebro
University Hospital, Pediatrics, Örebro, Sweden, 4Linköping University
Hospital, Linköping University, Pediatrics, Linköping, Sweden
2
Objective: To study remission rate, defined as < 0.5 U/kg/BW, in
children with Type 1 diabetes (T1D) in relation to clinical parameters
at diagnosis and during the first 2.5 years (15 first clinical visits).
Methods: Data obtained from 4162 subjects, age 1–18 years at diagnosis, 44.8 % females. These individuals were registered in the Swedish pediatric diabetes quality registry (Swediabkids) and diagnosed
between 2007/01-2012/05.
Results Table.:
Table. Remission in relation to certain clinical parameters.
* < 0.01, # < 0.05
Visit 5
Visit 10
Visit 15
<0.5 U/kg/BW
90 25* n = 468
51 10* n = 1185 (33%)
53 11* n = 477 (15%)
56 10* n = 98 (9%)
≥0.5 U/kg/BW
56 10* n = 98 (9%)
56 14* n = 2412
58 12* n = 2687
63 13* n = 969
<0.5 U/kg/BW
12.7 4.9*
10.1 4.3
10.1 4.3
10.4 4.3#
≥0.5 U/kg/BW
11.9 4.3*
10.4 5.0
10.8 4.2
11.5 4.1#
<0.5 U/kg/BW
0.5 0.4
1.3 0.9
2.3 0.9
≥0.5 U/kg/BW
0.8 0.7
1.9 0.8
2.5 0.8
<0.5 U/kg/BW
−0.27 1.5
0.42 1.1
0.5 1.1
0.48 0.9
≥0.5 U/kg/BW
−0.5 1.5
0.52 1.1
0.5 1.1
0.68 1.0
Disparities in the quality of care for patients with type 1 diabetes
(T1D) undergoing transition from children’s to adult services are well
recognised. Poor planning and ill-defined care pathways promote
patient disengagement with many becoming ’lost’ to specialist followup for years. This study sought to obtain the views of young people’s
experiences of transition to identify perceived barriers to an effective
and rewarding transition experience.
A qualitative questionnaire was distributed to all youth with T1D
aged 14–19 yrs, undergoing ’transition’ (June-Sept 2015) within a
regional diabetes network in the UK. Areas explored included views
on clinic process; information provided and access to structured
education.
189 youth participated in the survey. 74% reported discussing
transition with their diabetes team prior to the first appointment.
81% had a good understanding of transition and its aims /objectives; yet only 66% had been given written information about
this. During clinics, patients received input from either a paediatric
(63%) or adult diabetologist (24%). Only 53% felt that teams
explained things well to them, and that there was sufficient time
to explore (69%) and address (65%) their concerns. 88% reported
receiving structured education during the transition process. 94%
indicated a preference to see the same team members during visits and preferred clinics to be scheduled mid afternoon (3-5 pm),
on a working day (50%) and at their local hospital (80%). Narrative
feedback
highlighted
recurring
themes
including
Conclusion: Remission in children with T1D was associated with
lower HbA1c and higher pH at onset but only to minor difference
in age.
P255
Clinical characteristics of slowly progressive
autoimmune diabetes mellitus of youth in a single
center
S.H. Lee1, J. Yu1
1
Dankook University Hospital, Pediatrics, Cheonan, Korea, Republic of
Objectives: Diabetes mellitus (DM) was mostly type 1 DM (T1DM)
in childhood, but recently there is a dramatic increase of type 2 DM
(T2DM). Sometimes it is not easy to classify based on clinical features, especially in case having clinical phenotype of T2DM with
autoantibody positivity. It is named as type 1.5 DM or slowly progressive autoimmune DM of youth. This study was designed to evaluate the clinical characteristics of T1.5DM.
Methods: A total of 95 subjects were enrolled in the study. Subjects
were classified into 3 groups: T1, T1.5, and T2DM. Age at diagnosis,
follow-up duration, BMI Z score, presence of DKA at the time of
diagnosis, and treatment modality as well as laboratory findings such
as autoantibody status, HbA1C, fructosamine, serum and urine C-
130
peptide were compared between groups. Mann-Whithney U test,
Kruskal-Wallis test, and Chi-square test were used for statistics using
IBM SPSS Statistics ver. 20.0 (IBM Co., Armonk, NY, USA).
Results: Among 95 subjects, type 1, 1.5, and 2 DM were 51 (53.7%),
11 (11.6%), and 33 (34.7%), respectively. Age at diagnosis and BMI Z
scores were lower ( p < 0.001), and DKA was more common in
T1DM. Serum c-peptide levels were significantly lower in T1DM
(0.52 vs. 2.28 vs. 3.61 ng/mL, p < 0.001). Autoantibody positivity
was 94.1% in T1DM, and anti-GAD autoantibody was most common.
The titers of anti-IA2 autoantibody were significantly higher in T1DM
compared to T1.5DM (45.95 vs. 4.86 U/mL, p < 0.001). In T1.5DM,
the mean duration was 3.22 years, among them 27% turned out
autoantibody negative. Twenty five percent of the patients with persistently positive autoantibody needed intensive insulin treatment
during follow-up.
Conclusions: It is valuable to check autoantibody for classification
and management. It is important to closely monitor patients with
T1.5DM because they may need intensive insulin treatment within
several years.
P256
Towards a personalised care of T1DM in a nonprofit organisation, T1 Diams, in Mauritius
P.K. Guness1, A. Dustagheer2, D. Jean Pierre2
1
Private, Saint Clothilde, Réunion, 2NGO/ T1Diams, Vacoas, Mauritius
Introduction: T1Diams, a Mauritian non-profit organisation, is specialised in the care and self-management of Type 1 Diabetes in the
island of Mauritius. In 2015, they revised and implemented a new
global approach (’Le Pt’1 medicale’) for the management of patients
with Type 1 Diabetes. The aim of the study is to give a preliminary
results on this new protocol.
Methods: This prospective study was carried out, in 2015, for a period
of 3 months. Patients having an HbA1c greater than 8.75% was
included. Their parents were also present. They were given intense
therapeutic education at home and during outdoor activities. Consultations with an eye specialist, a medical practitioner, a dietitian and a psychologist/social worker were scheduled. A questionnaire on knowledge
of Type 1 diabetes (what is T1D, Surveillance, Hypo-Hyper, Insulin and
nutrition) and another to evaluate the impact of T1D on quality of life
(SF36) was carried out before and after completion of the program.
HbA1c values were noted before and at the end of the study. Microalbuminuria was also carried out. Data was collected on a tablet.
Results: 45 patients were identified and only 38 patients (20 Male
and 18 females) having 16.2 6.2 years completed the study. . All of
them were seen by the diabetes educators and general practitioner.
Proactive mental health support was provided to all patients by the
psychologist/social worker, 42% (n = 16) eye specialist, 21% (n = 8)
dietitian. 81% (n = 31) had a recent Hba1c. There was a decrease of
1.39 2.77 in HbA1c (P < 0.05). 5 cases of microalbuminuria and
5 cases of proteinuria were diagnosed.
Conclusion: This study has shown that the management of T1D
requires a multidisciplinary approach. With an intense medical and
psychological care, there is a positive outcome of metabolic control
and quality of life. This study lays the foundation for the second
phase of the project.
P257
Diabetes education and regular self-monitoring of
blood glucose in the management of people with
type 1 diabetes
A. Fawwad, M.Y. Ahmedani, B. Tahir, A. Basit
Baqai Institute of Diabetology and Endocrinology, Baqai Medical
University, Karachi, Pakistan
Aims: To observe the impact of diabetes education and regular selfmonitoring of blood glucose (SMBG) on acute complications in people
with type 1 diabetes.
POSTER TOURS
Methodology: This prospective study was conducted at Baqai Institute of Diabetology and Endocrinology, Karachi - Pakistan. People
with type 1 diabetes aged < 25 years, who attended the outpatient
department from September 2011 to September 2013, were included
in the study after obtaining informed consent. Structured diabetes
education was given through one to one sessions and group sessions
along with 24 hour telephonic helpline service. All other relevant clinical care were provided as per standard guidelines. The study participants were provided glucometer and strips, advised to monitor their
blood glucose at home on different specified timings. Blood samples
were collected for HbA1c at baseline and after every six month.
Results: Out of 106 people with type 1 diabetes, 50 (47.16%) were
males and 56 (52.83%) were females. Mean age of the participants
was 16.42 5.42 years with mean duration of diabetes of
6.78 4.15 years. Based on 18,093 blood glucose readings, there
were 778 (4.3%) and 4921 (27.2%) blood glucose readings in hypoglycemic (<70 mg/dl) and severe hyperglycemic (>250 mg/dl) ranges
respectively were obtained during eighteen months. Six episodes
[2 for severe hypoglycemia and 4 for severe hyperglycemia / diabetic
ketoacidosis (DKA)] required hospitalization. Mean HbA1c of the participants at baseline was 11.28 2.69% which decreased significantly to 9.79 2.41% (p = 0.001) after 18 months.
Conclusion: The results of the study suggest that with diabetes education and regular SMBGs, better glycemic control is achievable and
acute complications of diabetes can be prevented in people with type
1 diabetes.
Acknowledgment: This is a study from “Insulin my life” project, a collaborative project of World Diabetes Foundation, Life for a Child program and Baqai Institute of Diabetology and Endocrinology.
P258
Transient extreme insulin resistance in childhood
onset diabetes mellitus type 1 presenting with
severe diabetic ketoacidosis, hyperlipidemia and
acute pancreatitis
N. Rojnic Putarek1, M. Novak2, A. Spehar Uroic1, N. Krnic1, K. Dumic
Kubat1
1
University Hospital Center Zagreb, University of Zagreb Medical School,
Department of Pediatric Endocrinology and Diabetes, Zagreb, Croatia,
2
University Hospital Center Zagreb, University of Zagreb Medical School,
Pediatric Intensive Care Unit, Zagreb, Croatia
Background: Mild increase in serum lipid concentrations is a common feature of diabetic ketoacidosis (DKA) while severe hyperlipidemia (HL) with milky plasma is rare. HL is an uncommon cause of
acute pancreatitis (AP), especially in children. The risk for developing
AP rises when serum triglyceride level exceeds 11 mmol/L
(1.000 mg/dL). Some extent of insulin resistance (IR) is present in
almost all cases of DKA while severe IR is exceedingly rare.
Case report: We report on a 5-year-old, previously healthy, nonobese girl with newly diagnosed diabetes mellltus type 1 who presented with distended abdomen, severe abdominal pain, hypovolemic
shock and altered mental status. Laboratory examination revealed
DKA. As well, her serum was milky showing severe HL (triglycerides:
241.97 mmol/l; ref. < 1.7 mmol/l and total cholesterol 40.1 mmol/L;
ref. < 5.0 mmol/l), while the CT scan showed signs of AP.
In spite of insulin and fluid therapy introduced according to ISPAD
DKA protocol, blood glucose levels remained high with prolonged
metabolic acidosis until extremely high doses of insulin were administered (up to 1.1 IU/kg/h). Due to severe HL and AP two courses of
plasmapheresis were performed with consequent decrease in triglyceride and lipase levels. However, we also noticed restituition of insulin sensitivity, reverse of acidosis and clinical improvement.
Conclusion: To the best of our knowledge this is the first report of
co-existence of DKA, HL and AP accompanied with extreme IR in
pediatric patient. Plasmapheresis was shown to be an effective treatment for severe hyperlipidemic pancreatitis in a child with DKA. Nevertheless, we also observed recovery from extreme IR that was not
previously reported in such settings.
131
POSTER TOURS
P259
Second national examination of HbA1c in Bulgarian
children with type 1 diabetes mellitus: an impact of
education and social status
M. Archinkova1, M. Konstantinova1, R. Savova1, V. Iotova2,
C. Petrova3, K. Koprivarova1, V. Boyadzhiev4, V. Mladenov4,
N. Kaleva5, R. Koleva6, V. Despotova7
1
Medical University-Sofia, University Children’s Hospital, Clinic of
Endocrinology and Diabetes, Sofia, Bulgaria, 2Medical University,
University Hospital, Clinic of Pediatric Endocrinology, Varna, Bulgaria,
3
Medical University Pleven, University Hospital ’George Stransky, Clinic
for Children’s Diseases, Pleven, Bulgaria, 4Medical University, University
Hospital "Sv. Marina", Clinic of Pediatric Endocrinology, Varna, Bulgaria,
5
Medical University of Plovdiv, UMBAL ’St. George’, Clinic of Pediatrics
and Genetic Diseases, Plovdiv, Bulgaria, 6Diagnostic and Consulting
Center I, Stara Zagora, Bulgaria, 7Tokuda Hospital, Pediatric clinic, Sofia,
Bulgaria
Objectives: 1. To evaluate the actual level of HbA1c in a cohort of
Bulgarian patients with type 1 diabetes aged 0–18 years in 2014.
- With the same standardized method: HPLC /Bio-Rad/
- With the same device in a Central lab /Sofia/
2. To compare the mean levels of HbA1c in patients studied in
2012 and 2014.
3. To analyse the factors - sex, age, educational level and family
social status on the glycemic control
Methods: 1. A standardized method: HPLC /Bio-Rad/ for measurement of HbA1c in a Central lab was used.
- The survey was conducted in 11 paediatric endocrine practices in
the country: 498 diabetic children were examined (261 boys and
237 girls) from January to September 2014. The results were compared to that of the previous study in 2012.
2. Statistical analysis: SPSS for Windows, Version 16.0. USA, Chicago, SPSS Inc.
Results: 1. The mean level of HbA1c for diabetic patients studied in
2014 (8.43% 1.69) is significantly lower compared with patients
studied in 2012 (8.93% 1.98).
2. Significantly more patients in the second study (36%) have optimal control with HbA1c < 7.5% compared to that from the first
study (24.9%)
3. Significantly lower proportion of patients with poor glycemic
control (HbA1c > 9%) was found in the second study (30.3%) compared to the first one (42.7%).
4. The analyses of the factors influencing the control of diabetes
showed that:
- The patients from the lower social status and educational level of
the parents have the highest level of HbA1c in both studies.
- Teenagers in both studies had significant higher HbA1c compared
to other age groups (p = 0.003)-mean HbA1c is 9.19% for the first
study in 2012 and 8.8% for the second study in 2014.
Conclusions: Maintaining a good glycemic control is most difficult by
teenagers and children from families with low social status. Recurrent
training is required for these patient groups with social support to
their families. The latest have more difficult access to the specialized
paediatric centres.
P261
Our experience of using sensor augmented pump
Y. Hotta1, T. Kawamura1, K. Hashimura1, M. Joo1, Y. Kashihara1,
T. Hashimoto1, M. Hirose1, T. Higashide1, M. Aono1, S. Aono1,
H. Shinkaku1
1
in our hospital had started to use SAP by April 2016, whereas over
30 patients stopped using them.
Methods: We retrospectively analyzed the clinical features of patients
who started SAP. The reasons why some patients stopped SAP were
examined. Then we identified 35 patients who had used SAP for more
than one year (aged 2 to 75, HbA1c 7.63 1.14 %). We retrospectively examined whether their HbA1c had improved or not. The factors
which might affect on the blood glucose control were analyzed. Then
we asked them how they felt about SAP by the questionnaire.
Results: The major reasons for stopping SAP were the itching and
the bothering by wearing the sensors. The level of HbA1c in
35 patients who continued SAP for 1 year, had not changed
(7.63 1.14 % to 7.65 1.03 %). Their average blood glucose level
and standard deviation had not changed (192.4 81.3 mg/dl to
180.7 70.3 mg/dl). Some patients, whose HbA1c were high level
before using SAP, improved significantly. The using time of the sensors per week, age, nor sex were not related to the improvement of
HbA1c. Their satisfaction about Minimed 620 G with Enlite® was
high (7–8 points at ten points of perfect scores), even though HbA1c
in many patients was not improved. Almost all of them answered that
they felt that it was comfortable and convenient to use SAP, because
of showing glucose level and its trend.
Conclusion: Thirty % of patients stopped using Minimed 620 G with
Enlite system because of the sensor troubles. Thirty-five patients so
far continued using it for more than 1 year. SAP had not changed
blood glucose control significantly in one year. However, many
patients felt highly satisfaction to use the SAP system.
P262
Comparison of diabetes management outcomes in
under 5 s in 2 UK diabetes centres
F. Annan1, L. Bull2
1
Alder Hey Children’s Hospital, Nutrition and Dietetics, Liverpool, United
Kingdom, 2University College London Hospitals, London, United Kingdom
Introduction: Type 1 diabetes in the under 5 s presents unique challenges. Insulin pump therapy (CSII) is considered to be the treatment
of choice.
Objectives: A cross-sectional audit to compare HbA1c and BMI in
children diagnosed under 5 years of age in 2 different UK centres
[Alder Hey (AH) and University College London Hospitals (UCLH)].
Similar approaches to dietetic education with carbohydrate counting
and pre meal insulin advised from diagnosis. Treatment at diagnosis
varied between centres.
Methods: Data was obtained by retrospective record review. Treatment at diagnosis, current treatment, height, weight and HbA1c were
collected. Patients diagnosed before the age of 5 and currently under
the age of 6 were included for analysis. Patients were excluded if
diagnosis and initial management was in another centre. BMI SDS
was calculated for each patient. Descriptive statistics were used to
compare centres and treatment types.
Results: 30 patients diagnosed between November 2012 and February
2016 were identified. All patients at AH started on multiple daily injection therapy (MDI) and 11/18 patients converted to CSII 6 days - 1.7
years post diagnosis, 5 patients moved to pump therapy within 6 weeks
of diagnosis. UCLH commenced 11/12 patients on CSII at diagnosis.1
patient commenced MDI. The mean and median HbA1c achieved in
each centre were similar and there was no statistical difference in BMI
SDS. Patients on CSII had a tendency to a lower HbA1c and BMI SDS.
Centre
Osaka City University Graduate School, Pediatrics, Osaka, Japan
Background: In October 2014, we started to introduce the sensor
augmented pump (SAP: Minimed 620G with Enlite®) for patients with
type 1 diabetes for the first time in Japan. SAP which is available in
Japan is only Minimed 620G with Enlite®. So far about 100 patients
Treatment
BMI SDS
Mean HbA1c
AH
−2.13 -2.02
60
UCLH
−2.08 -1.84
57
CSII
−2.13-2.02
57
MDI
−0.8-1.5
62
[Comparison BMI and HbA1c]
132
Conclusions: No statistical difference in HbA1c or BMI SDS was
observed. Some patients on MDI achieved similar outcomes to those
on CSII. More detailed enquiry is needed to understand the factors
other than treatment choice that impact on glycaemic control and
weight.
P263
Clinical experience of insulin degludec for better
type 1 diabetes control in Lithuanian paediatric
patients
R. Navardauskaite1, E. Jasinskiene1, R. Dobrovolskiene1,
G. Mockeviciene1, I. Petraitiene1, R. Verkauskiene1
1
Lithuanian University of Health Sciences, Department of Endocrinology,
Kaunas, Lithuania
Objectives: Insulin degludec decreasing variability of glycaemia and
improving glycemic control.
Methods: We analysed 69 (27 boys) children at the age 4–17 years
(mean 14.55 3.13) with type 1 diabetes (DM1). DM1 duration was
6.0 4.22 years and poor control of diabetes: high HbA1C (mean
8.93 1.9), high variability of glycaemia, high rate of hypo- and
hyper- glycaemia, dawn phenomenon. Study included 60 patients
with multiple dose injections (MDI) and 9 insulin pump users. Insulin
degludec therapy was started in same paediatric diabetes centre.
Two groups were conducted in this study: 36 children with HbA1c <
9.0% and had higher rate of hypoglycaemia; 33 children with HbA1C
≥9.0%. Insulin degludec was administered once-daily at the same
time. The final dose of insulin degludec was considered, when the
lowest of three pre-breakfast glycaemia value was 4.0-8.0 mmol/L.
The percent change of rates of general/nocturnal (00:00–06:00 hours) hypoglycaemia and hyperglycaemia was analyzed
(n = 19) before changes of treatment and 1–3 month after switching
insulin degludec.
Results: The final insulin degludec dose of first group was
78.6 14.4% of previous basal insulin dose. Second group achieved
good glycaemia control with - 81.4 16.8%. The difference between
groups was not significantly (p = 0.563). The final dose of insulin
pump users was 99.3 10.1%. About 25% (n = 17) of patients had
dawn phenomenon and the dawn phenomenon expression disappeared for 80% of them. The changes of general and nocturnal rate
of hypoglycaemia before and after switching decreased
2.84 3.18% (p = 0.021) and 6.89 13.9% (p = 0.883), respectively.
The
general
rate
of
hyperglycaemia
decreased
9.13 19.43% (p = 0.09).
Conclusions: The basal insulin requirement for patients with MDI
was decreased, independent of control of DM1. Although the rate of
hypo- and hyper- glycaemia did not decreased significantly, but the
insulin degludec decreased variability of glycaemia and shown less
prominent dawn phenomenon.
P264
Patients commenced on insulin pump therapy
despite failing to meet NICE criteria show
improvements in diabetes management - a pilot
study
E. Storr1, J. Pichierri1, B. White1, P. Hindmarsh1, L. Potts1
1
POSTER TOURS
glucose concentrations between meals. Pump therapy was started
following structured education and the CYP contracted to undertaking a minimum amount of blood glucose testing. Pump therapy was
commenced for an initial period of 6 months and CYP were allowed
to continue after this time period.
Results: All 9 CYP completed the first 6 months of the study and all
9 remain on pump therapy. The median duration of therapy was
1 (range 0.75 - 3.25) year. The median HbA1c at pump start was 11%
(9.3-13.2). Mean pump therapy duration was 1 year (0.75-3.25) and
was associated with a mean reduction in HbA1c to 8.5% (7.4-11.6)
after 6 months (P = 0.009). This reduction was maintained after the
6 months period with a mean HbA1c of 9.1% (7.8-12.9). Pump therapy was also associated with a reduction in admission frequency and
presentation in Diabetic Ketoacidosis and an improved quality of life.
There was also an increase in participation in diabetes care managing
illness/exercise and use of temporary basal rates.
Conclusions: Insulin pump usage in this pilot study appeared to be
associated with an improvement in diabetes control and better
engagement of the CYP with diabetes care. These initial observations
in a hard to help group suggest a more formalised study is warranted
to ascertain the overall benefits for this group of CYP.
P265
Diabetes care and preventation by VNOW fitness
device technology
V. Sharma1, S. Sinha1
1
Guru Gobind Singh Indraprastha University, School of Biotechnology,
Delhi, India
Objectives: VNOW is a Indian fitness device start up that check on
human health via fitness watch and band with regular monitoring of
step count, calorie burnt, motion time, mileage, sleep time, deep
sleep, light sleep, wake up time, heart rate, average heart rate & heart
rate during workout each & every second of our life for a proper
knowing of our body.To study effects of daily routine of diabetic
patients by a VNOW fitness device technol,ogy and see whether it
may control and prevent the diabetic complication.
Methods: Total of 50 diabetic patient were taken as subject with an
equal ratio of male and female of age group between 20 to 50 years.
VNOW device put on the wrist of diabetes patient for one month
and regular reading were taken with VNOW device .Blood glucose
was measured on daily basis and daily data of their step count, calorie
burnt, motion time, mileage, sleep time, deep sleep, light sleep, wake
up time, heart rate, average heart rate & heart rate during workout
measured with VNOW device Technology.
Results: 1) VNOW device reading showed there was increase in
heart rate, less calorie burnt and average sleep count in the age of
20–30 years diabetic patients.
2) VNOW device reading showed there was less increase in heart
rate, average sleep count and heart rate during workout in the age
group of 30–50 years of diabetic patients.
Conclusions: Young diabetic patients of the age group 20–30 years,
showed increase in the blood glucose level and other diabetes complication due tosedentary lifestyle. In diabetes patients of age group
of 30–50 have showed a control level blood glucose level and controlled heart rate , sleep time which may be due to proper diet and
physical activity. VNOW device technology helps diabetes care and
preventation.
University College London Hospitals, London, United Kingdom
Objectives: In England poor diabetes is an exclusion criteria for commencing insulin pump therapy. We evaluated whether Children and
Young People (CYP) with type 1 diabetes who do not meet the criteria for insulin pump therapy would show an improvement in control
if pump therapy was introduced.
Methods: 9 (4 M) CYP, aged 13 to 17 years commenced insulin
pump therapy after a team assessment of motivation. None of the
CYP fulfilled the NICE criteria for pump therapy: minimum of 6 blood
glucose tests per day, carbohydrate counting and correcting blood
P266
Longitudinal observation of clinical course of type
1 diabetes (T1DM)
ski1, B. Małachowska2,3, W. Fendler2,
A. Kadłubiska1, W. Łuczyn
ska-Olszewska1, A. Bossowski1
K. Noiszewska1, B. Głowin
1
Medical University of Bialystok, Department of Paediatrics,
Endocrinology, Diabetology with the Cardiology Division, Bialystok,
Poland, 2Medical University of Lodz, Department of Paediatrics,
133
POSTER TOURS
Oncology, Haematology and Diabetology, Lodz, Poland, 3Medical
University of Warsaw, Studies in Molecular Medicine, Warsaw, Poland
Objectives: Children with T1DM are more often overweight or
obese than their healthy peers, it especially affects girls in puberty.
The goal of the work was to determine the relationship between
body weight and metabolic control in children with T1DM.
Methods: A retrospective analysis was carried out on the clinical
course of diabetes in children with diagnosed T1DM under the care
of pediatric diabetology department in Bialystok. The analysis
included the diagnosis period and the 5-year follow-up. Anthropometric data (BMI-SDS), HbA1c, the type of insulin therapy (pens vs
pump) and the daily dose of insulin per kilogram body weight
(DDI/kg) were assessed.
Results: The study included 112 children (51.79% boys). The existence of a statistically significant trend of annual growth of BMI-SDS
(p = 0.0006), HbA1c (p < 0.0001) and DDI/kg (p < 0.0001) has been
shown in the years of observation. The girls however have shown a
significantly higher percentage of visits in which they had abnormal
metabolic control (HbA1c > 6.5%) (84.5% vs 77.9%; p = 0.0190).
Analysis of the long-term treatment of DM1 has shown a significant
correlation between variation of BMI-SDS and the variation of
HbA1c (B = 0.04, p = 0.0147), taking into account individual patient
variability. However, in the multivariate model, which takes into
account factors i.e. age at the time of the test (B = 0.07, p = 0.0032),
DDI/kg (B = 0.06, p = 0.5080), the type of therapy (B = −0.07,
p = 0.2501) and individual variability of patients showed no significant relationship between HbA1c and BMI-SDS (B = −0.02,
p = 0.2985). Age and variability of patients explained 82% of the variation in BMI-SDS during the 5-year follow-up.
Conclusions: The age of patients with diabetes is a strong predictor
of BMI-SDS. It seems that the clinical course of diabetes (expressed
as HbA1c) has less impact on annual growth of BMI-SDS than the
non-diabetes factors, i.e. physical inactivity or a high-fat diet.
P267
What do young people think about the diabetes
transition service they receive?
1
M. Gardiner
1
Taunton and Somerset NHS Foundation trust, Children’s Diabetes,
Taunton, United Kingdom
Objectives: User views are vitally important to shaping and developing services, particularly in a cohort that can be challenging to engage
and has consistently higher failure to attend rates than other age
groups. Service providers need to understand the key issues affecting
young people’s clinic attendance and clinic experience and what
changes are required to better meet the expressed need of the
cohort.
Methods: A paper questionnaire designed and evaluated by the Lead
Nurse was offered to all transition service users over a 4 month
period. The questionnaire encouraged both simple box ticking from a
list of options and free text comments on a range of issues, was completed immediately before or after attending their clinic appointment
and submitted via a sealed box in the clinic waiting room.
Results: 77% response rate, equal male and female respondents.
Mean self-reported age at diagnosis 6.6 years.
96% thought it very worthwhile to maintain good control of their
diabetes and reported themselves as knowing enough about managing blood glucose and hypos.
22% did not know who to contact for diabetes advice at evenings
and weekends.
Most didn’t mind but 33% would want to be admitted to an
adult ward.
11-33% wanted more information about particular topics like family planning, travelling, drugs and exercise. Only 7% wanted to know
more about long term complications.
The most frequently raised critical comment related to clinics running late and waiting around, but there was a balance of positive
comments about friendly, helpful and understanding staff.
Conclusions: All service users were sent key findings and action
feedback along with reminders of team contact details including
accessing out-of-hours advice and documenting preference for hospital admission environment.
A county-wide transition education event was delivered and a
detailed audit of appointment waiting times was undertaken towards
improving operational efficiency.
P268
Comparison of blood sugar outcome between two
groups of young diabetics attending annual diabetic
camps (2014 v/s 2015) in Mauritius
P.K. Guness1, A. Dustagheer2, D. Jean Pierre2
Private, Saint Clothilde, Réunion, 2NGO/ T1Diams, Vacoas, Mauritius
1
Introduction: The aim of this study is to compare blood sugar outcome between two groups of young diabetics attending annual diabetic camps (2014 v/s 2015) in Mauritius.
Methods: A seven-day camp was organised by non-governmental
organisation, T1 Diams (Type 1 Diabetes Mellitus Support) in 2015
for 55 diabetic members aged 4–40 years. Blood glucose levels were
compiled on Microsoft Excel® and analysed on IBM Statistical Package for the Social Science (SPSS) ®. Data from 2014 diabetic camp
was computerised for comparative study. Authorisation to conduct
the study was obtained from the managing committee of the
organisation.
Results: Two cases of severe hypoglycaemia were noted requiring
administration of intramuscular Glucagon injection. No case of ketoacidosis was reported.
Conclusion: This study has confirm the positive impact on metabolic
control when attending a diabetic camp in Mauritius. Glycaemic control was improved. The benchmark has been established for future
comparison among T1 Diams camps. In any case, present day camping experiences are essential.
Results:
Variables
2014
2015
Age (years)
16.3 3.6
(11–27)
15.756.8
(4 –40)
Gender
Male (n [%])
11(41)
23(42)
Female (n [%])
16(59)
32(58)
No insulin regimen(Honeymoon
phase)
0(0)
2(4)
MDII with NPH insulin (n [%])
1 (4)
0(0)
MDII with rapid-acting insulin
analogue and long- acting
insulin analogue) (n [%])
26 (96)
53(96)
CSII (n [%])
0 (0)
Insulin regimen
Average blood glucose
Breakfast
8.23 5.18
6.93 4.39
Lunch
8.325.92
7.55 4.02
Dinner
7.89 3.94
3.94
8.33 4.00
Bedtime
13.0 6.10
12.6 7.09
Average HbA1c before camp
9.552.77
9.412.28
Hypoglycemia(n [%])
18(5.3)
71(14.9)
Normoglycemia(n [%])
187(55.2)
266(56)
Hyperglycemia(n [%])
134(39.5)
138(29.1)
[Table showing the differences between 2014 vs 2015]
134
P269
Optimizing annual urine microalbumin screening for
type 1 diabetes mellitus patients in diabetes clinic
H. Larson1, K. Obrynba2, D. Vanlandingham3, D. Buckingham4,
M.K. Kamboj2
1
Nationwide Children’s Hospital, Pediatrics - Endocrinology, Columbus,
United States, 2Nationwide Children’s Hospital at The Ohio State
University, Pediatrics - Endocrinology, Columbus, United States,
3
Nationwide Children’s Hospital, Business Process Improvement,
Columbus, United States, 4Nationwide Children’s Hospital, Quality
Improvement Services, Columbus, United States
Objectives: To Increase the % of T1DM patients (Age ≥ 10 years,
T1DM for ≥ 5 years) screened yearly for urine microalbumin in our
T1DM clinic from 67% to 90% by June 30, 2015 and sustain until
12/31/2015.
Methods: Diabetes team made aware of the guidelines for urine
microalbumin screening; “Best Practice Alert” built in EMR (electronic Medical record); process flow map made; urine sample collected in clinic; order placed, labels printed, LPN alerted and
provided urine specimen cup to patient; water provided for hydration. Urine sample collected, stored in fridge for up to max 1 hour,
transported to the lab from clinic via a lab tube system. Results
were followed by the provider and appropriate evaluation made
based on test results.
Results: The number of eligible T1DM patients screened for the
microalbumin increased from a baseline of 67% to 94% by 12/31/15.
POSTER TOURS
Objectives: Recommended basal insulin rates for insulin pump
(IP) T1DM treated patients are about 40-50% of total daily insulin
dose. Regarding growth and puberty, need for appropriate bolus insulin increases. There was an idea for evaluation basal insulin rates in
insulin pump treated pediatric T1DM patients in regard of their metabolic control and body mass index.
Methods: Average basal insulin rates during 3 months were evaluated in IP treated T1DM pediatric patients and correlated with
HbA1c results for that period and BMI index .
Results: We analyzed data from 41 patients (21 M/17 F) mean age
14,1 2,2 ( 9–17), mean diabetes duration 7.1 2.38 years (3–15).
Average HbA1c of whole group was 8,2 % (6,2-9,8), and mean total
insulin dose was 0,91 IU/kg/day ( 0,56-1,22). Mean basal rate was
0,41 IU/kg//day (45% of total daily dose), and BMI of 84,3% patients
indicated normal weight. Best regulated patients (mean HbA1c 7, 2%)
had basal rate 0,30-0,40/kg/day, and 90,5 % of them had regular
BMI. Mean HbA1c was worse (9,1%) in patients with basal rate under
30 % od total daily delivered insulin, and there were 29 % undernoutrished among them. 16,7% of patients with basal rate over
0,41 IU/kg/day were obese and their mean HbA1c was 8,4%.
Conclusion: Basal insulin rate is very important factor for attaining
good metabolic control and normal BMI in IP treated T1DM children
and adolescents. Ideal basal insulin rate in our patients was lower
than recommanded probably because of higher bolus insulin needs in
regard of of growth and puberty.
P271
An audit of the success of the ’Four Stage Plan’
admission in adolescents with type 1 diabetes
(T1DM) in reducing HbA1c and future hospital
admissions with DKA or severe hypoglycaemic
episodes
J. Pichierri, E. Storr, B. White, L. Potts, P. Hindmarsh
University College London Hospitals, London, United Kingdom
[ISPAD Microalbumin p chart]
Conclusions: This QI project is a part of an institution-wide initiative
towards journey to best outcomes. We demonstrate here the success
of a comprehensive, multidisciplinary approach to optimizing the
recommended screening with annual urine microalbumin in patients
with T1DM Age ≥ 10 years, T1DM for ≥ 5 years (ADA/ISPAD). Similar strategies may be adapted to achieve success in optimizing recommended health maintenance screenings, not just for patients with
T1DM but with other chronic illnesses as well. Ongoing efforts need
to continue to maintain the successful established work flow to
achieve the best results.
P270
Basal insulin rate in insulin pump T1DM treated
pediatric patients - seeking for optimal
S. Hasanbegovic1, E. Obarcanin2
1
Clinical Center University of Sarajevo, Pediatric Clinic, Endocrinology
and Diabetes, Sarajevo, Bosnia and Herzegovina, 2Universität Düsseldorf,
Institut für klinische Pharmazie und Pharmakotherapie Heinrich-Heine,
Düsseldorf, Germany
Objectives: Managing T1DM requires a motivating and supportive
clinical team. At times it may be useful to “reboot” the situation in
Children and Young People (CYP) with T1DM adolescents with type
1 diabetes. At University College Hospital London CYP who are finding it hard to cope with their diabetes are offered an admission to
hospital for a period of 2–4 weeks to help improve overall control.
We undertook on audit of this practice to determine how effective
the intervention was.
Method: 10 (8 F) CYP aged 14 to 17 years were admitted for a
4 Stage Plan between May 2014 and January 2016. Each admission
followed a similar pattern with intravenous insulin therapy to recalculate insulin requirements, followed by a period of 4–7 days recommencing on their initial treatment, pump or injections with all
diabetes care carried out but ward staff to insure doses are correct.
Once doses were established the patient slowly took over their own
care first supervised, leading to graded discharge and finally discharge
with frequent outpatient follow up. During this period the patient
receives intensive teaching and motivation and where appropriate
psychology input.
Results: Follow up was available on all 10 patients with a median follow up of 0.9 (years (range 0.5 - 2.0). Median HbA1c before admission was 12.7% (9.9 - 15.0); HbA1c declined in the three months
after the 4 stage plan admission to 9.9%(8.6 - 14.0) (p = 0.05);HbA1c
then rose thereafter such that the most recent value 0.9 years after
the intervention was slightly but not significantly lower than before
the admission with HbA1c 11.4% (9.6 - 14.0). There was a slight
reduction in Diabetic Ketoacidosis admission rate.
Conclusions: The 4 stage plan appears to produce a transient reduction in HbA1c (Hawthorn effect). Strategies now need to be devised
to enable CYP to maintain this improvement. This is less about motivation and more about maintenance of interest.
135
POSTER TOURS
P272
Does singing improve glycaemic control?
P. Sundaram1, S. Lockwood-Lee2, D. Kitchener1, V. Tziaferi1
1
University Hospitals of Leicester, Paediatric Diabetes, Leicester, United
Kingdom, 2University Hospitals of Leicester NHS Trust, Paediatric
Diabetes, Leicester, United Kingdom
Objective: “Highs and Lows” choir was started by our paediatric diabetes team at a University Hospital to provide peer to peer support
to children with Type 1 diabetes and their families in a non-clinical
setting. The aim of the study was to find if there was an improvement
in glycaemic control in the children who participated in the choir.
Method: 16 children with type 1 diabetes attended weekly choir
practice and they also had multiple opportunities to perform choir
concerts at different times. Children and families had opportunities to
discuss about their diabetes care with paediatric diabetes team members who facilitated the choir. HbA1c levels of the above group were
analysed before and after the initiation of choir at 3 monthly
intervals.
Results: The mean age of the children were 10.9 years (7.6 13.6 years). The mean duration of diabetes was 6.2 years and
13 (81%) were using insulin pump. The mean HbA1c levels of the
group before they joined choir was 72.3 mmol/mol (8.7%). The mean
HbA1c levels of this group at 3, 6, 9, 12 and 15 months after starting
choir were 69.7(8.5%), 67(8.3%), 67.7(8.4%), 69.5(8.5%) and 64.5(8%)
mmol/mol respectively.
Conclusion: The children attending the choir had 7 mmol/mol (0.7%)
reduction in their mean HbA1c levels over a period of 15 months.
Team members facilitating the choir reported positive impact on the
children’s personal confidence and on their attitude towards diabetes.
They also reported that choir also offered children and parents to
developed friendships and networking opportunities. We have not
measured quality of life benefits but we plan to look into this in a
prospective way in future.
[HbA1c levels before and after starting choir]
P273
Evaluation of a senior nurse led pilot delivering
weekend healthcare professional advice for
children newly diagnosed with diabetes
M. Gardiner1, N. Green2
1
Taunton and Somerset NHS Foundation Trust, Children’s Diabetes,
Taunton, United Kingdom, 2Taunton and Somerset NHS Foundation
Trust, Children’s Diabetes, Musgrove Park Hospital, Taunton, United
Kingdom
Objectives: National Best Practice Tariff (BPT) requires all newly
diagnosed children to be discussed with a senior member of the children’s diabetes team within 24 hrs of diagnosis and for this to be
documented in patient medical notes. The pilot aimed to demonstrate
meeting this requirement, adding value to the patient journey by
assuring specialist advice to facilitate quality clinical care planning
from diagnosis.
Methods: Over 7 months, 2 senior children’s diabetes nurses
initiated contact with the on-call paediatric consultant or registrar at
weekends within an agreed timeframe, when diabetes team paediatricians were not on-call. Data about each contact was recorded on a
specifically designed form. The senior nurses undertook this without
remuneration, taking time in-lieu when possible.
Results: 31 nurse contacts made, representing nurse cover for 60%
of the weekends.
It proved challenging at times to contact medical staff, with up to
35minutes of delay / unsuccessful attempts.
No newly diagnosed were identified during any of the contacts,
therefore it was not necessary to check accuracy of medical record
entries.
10 occasions of discussion and advice for pre-existing patients,
largely initiated by the Registrar regarding calls for clinical advice they
had received (out-of-hours process for cohort) or current inpatients.
Conclusions: The effort, inconvenience and intrusion into personal
life to voluntarily deliver an enhanced weekend service that could
not demonstrate meeting BPT and did not add sufficient value to the
patient experience determined continuance was unwarranted. Insufficient evidence of need or effectiveness to business plan for permanent nurse-led service enhancement resulting in the proposal for the
BPT requirement to be met by medical staff evoking an existing escalation policy in the event of a newly diagnosed child presenting at
weekends.
P274
Should children’s diabetes specialist nurses wear
uniform? A service user survey
M. Gardiner1
1
Taunton and Somerset NHS Foundation Trust, Children’s Diabetes,
Taunton, United Kingdom
Objectives: The Director of Nursing led a project that saw Trust Specialist Nurses (Adult services) wearing a uniform that resulted in positive feedback from patients and other hospital staff relating to
increased visibility and identification of senior nurses within the hospital and expressions of greater patient confidence in consultations.
Empirical evidence based on almost 30years of professional practice
suggests some children find uniforms intimidating and frightening.
Methods: Service user views were sought through surveying a randomly selected sample of children from our cohort over a 3 month
period using email, however responses to the ’question’ were
included if submitted via another media such as phone message or
face-to-face. Responses were collated and analysed by the Lead
Nurse.
Results: 45% of those invited to take part in the survey submitted a
response.
63% firmly reported their view that children’s diabetes specialist
nurses should not wear uniform.
31% did not have a preference
5% thought children’s diabetes nurses should wear uniform.
Powerful individual comments were presented in a colourful pictorial way for example; ’yes on the ward, no in clinic at training events
or home visits’, ’I think they should wear their own clothes because I
wouldn’t want to wear uniform’, ’no can’t see the point, doesn’t make
them better at their job - more appearance over substance. Could
scare younger children by formalising interactions’, ’no, doctors don’t!’
Interestingly, patients felt uniform would not add anything to their
confidence in or experience of professional consultations with
their Team.
Conclusions: Actively seeking and valuing patient views to inform
service design and development means accepting the majority opinion. Children’s diabetes specialist nurses will abstain from the Trust
direction to wear a uniform.
136
P275
Reasons for insulin pump discontinuation
H. Minhas1, S. Williamson2, C. Findlay2, S. Graham2, Paediatric
1
Crosshouse Hospital, Paediatric Diabetes, Kilmarnock, United Kingdom,
Ayrshire and Arran Health Board, Uk, Paediatric Diabetes, Kilmarnock,
United Kingdom
2
Aims: To explore reasons for discontinuing insulin pump usage in
children with Type 1 Diabetes
Methods: Children in the Ayrshire region of Scotland who commenced insulin pump therapy between May 2008 and December
2015 were identified using the Scottish national database (SCI-diabetes)(88 children/young people). Eight of these children discontinued
use ( 5 Females :3 Males) after different durations .Seven were teenagers and one four year old. Each patient/ parent was contacted and
a prospective survey was undertaken in the form of a telephone
questionnaire to determine the parents and patient’s views about discontinuing pump usage.
Results: Regarding the pre-pump period, respondents generally felt
well informed about the pump, and felt involved in the decision. 50%
felt they expected the pump to be on for a “trial” period. Most
respondents gave positive remarks about their time on the pump.
Discussion about the reasons for pump discontinuation revealed
varying opinions. 75% didn’t like being on the pump ,62% continued
to have poor control of their diabetes and 37% continued to have
high HbA1c. Other reasons were issues in school , limited sports
activity ,cannula insertion, too much effort and “always attached to
something”. Decision was made jointly with diabetes team ,child and
parent and 75% felt the right decision was made and they didn’t
regret the decision. The four year old was able to unlock the pump
hence it was withdrawn.
Conclusion: Approximately 9% of the total number of patients commenced on insulin infusion discontinued it. They were mostly older
children / young people. A lack of improvement in glycemic control
or dislike of the pump were the 2 main reasons for discontinuation.
When preparing a child for pump therapy, time should be given to
initially exploring their expectations, and what criteria may be used to
determine whether the pump may be discontinued. This was a small
study but revealed significant view points of the patients.
P276
Evolution of body mass index in children with type
1 diabetes mellitus
M. De Keukelaere1, E. Vandoorne1, S. Fieuws2, K. Vande
Kerckhove1,3, T. Praet4, F. Delaere4, W. Asscherickx1, N. Reynaert1,
K. Casteels1,5
1
University Hospital Leuven, Pediatric Diabetes, Leuven, Belgium, 2KU
Leuven, I-Biostat, Leuven, Belgium, 3University Hospital Leuven, Clinical
Nutrition Unit, Department of Endocrinology, Leuven, Belgium,
4
University College Leuven, Department of Health and Technology,
Leuven, Belgium, 5KU Leuven, Department of Development and
Regeneration, Leuven, Belgium
Objectives: The prevalence of childhood overweight and obesity has
risen during the last 30 years. Not only children with type 2 diabetes,
but also those with type 1 diabetes (T1D) are overweight and obese.
In children with type 1 diabetes, obesity has been linked to an
increased cardiovascular risk. A better understanding of the evolution
of weight patterns in the years after diagnosis of T1D, may be important to identify those children with a risk for excess weight gain.
Identification of these subgroups might lead to intervention strategies
to decrease excess weight gain.
Methods: We retrospectively analyzed data of all children with type
1 diabetes followed at the department of Pediatric Endocrinology in
the University Hospital Leuven (UZLeuven) and diagnosed between
June 1991 and February 2015. Data as age, sex, BMI and tanner
score were extracted. A total of 396 subjects were included in the
database and more than 6000 BMI measurements were analyzed.
POSTER TOURS
The longitudinal BMI SDS measurements were analyzed using linear
mixed models.
Results: Standardized BMI (BMI SDS) using all data (n = 6088) was
0.3, with a deviation of 0.95. Seventeen % of the male patients
and 19% of the female patients were obese or overweight. An
increase in BMI SDS was seen as a function of (1) time since diagnosis and (2) age, both being independent predictors. Data of girls
and boys were compared and a significant stronger relation
between BMI SDS and time since diagnosis, as well as with age,
was seen in girls.
Conclusions: These data suggest an import increase in BMI in children with type 1 diabetes, especially in girls. Given the increased risk
of metabolic syndrome and other complications in overweight children, special attention is needed to prevent this evolution.
P277
A collection of case studies: Investigating the
efficacy of a psychological intervention designed to
promote higher levels of self-esteem within
adolescents exhibiting poor diabetes selfmanagement
V. Cawley1,2, J. Daley3, J. Harkin3
1
Salford University, Medway NHS, Health and Social Care, Manchester,
United Kingdom, 2Salford Uni NHS Foundation Trust, Health and Social
Care, Manchester, United Kingdom, 3Oakfield Psychological Services,
Oakfield, United Kingdom
The aim of the study was to identify whether improving self-esteem
in adolescent diabetic patients with a poor diabetic control could
have a beneficial impact upon their overall glycaemic control. The
cohort of patients identified took part in six self-esteem focused sessions. The self-image profile questionnaire was used to measure selfesteem pre and post intervention and data was collected relating to
biological glucose levels (HbA1c). Analysis of our data identified a
positive correlation between increased self-esteem and improved diabetes management.
P278
Visceral fat and fatty liver could predict subclinical
atherosclerosis in lean adolescents with Type1
diabetes
H. Atwa1, K. Gad2, H. Hagrasy3, A. Elkelany1, S. Shalaby1
1
Faculty of Medicine, Suez Canal University, Pediatrics, Ismailia, Egypt,
Faculty of Medicine, Suez Canal University, Diagnostic Radiology,
Ismailia, Egypt, 3Faculty of Medicine, Suez Canal University, Pediatrics
Department, Ismailia, Egypt
2
Background: There is more than 11-fold higher prevalence of cardiovascular complications in patients with T1DM compared with normal
population.
Objective: To assess the relationship between subclinical arthrosclerosis and visceral fat and fatty liver.
Subjects and Methods: The study was performed on 110 of adolescents with type 1 diabetes mellitus attending the Pediatric Diabetes
Clinic of Suez Canal University Hospital. Their mean age was
(14.2 0.7) years. Their mean duration of diabetes was (6 3)
years. This study was a case–control study. Group 1 consists of
55 adolescents with T1DM and normal carotid intima media thickness (cIMT). The second group included 55 adolescents with T1DM
and subclinical atherosclerosis. There was no significant difference
between the two groups as regard weight, height, BMI and waist circumference. All adolescents were normotensive, normo-albuminuric
and had no retinopathy. Lipid profile and Hba1c were measured. An
experienced radiologist who was blinded to clinical data performed
ultrasonography scanning. The cIMT, subcutaneous fat, visceral fat
thickness, and area were estimated. Hepatic steatosis was diagnosed
137
POSTER TOURS
based on enlarged liver size and evidence of diffuse hyperechogenicity of liver relative to kidneys.
Results: The mean visceral fatwas significantly higher in adolescents
with increased cIMT (4.8 1.6) than in the normal CIMT group
(3.9 1.4), P < 0.05. Liver size was significantly larger in adolescents
with increased cIMT (13.73 2.26) than with normal cIMT
(12.63 2.20) (p 0.022). There was a significant linear regression
between cIMT and visceral fat, age and liver size.
Conclusion: Visceral fat, liver size and patient, s age could be a predictor of subclinical atherosclerosis.
P279
Neutrophile to lymphocyte ratio in children and
adolescents with type 1 diabetes
H. Jasser-Nitsche1, P. Rubic1, G. Schwantzer2, E. Suppan1,
G. Weinhandl1, W. Muntean1, E. Fröhlich-Reiterer1
1
Medical University of Graz, Department of Pediatrics, Graz, Austria,
Medical University of Graz, Institute for Medical Informatics, Statistics
and Documentation, Graz, Austria
2
Objectives: Angiopathy and consequently cardiovasular disease are
well known long term complications of type 1 diabetes (T1D). Leukocytes play a key role in the development of atherosclerosis as lowgrade chronic inflammation is one of the underlying causes. High
neutrophiles and low lymphocytes indicate an increased risk of atherosclerosis. An increased neutrophile to lymphocyte ratio (NLR) correlates with a less favorable cardiometabolic profile and has been
shown to be a marker for mortality in cardiovascular disease in adults.
Several biomarkers to identify a subclinical atherogenic risk in
patients with T1D have been discussed recently. We investigated if
NLR in children with T1D is increased and might represent a useful
tool to detect first signs of macroangiopathy preceding
atherosclerosis.
Methods: In a retrospective analysis we compared data of 121 children and adolescents (61 male, 60 female) with T1D (mean age
12.06 3.92 SD, mean diabetes duration 4.77 years 3.17 SD,
mean HbA1c levels 66.60 mmmol/mol 12.11 SD) to 121 healthy
children and adolescents (mean age 12.12 3.97 SD). CRP values >
10 mg/l indicating an acute inflammation were considered as exclusion criteria.
Results: NLRs in children and adolescents with T1D were lower than
in healthy controls (1.96 2.80 vs 2.53 1.93 SD, p < 0.001) . The
lower NLRs in patients with T1D were due to lower absolute neutrophil counts (3.17 1.19 SD vs. 4.92 2.62 SD, p < 0.001).
Conclusions: Correlations between NLR and BMI have been
described in children over 7 years of age and confirmed by our
results. NLR cannot be used in T1D as an atherogenic marker as
patients with T1D have a reduced amount of circulating neutrophils.
The reasons for this reduction of neutrophils in T1D are still
unknown, immmunopathogenetic causes are being discussed.
P280
Evaluation of serum cystatin C in type 1 diabetic
children and adolescents as an early indicator of
diabetic nephropathy
A. Sayed1, M.M. Farid Konsouh1, A.A. Al Ashmawy1, H. Abdel
Ghaffar1, A. Sayed Kamel1, A.S. Abd El-Aziz Ahmed1
1
University Fayoum, Fayoum, Egypt
of serum cystatin c in 85 patients with type 1 diabetes mellitus at
Diabetes, Endocrinology and Metabolism clinic in pediatric hospital
Cairo university, patients categorized into two groups (normoalbuminuric and microalbuminuric) according to A/C ratio.
Results: Our study revealed increased level of serum cystatin c in
microalbuminuric diabetic patients. Serum cystatin c negatively correlated with GFR. Also, it was found that serum cystatin c increased in
parallel with the severity of renal disease, poor glycemic control and
duration of diabetes.
Conclusion: Serum cystatin c measurement might become a useful
and accurate noninvasive tool for early detection of diabetic
nephropathy.
P281
Prevalence and risk factors for microalbuminuria in
children and adolescents with type 1 diabetes:
long-term experience of a single centre
L. Iughetti1, A. Iori1, P. Bruzzi1, A. Dozza1, A. Boncompagni1,
V. Cenciarelli1, S. Mazzoni1, L. Lucaccioni1, B. Predieri1
1
University of Modena and Reggio Emilia, Department of Medical and
Surgical Sciences of the Mother, Children and Adults, Modena, Italy
Objectives: Diabetic nephropathy is a late complication of type 1 diabetes mellitus (T1DM) and microalbuminuria (MA) is an early and
reversible sign of diabetic renal disease. Aims of this longitudinal
study were: to define the prevalence of MA in children and adolescents with T1DM; to identify which risk factors are predictive for the
development of MA.
Methods: Seventy children and adolescents with T1DM [57% male;
age at T1DM onset (T0) 5.95 3.16 yrs] were enrolled. The mean
follow-up (FU) period was 7.18 1.89 yrs. Blood and urinary tests
were performed once a year from the T0. MA screening was evaluated by urinary albumin concentration (UAC) or by timed urine collections for urinary albumin/creatinine ratio (ACR). MA was considered
persistent (PMA) when at least 2 out of 3 consecutive evaluation of
UAC and/or ACR were found positive.
Results: PMA was found in 13% of patients. Subjects with PMA
compared to normoalbuminuric ones had both significantly higher
GFR at T0 (p = 0.025) and UAC at 1-year FU (T1) (p = 0.045). Predictive cut-off values for PMA development were 160 ml/min/1.73 m2
for GFR at T0 (sensitivity: 57%, specificity: 75%) and 8.5 mg/L for
UAC at T1 (sensitivity:75%, specificity:80%). Relative risk for PMA
was 23-times higher when UAC was >8.5 mg/L (p = 0.004). KaplanMeier survival curves as a function of age at T0 showed an increased
probability of developing PMA among children in which T1DM onset
occured between 5 and 11 years of age compared to those with
younger onset (p = 0.014) and a pubertal diabetes duration >5 years
was also a significant risk factor for PMA (p < 0.0005).
Conclusions: Age at T1DM onset, pubertal timing, high UAC, and
hyperfiltration predispose to PMA development and increase the risk
for diabetic nephropathy. Specific cut-off values at T1DM onset and
during first years of FU could provide indications to avoid disease
progression.
P282
To study the prevalence of musculoskeletal
abnormalities in type 1 diabetes patients
S.M. Jali1, D. Metgud2, M.V. Jali3, J.P. Wasedar4
1
Diabetic nephropathy is a major cause of morbidity and mortality
among young adults with type 1 diabetes. Clinical management and
therapeutic intervention from early stage of DN is of major importance to prevent progression to end stage renal disease. The aim of
this study: is to evaluate serum cystatin c and albuminuria in Type
1 Diabetic Children and Adolescents.
Methods: In the present case control study, we evaluated the level
KLE University J N Medical College and KLES Dr Prabhakar Kore
Hospital & MRC, Pediatrics KLES Diabetes Centre, Belagavi, India, 2KLE
University KLE Physiotherapy College, Pediatrics, Belagavi, India, 3KLE
University J N Medical College and KLES Dr Prabhakar Kore Hospital &
MRC, KLES Diabetes Centre, Belagavi, India, 4KLES Dr Prabhakar Kore
Hospital & MRC, KLES Diabetes Centre, Belagavi, India
138
Objectives: To know the prevalence of musculoskeletal abnormalities
(MSA) in type1 diabetes patients. To find the correlation between the
duration of diabetes and glycemic control with MSA.
Methods: This cross-sectional observational study was performed in
107 T1DM patients attending diabetes clinic at KLES Diabetes Centre, Belagavi. Subjects were evaluated for MSA between the age
group of 5 to 25 years using standardized questionnaire which
included age, sex, disease duration and muscular pains. Deformities
were assessed using Chippaux index, Q angle, and special tests
assessed by Prof. of KLES Physiotherapy College. The mean HbA1c
was analysed for glycemic control. Skin changes over foot were
assessed.
Result: Musculoskeletal abnormalities was present in 62(57.94%)
subjects. Among lower limb deformities - foot abnormalities were
seen in 54(50.46%). Of which Hallux valgus was seen in 24(44.44%)
pes planus 16(29.6%) pes cavus was 7(12.96%), other foot abnormalities in 7(12.96%) and skin changes were seen in 10(9.34%). Genu
valgus was seen in 3.73% and varum in 2.80%. In upper limb deformities prayer sign was present in 27(25.2%) subjects of which
13(48.14%) had thenar & hypothenar wasting with significant p value
(p = < 0.001). Thus presence of prayer sign was associated with muscle wasting. Pearson Correlation Coefficient between foot abnormality and prayer sign is (r2 = 35.443) with p value (p = < 0.001) which
were significant. Our study did not show significance between duration of diabetes (p = 0.24) and glycemic control (p = 0.68). 3(2.80%)
had spinal abnormalities. Muscular pains were present in 22(20.56%)
subjects.
Conclusion: Musculoskeletal abnormality is common with T1DM
with higher prevalence of foot and hand abnormalities. This study
suggests that clinicians should regularly screen for MSA for early
intervention and prevention of long term functional disabilities.
P283
Blood pressure regulation determined by
ambulatory blood pressure profiles in children and
adolescents with type 1 diabetes mellitus: impact
on diabetic complications
A. Dost1, S. Bechtold - Dalla Pozza2, E. Bollow3, R. Kovacic4,
P. Vogel5, L. Feldhahn6, K.O. Schwab7, R.W. Holl3
1
University Hospital Jena, Department of Pediatrics, Jena, Germany,
University Hospital Munich, Department of Pediatrics, Munich,
Germany, 3University of Ulm, Institute of Epidemiology and Medical
Biometry, Ulm, Germany, 4Pediatric Diabetes Center, Debant, Austria,
5
German Center for Pediatric and Adolescent Rheumatology,
Department of Pediatrics, Garmisch-Partenkirchen, Germany, 6Hospital
Böblingen, Department of Pediatrics, Böblingen, Germany, 7University
Hospital Freiburg, Department of Pediatrics, Freiburg, Germany
2
Objectives: The combination of high blood pressure and chronic
hyperglycemia significantly contributes to the development of diabetic complications. Ambulatory monitoring of blood pressure (ABPM)
has been recognized as standard to assess blood pressure
(BP) regulation.
Methods: We evaluated 24-hours BP regulation in 3529 type 1 diabetic children from Germany and Austria and studied the influence of
BP parameters including pulse pressure (PP) and blood pressure variability (BPV) on microalbuminuria (MA) and diabetic retinopathy (DR).
Results: In general, BP was increased in the diabetic children compared to healthy German controls, while nocturnal diastolic BP and
dipping were reduced. PP showed reverse dipping but to a lesser
extent than expected. Children with microvascular complications had
higher BP parameter, except of nocturnal PP in MA and diurnal and
nocturnal PP in DR. Reverse dipping of PP was more pronounced in
the children with early signs of diabetic complications. BP alteration
was stronger in girls than in boys and increased with age.
Conclusions: Our data show that there is an early and close link
between 24-hour blood pressure regulation and the development of
POSTER TOURS
diabetic complications not only for systolic, diastolic and mean arterial BP but also for the derived BP parameter pulse pressure and
BPV. We assume that early and sufficient control of these parameters
already in childhood and adolescents might reduce the development
and progression of diabetic complications.
P284
The use of urinary C-peptide as a marker of beta
cell function in children and adolescents with type
1 diabetes
T. Wu1, B. Strutt2, M. Lovell3, M. Miller3, R. Stein1,3, C. Clarson2,3,
D. Hill2, P.H. Gallego2,3
University of Western Ontario, London, Canada, 2Lawson Health
Research Insitute, University of Western Ontario, London, Canada,
3
Children’s Hospital, London Health Sciences Centre, Pediatrics, London,
Canada
1
Objectives: To examine the association between urinary C-peptide
and stimulated serum C-peptide as a marker of beta-cell function;
and to assess the role of C-peptide as predictor for microalbuminuria
(MA) in adolescents with type 1 diabetes (T1D).
Methods: Twenty-six (14 males) children (age mean SD 15.1 yrs
2.2; duration mean SD 4.5 yrs 2.3) were recruited. Subjects
had a fasting mixed-meal tolerance test. Serum glucose and Cpeptide were measured at baseline, 30’, 60’, 90’ and 120’min. Serum
cystatin-C, uric acid and A1C levels were collected at baseline. Urinary C-peptide-to-creatinine ratio (UCPCR) was collected at
120 min. Albumin-creatinine-ratio (ACR) was measured in 3overnight urine samples. Pearson correlation examined the association between serum C-peptide (baseline, AUC and peak) and ACR;
and between serum C-peptide and UCPCR. Student’s t-test was
used to compare differences between MA and non-MA groups;
multivariate analysis examined the effect of variables as predictors
for MA.
Results: Five subjects (19%) had MA. Mean A1C% SD was
8.0 0.68; ACR mg/mmol was 0.98 1.15. Baseline C-peptide ug/L
mean SD was 0.55 0.42; peak C-peptide was 0.84 0.64 and
UCPCR nmol/mmol was 0.23 0.58. UCPCR correlated with serum
C-peptide at all times except baseline (r > 0.70, p < 0.0001); with Cpeptide peak (r = 0.67, p = 0.001) and with AUC (r = 0.90,
p < 0.0001) adjusting for age, gender and duration. There was a negative trend correlation between baseline C-peptide and A1C
(p = 0.06). ACR was positively associated with serum uric acid
(r = 0.51, p = 0.01). No differences were found between MA and
non-MA or between upper-ACR and lower-ACR groups.
Conclusion: Urinary C-peptide correlates with stimulated serum Cpeptide and may be used as an alternative tool for assessment of
beta cell function in T1D children. The association between serum
uric acid and ACR suggests its role as a potential biomarker for
vascular complications and as an additional therapeutic target
in T1D.
P285
Predictors of renal complications in pediatric
patients with type 1 diabetes mellitus: a
prospective cohort study
G. d’Annunzio1, A. Beccaria1, A. Pistorio2, E. Verrina3, N. Minuto1,
R. Pontremoli4, M. Maghnie5
1
Giannina Gaslini Institute, Pediatric Clinic, Regional Center for Diabetes,
Genoa, Italy, 2Giannina Gaslini Institute, Epidemiology and Biostatistics
Service, Genoa, Italy, 3Giannina Gaslini Institute, Nephrology and
Dialysis Unit, Genoa, Italy, 4IRCCS AOU San Martino-IST, Genoa, Italy,
5
Giannina Gaslini Institute, Pediatric Clinic, Genoa, Italy
139
POSTER TOURS
Objective: Clinically evident diabetic nephropathy (DN) is rarely
encountered in childhood, even if early structural and functional subclinical abnormalities are detectedable few years after diabetes diagnosis. The aim of this study was to examine which variables among
demographical and clinical parameters could influence the development and progression of DN in a cohort of type 1 diabetes patients
diagnosed during childhood. Secondary aim was to evaluate the incidence rate of microalbuminuria.
Research design and method: We longitudinally evaluated of
137 young patients with type 1 diabetes diagnosed between 1994
and. Median duration of follow-up was 11.8 years (1st - 3rd q: 9.715.0). Overnight albumin excretion rate, degree of metabolic control
and other metabolic parameters, presence of other microangiopathic
complications and autoimmune comorbidities were restrospectively
collected.
Results: DN showed a frequency of 16/137 cases (11.7%), with an
incidence rate of 10.0 ´ 1000 person-years. A significant relationship
was found between DN and HbA1c mean values of the last 4 years
(P = 0.004), age at diabetes diagnosis (P = 0.013), presence of retinopathy (P = 0.011) and subclinical peripheral neuropathy (P = 0.003).
Conclusions: Strong predictors of DN were age at type 1 diabetes
diagnosis and mean HbA1c levels. Even if the incidence of DN is
lower than previously reported, periodical screening is mandatory.
Moreover, borderline microalbuminuria as additional risk factor
deserves attention.
P286
Diabetic cardiomyopathy is associated with
endothelial dysfunction in children and adolescents
with type1 diabetes mellitus (T1DM )
E. Sherif1, O. Youssef1, N.H. Amr1, K.A. Abd El-Tawab2, H. Ez-Elarab3,
M.G. Ibrahim1
1
Ain Shams University, Pediatric Department, Cairo, Egypt, 2Ain Shams
University, Radiology Department, Cairo, Egypt, 3Ain Shams University,
Clinical Pathology, Cairo, Egypt
Background: Type 1DM is a risk factor for cardiovascular disease.
Cardiomyopathy is defined as disease of the myocardium associated
with cardiac dysfunction. Endothelial dysfunction is the earliest event
in atherosclerosis and cardiovascular disease.
Objectives: To assess cardiac function in relation to endothelial function in Egyptian children and adolescents with T1DM.
Methods: One year cross sectional study on 40 children and adolescents with T1DM and 40 healthy controls. They were subjected to
laboratory investigations (lipid profile, Microalbuminuria, HbA1C),
conventional and tissue Doppler echocardiography. Flow mediated
dilation (FMD) of brachial artery was assessed by measuring brachial
artery diameter at baseline (A) and at one minute after release of
pressure (B). The absolute change in brachial artery diameter in mm
[FMD (B - A)], and the Delta change (Δ FMD) = (B - A)/ A were
estimated.
Results: The absolute difference and the delta change in the brachial
artery diameter was significantly reduced in patients compared to
controls. Diastolic dysfunction was proved in all studied diabetics in
form of decreased E/A, Em/Am and increased E/Em .A significant
decrease was found in E/A ratio in patients compared to controls. A
significant negative correlation was found between HDL level and
Em/Am. The factor with the strongest impact on FMD of brachial
Artery were LDL level and age.
Conclusions: Diastolic abnormalities detected in type 1 diabetic children suggests an early functional effect of specific diabetic cardiomyopathy. Endothelial dysfunction and risk of atherosclerosis exist early
in type1DM. Dyslipidaemia is a contributing factor in such events.
Early recognition of these events is recommended to prevent progression of atherosclerosis and cardiovascular disease.
Abbreviations: Em(cm/s) = peak early diastolic myocardial velocity at
mitral valve ring, Am(cm/s) = peak late diastolic myocardial velocity
at mitral valve ring , (cm/s) = centimeter per second.
P287
BMI before disease onset is an important
determinant of adult overweight or obesity in
young adults with type 1 diabetes
A. Wijnands1, R. Zeevaert1, G. Massa1
1
Jessa Ziekenhuis, Pediatric Endocrinology and Diabetology, Hasselt,
Belgium
Background: The initiation of insulin therapy in children with type
1 diabetes (T1D) is often associated with weight gain. It has been
suggested that excessive weight gain is a risk factor for the development of adult overweight/obesity.
Objective: We evaluated the prevalence of overweight/obesity in
young adults who developed T1D during childhood. We studied BMI
before the disease, at diagnosis of T1D, after 6 months of insulin
therapy and at young adulthood, and we examined if the change in
BMI in the 6 months after diagnosis is associated with adult overweight/obesity.
Methods: We retrospectively studied growth data of 71 children
(29 girls) with T1D who attained final height at a mean (SD) age of
18.0 (0.4) yrs. Age at diagnosis was 11.4 (3.0) yrs. Measured heights
and weights were used to calculate BMI z-scores based on the Flemish BMI reference values. BMI z-scores between 1 to 3 yrs before
diagnosis (available for 64 patients), at diagnosis, 6 months after diagnosis and at young adulthood were calculated. Data of patients with
overweight/obesity at adulthood (BMI ≥ 25 kg/m2; group 1) were
compared with those with BMI < 25 kg/m2 (group 2).
Results: 18 (25%; 10 girls) patients had overweight/obesity at adulthood (range: 25.0 - 35.2 kg/m2). BMI z-score was higher (p < 0.001)
in group 1 than in group 2 at all studied time points (before: +1.4
(0.9) vs −0.1 (0.8); at diagnosis: +0.6 (1.2) vs −1.0 (0.9); at 6 months:
+1.0 (0.9) vs −0.3 (0.6)). 11 out of 15 subjects of group 1 had overweight/obesity before diagnosis whereas only 7 out of 49 subjects of
group 2 (p < 0.001). The change in BMI z-score during the first
6 months after diagnosis was not different between patients of group
1 or 2 (+0.5 (0.8) vs +0.7 (0.7)).
Conclusions: 25% of the studied young adults with T1D had overweight/obesity. Most of them had already overweight before the
onset of T1D. We conclude that BMI before the onset of T1D is an
important determinant of adult overweight/obesity.
P288
Incidence of lipoatrophy associated with rapidacting insulin analogs in children with type
1 diabetes mellitus
K. Dżygało1, K. Ignasiak2, A. Szypowska1
1
Medical University of Warsaw, Department of Pediatrics, Warsaw,
Poland, 2Medical University of Warsaw, Students’ Scientific Association,
Warsaw, Poland
Lipoatrophy (LA) is a rare complication of treatment with insulin analogs. Some authors report the raising incidence of lipoatrophy following the use of insulin pumps (CSII). It is relevant not only because of
the cosmetic problem, but also because of the variability of absorption it causes in the site of injection. The aim of our study was to
evaluate the current prevalence of insulin-induced LA in children with
type 1 diabetes (T1D).
Routine examination of insulin injection sites were conducted in
1763 patients in our outpatient clinic from 2009 till 2015. In case of
lipoatrophy, medical and anthropometric data were collected.
We identified 43 children (55% boys) treated with rapid-acting analogs: aspart (90.5%) and lispro (9.5%). Overall prevalence of lipoatrophy was 2.5%. All patients, except one, were on CSII. The mean age
and diabetes duration at the onset of lipoatrophy were 8.86 3.85
(2.24-17.49) years and 2.85 2.60 (0.11-13.16) years, respectively.
The mean HbA1c was 6.8 1.19 (5.3-10.8)%, mean daily insulin
dose 0.78 0.28 (0.28-1.48) units/kg. Most of the LA cases were
140
multiple (69%). All changes were localized to the insulin injection sites
(abdomen was the least often location). In 29 patients, lipoatrophy
resolved after switching to different insulin analog and changing the
site of insertions after average 7 months (2–12). Total regression of
single lesions was observed faster - after 2.5 months (1–3). In four
cases recurrence of LA lesions was seen, despite of insulin change.
Concomitant autoimmune diseases (thyroiditis, celiac disease and/or
arthritis) were present in about one-third of the cases (mostly in
cases with multiple lesions).
Lipoatrophy reactions remain a potential problem when managing
T1D patients. Regular routine examination of insulin injection sites
with early intervention is essential. In cases of localized LA the beneficial therapeutic approach is to change the insulin molecule and the
site of insulin injections.
P289
Overweight, obesity and metabolic syndrome in
T1D paediatric patients
J. Galhardo1, P. Semedo1, L. Lopes1
1
CHLC - Hospital de Dona Estefânia, Diabetes and Paediatric
Endocrinology Unit, Lisboa, Portugal
Objectives: We aimed to determine the prevalence of overweight,
obesity, metabolic syndrome and its components among a paediatric
population of T1D patients.
Methods: We conducted a cross-sectional study in our tertiary paediatric hospital Diabetes Clinic that included 256 patients at least one
year into T1D diagnosis. Age, gender, ethnicity, time since diagnosis,
additional diseases/drugs, total daily insulin dose (TDI) and delivery
method, anthropometrics, blood pressure, HbA1c, lipids, and presence of microvascular complications were obtained from clinical
records. Patients with TDI ≥ 1U/Kg were considered insulin resistant.
Results: Patients were 52% female and 91% white; median age was
11 (4–17)yr. Median T1D duration was 5.5 (1.2-14.3)yr; intensive
insulin treatment was delivered by multiple daily injections in 79.7%;
global mean HbA1c was 7.9 1.6%. Overweight was present in 21%
and 9.8% were obese. Among those above 10 yr, 7.4% met metabolic
syndrome criteria: 5.9% had high triglycerides, 5.5% had low HDL,
but none had hypertension.
Patients with TDI ≥ 1U/Kg (18%) were older (14.3 vs 8.1 yr), had
longer diabetes duration (6.3 vs 3.5 yr), were more obese (2.8 vs 1.6
BMI-SDS), had lower HDL-c (37.4 vs 52.1 mg/dL), had higher triglycerides (168 vs 131 mg/dL) and had higher ALT (49 vs 22U/L); there
was no difference in age of onset or in HbA1c levels.
Conclusions: In our country, the prevalence of overweight in youth
is 30%, amongst which 10% is obese. The increasing number of overweight in T1D is associated with insulin resistance and metabolic syndrome. In this “double diabetes” scenario, as the weight comes up,
insulin resistance also grows, increasing the TDI and ending in an
even heavier child.
In these patients, our next goal will be to study how a change in
life style and an improvement in peripheral insulin sensitivity will be
able to postpone a TDI increment, cutting this vicious circle and reducing the risk for future vascular complications.
P290
Perceived efficacy of the ISPAD science school for
physicians on fellows’ career development,
scientific expertise, networking and social
opportunities: the JENIOUS* evaluation survey
E. Giani1, M. Macedoni1, C. Mameli1, R. Cardona-Hernandez2,
K. Dovc3
1
University of Milan, V. Buzzi Children’s Hospital, Pediatric
Endocrinology, Diabetes and Metabolism, Milan, Italy, 2Hospital Sant
Joan de Déu, Division of Endocrinology and Diabetes, Barcelona, Spain,
POSTER TOURS
3
University Children’s Hospital, UMC Ljubljana, Department of Pediatric
Endocrinology, Diabetes and Metabolic Diseases, Ljubljana, Slovenia
Objective: The ISPAD Science School for Physicians (ISSP) is an
international program aimed to enhance endocrine fellows’ knowledge in principles of research methodology. This study investigated
the fellows’ perceived efficacy of the ISSP on career development,
scientific skills and production, scientific networking and social
opportunities.
Methods: A survey was sent to 361 fellows who attended the ISSP
between 2000 and 2015, to test the efficacy of the ISSP on 4 major
areas: career development, scientific enhancement (overall 18-items
rated on a 5-point Likert scale), scientific networking and social
opportunities (overall 20 fixed choice items).
Results: 84 (23%) participants completed the survey (63% female;
mean age 37 6 yrs; 63% from Europe). The ISSP attendees were
residents (37%) or fellows (26%) in pediatrics (29%), pediatric diabetes (21%) or pediatric endocrinology (20%). For 81% of attendees the
ISSP supported their career, helping to achieve a research position
(60%), to be engaged with diabetes care (65%) or research (75%) or
to start a research fellowship (48%).The ISSP was effective in increasing interest in diabetes research (95%), and enhancing the number
(62%) and the quality (85%) of scientific productions. After the ISSP,
40% of attendees had ≥2 abstracts/year accepted at international
meetings and 30% won research grants. The ISSP promoted scientific
networking (93%): 58% of attendees continued to share knowledge
and clinical cases, and 15% started research collaborations. About
social opportunities, the ISSP helped to meet new friends (93%) with
83% of participants still in contact with other attendees, primarily by
Facebook (29%) and mail (16%). Finally, 96% of attendees recommend the ISSP as an effective scientific program.
Conclusions: The ISSP is effective in improving engagement with diabetes research, supporting career opportunities, increasing scientific
skills and enhancing networking and social connections among young
scientists.
P291
Changes in insulin dose and diabetes knowledge
during a diabetes camp for patients with type
1 diabetes
L. Diaz-Naya1, J. Ares2, A. Martín-Nieto1, S. González-Martínez1,
L. Suárez-Gutiérrez3, I. Riaño-Galán4, B. Mayoral5, E. MenéndezTorre1
1
Hospital Universitario Central de Asturias, Endocrinologia y Nutricion,
Buylla, Sección de Endocrinologia y
Oviedo, Spain, 2Hospital Alvarez
Nutricion, Mieres, Spain, 3Hospital de Cabueñes, Sección de
Endocrinologia y Nutricion, Gijón, Spain, 4Hospital San Agustín,
Pediatría, Avilés, Spain, 5Hospital de Cabueñes, Pediatría, Gijón, Spain
Objectives: The aim of this study was to evaluate the changes in
insulin dose and diabetes knowledge after a week-long residential
diabetes camp for patients with type 1 diabetes.
Methods: This is a descriptive retrospective study including data of
42 subjects who attended to an Educative Summer Camp in 2014
and 2015. They attended to diabetes education classes during at least
one hour per day, practised exercise, used supervised carbohydrate
counting method, and took a 32 question diabetes questionnaire at
the beginning and at the end of the camp. We collected data on age,
duration of diabetes, blood glucose at least six times per day, HbA1c
levels before the camp, and the test scores.
Results: We evaluated 42 patients diagnosed of Type 1 Diabetes
Mellitus, with a mean age of 13.95 years. The average duration of
diabetes was 3.67 years. The mean glucose was 151.88 mg/dl, with
an estimated HbA1c of 6.92%. The mean HbA1c prior to the camp
was 7.38%. The mean insulin dose prior to de camp was 0.78 IU/kg,
and at the end of the camp 0.60 IU/kg, absolute difference −20.44%.
The mean questionnaire score at the beginning of the camp was
25.73 (80.43% of correct answers), and at the end 29 (90.63% of correct answers).
141
POSTER TOURS
Conclusion: The results showed a decrease in the insulin dose and
the HbA1c average, as well as an improvement in diabetes knowledge after a diabetes camp where patients practised exercise, followed a supervised diet and took specific lessons. This could
encourage patients and proffesionals to take part into diabetes
camps.
P292
Trial of diabetes education for staff of Japanese
schools with a low incidence of type 1 diabates
M. Katsuyuki1, E. Yoshida2, T. Shiraishi2, Y. Maruo1
Shiga University of Medical Science, Pediatrics, Otsu, Japan, 2Shiga
University of Medical Science, Nursing Department, Otsu, Japan
1
Objectives: Incidence of type 1 diabetes mellitus (T1DM) is low in
Japan. Many schools have no school nurse, yet school staff members
are key people in the school life of children with T1DM. However,
their knowledge of T1DM is poor, and those who do have experience
with T1DM are unable to share it. Further, cooperation between
medical and school staff is slow to improve. We held a workshop for
school staff members and evaluated their character and the workshop’s effect.
Method: Before and nine months after the workshop, staff members
who did (WS) and did not (CO) participate in the workshop completed a questionnaire on the necessity of, their self-confidence with
respect to, and difficulty with the management of T1DM children.
Mean necessity (MNS; scores ranged from 1–5), self-confidence
(MSS; 1–5), and difficulty (MDS; 1–10) scores were compared
between the two groups.
Results: We received responses before and after the workshop from
28 WS and 22 CO participants. Initial MNS for both groups
(WS 4.47, CO 4.42) was high. MSS for WS (3.19) was significantly
lower than that for CO (3.68; P < 0.05), whereas MDS for WS (3.69)
was higher than that for CO (2.54; P < 0.05). Nine months later,
MNS and MSS were unchanged, except that MSS for CO increased
(WS: MNS 4.34, MSS 3.34; CO: MNS 4.53, MSS 3.94). MDS
increased to 4.19 for WS and 3.29 for CO (no significant difference
between groups).
Conclusions: The school staff members recognized the necessity of
management for T1DM children, but their self-confidence was low.
Staff members who had lower confidence and more difficulty in managing T1DM children tended to participate in the workshop. Those
who did not participate in the workshop had higher confidence. If
they were overconfident, they may not have recognized the importance of such training, and might manage such children inappropriately. Approaches to this problem other than workshops might
therefore also be necessary.
P293
SPECTRUM CGM education programme:
psychological elements of pediatric modules
K. Lange1, S. von Sengbusch2, M. Holder3, B. Gehr4, R. Ziegler5,
SPECTRUM Group of the AGPD and AGDT in the German Diabetes
Association (DDG)
1
Hannover Medical School, Medical Psychology, Hannover, Germany,
Klinik für Kinder- und Jugendmedizin, UKSH Campus Lübeck, Lübeck,
Germany, 3Olgahospital, Klinikum Stuttgart, Stuttgart, Germany,
4
Fachklinik Bad Heilbrunn, Bad Heilbrunn, Germany, 5Pediatric Diabetes
Centre Münster, Münster, Germany
2
Based on experiences in pediatric diabetes education a productindependent CGM program called SPECTRUM was developed with
age-appropriate tools and curricula for parents of young children with
T1DM, adolescents and adults. It combines practical education on all
relevant technical aspects, coaching in structured data analysis with
psychological elements to support the acceptance of the device and
families´ long-term motivation.
Qualitative data on psychological challenges associated with CGM
in pediatric care were assessed by the pediatric team members of
SPECTRUM: families’ expectations on effort of using CGM, information overload, and frustration due to unexpected glucose fluctuation,
young children´s refusal of the device, overreaction to glucose variation and alerts, and adolescents` difficulties using CGM in social
situations.
To address these challenges several psychological elements were
included in the 5 pediatric modules of SPECTRUM for parents of
young children and the 5 modules for adolescents: worksheets on
realistic expectations for adolescents and parents; role models on
introducing the device to young children; practical aspects of CGM in
nursery and school; discussion of parents’ and adolescents’ emotional
reactions on alerts and unexpected glucose variation, e.g. coping with
feelings of guilt, anxiety or learned helplessness; cognitive behaviour
techniques to prevent from overreaction on hypo alarms; step-bystep introduction of different alarms to prevent children, parents and
other carer from overload; worksheets to support positive parentadolescent cooperation (“coaching contract”); role models for focussing on successes at structured CGM data analysis.
SPECTRUM strives for qualified, structured information on CGM
for young people with T1DM and their families and also for supporting their motivation to sustainably use CGM and improving their
quality of life. An evaluation of SPECTRUM will be done within the
framework of a clinical trial.
P294
Diabetes care at your doorstep - DAUD: an
educative support
D. Hasnani1, B. Saboo1, M. Saiyed1, F. Patel1, V. Chavda1, K. Parmar1
1
Diacare- Diabetes Care and Hormone Clinic, Diabetology, Ahmedabad,
India
Education is a one of the strongest pillars for the basis of good glycemic control. Our team at Diacare has come up with this ground
breaking idea of “DAUD- DIABETES CARE AT YOUR DOORSTEP”.
A team of well trained diabetes educators along with a diabetic nurse
visit all our T1D patients at their place of residence. Here they go
through a detail history of the patient, including their medical history,
anthropometric data, SMBG charts, meal patterns, previous and current glycemic patterns. Based on this the parents, family and siblings
along with the patient are counselled and educated on ways to
improve their glycemic variability and their Quality Of life(QOL). The
unaffordable patients are provided with essential amenities - insulin,
syringes, glucometers and strips through our various programs CDIC, LFAC, Diacare trust, RSSDI. In this manner we have been able
to create 20 centres of references or “satellite centres” as we name
them, across the state of Gujarat. An additional support through the
availability of smart-phones is provided for day to day contact in form
of DAUD mobile application which tracks the progress of the patient.
We are trying to acquire support for providing smart-phones to the
unaffording population too. All the patients shall be tracked and
encouraged to stay on the platform in the future. The kids and adolescents are also counselled and helped to be independent and if they
are interested they are trained to become diabetes educators.
This endeavour has helped us in multiple ways:
1. Improve level of diabetes education, awareness and knowledge
about diabetes complications.
2. Improve the glycemic status.
3. Improve QOL
4. Remove the prejudices and taboos against T1D.
142
5. Empower these patients to take care of their own situation.
6. Make them independent by opening them to variety of career
choices.
7. Creation of our own type 1 diabetes registry for proper follow
up and management of the patients.
P295
Epidemiological data of type 1 diabetes mellitus in
children in Uzbekistan, 1998–2014
G.N. Rakhimova1, N.U. Alimova1, A. Ryaboshtan1, B. Waldman2, G.D.
Ogle2,3, S.I. Ismailov1
1
Center for the Scientific and Clinical Study of Endocrinology, Tashkent,
Uzbekistan, 2International Diabetes Federation Life for a Child Program,
Sydney, Australia, 3Diabetes NSW, Sydney, Australia
Objectives: We aimed to determine the incidence, prevalence and
mortality of type 1 diabetes (T1D) in Uzbekistan in
children < 15 years old.
Methods: In a prospective study from 1998–2014, we ascertained
incidence, prevalence, mortality, and cause of death via data collected
by regional endocrinology dispensaries in Uzbekistan’s 14 administrative divisions. Time trends were evaluated using Poisson regression.
Additionally, data from a national audit in 2011 was used to determine age structure for new T1D diagnoses between 2008–2010.
Results: Over 1998 to 2014 T1D prevalence roughly doubled (7.8 to
15.3 / 100,000 population aged
<15 years, p = 0.10), following a doubling of incidence (1.5 to 3.1
/100,000 < 15 years), 5.6% annualised increase, p = 0.001), with a
fall in mortality per 1,000 patient years (24.5 to 2.0, p = 0.001). There
was a female preponderance, with a male:female ratio 0.89 in
2008–2010.
In every year, T1D incidence was highest in the 10–14.99 year
age-group, although the proportion of diagnoses under 5 years of age
increased from 6.0% of total diagnoses in 1998–2002, to 13.4% in
2008–10. Peak age of onset in 2008–2010 was 13 years. Notable
regional variation was evident, with incidence being highest in
Tashkent-City (p = 0.005, one-way ANOVA).
The commonest cause of death was chronic renal failure - responsible for 18 out of 50 deaths in children < 15 years from 2003
to 2014.
Conclusions: Our results provide the first long-term epidemiological
data for T1D in Uzbekistan and the region. Uzbekistan is country of
low but rising T1D incidence and prevalence, and falling mortality.
Attention to improving clinical care is warranted, to reduce long-term
complications.
P296
Advance in insulin therapy of Japanese pediatric
and adolescent type 1 diabetes: the cohorts of the
childhood-onset type 1 diabetic patients in
Japanese study group of insulin therapy for
childhood and adolescent diabetes (JSGIT)
T. Kikuchi1, T. Urakami2, M. Mochizuki3, T. Kawamura4, N. Kikuchi5,
I. Yokota6, N. Matsuura7, N. Sasaki1, S. Amemiya1, S. Sugihara8,
Japanese Study Group of Insulin Therapy for Childhood and
Adolescent Diabetes (JSGIT)
1
Saitama Medical University, Department of Pediatrics, Saitama, Japan,
Nihon University School of Medicine, Department of Pediatrics, Tokyo,
Japan, 3University of Yamanashi, Department of Pediatrics, Yamanashi,
Japan, 4Osaka City University, Department of Pediatrics, Osaka, Japan,
5
Yokohama City Minato Red Cross Hospital, Department of Pediatrics,
Yokohama, Japan, 6Division of Pediatric Endocrinology and Metabolism,
Shikoku Medical Center for Children and Adults, Department of
Pediatrics, Kagawa, Japan, 7Seitoku University, Tokyo, Japan, 8Tokyo
Women’s Medical University Medical Center East, Department of
Pediatrics, Tokyo, Japan
2
POSTER TOURS
Objective: The aim of this study was to clarify whether the introduction of multiple daily injection, insulin analogues and CSII for insulin
therapy in Japanese pediatric and adolescent type 1 diabetes since
2000 to 2014.
Methods: We compared insulin regimens, HbA1c among three
cohorts of childhood-onset type 1 diabetic patients in JSGIT,
786, 852 and 1078 patients, in 2000, 2008 and 2013 cohorts.
Results: The frequency of multiple daily injection using regular and
NPH-insulin, and CSII were 55% and 0.3% in 2000. The frequency of
multiple daily injection using rapid acting and basal long acting insulin
analogs, and CSII were 70% and 26% in 2014. The regular and NPHinsulin were rarely used in 2014. HbA1c was 8.6% in 2000, 8.2% in
2014. HbA1c has been improved before and after using basal long
acting insulin analogs. The frequency of CSII in 0–5 year’s old
patients was 40% in 2014.
Conclusions: The insulin therapy advanced greatly by using insulin
analogs and CSII since 2000 to 2014.
P297
Update of trends in childhood type 1 diabetes in
Germany
J. Rosenbauer1,2, A. Stahl-Pehe1,2, C. Baechle1,2, K. Castillo1,2,
T. Meissner2,3, R.W. Holl2,4, in cooperation with the German Pediatric
Surveillance Unit (ESPED), the DPV initiative and the German Center
for Diabetes Research (DZD)
1
German Diabetes Centre, Leibniz Institute for Diabetes Research at
Heinrich Heine University Düsseldorf, Institute for Biometrics and
Epidemiology, Duesseldorf, Germany, 2German Center for Diabetes
Research (DZD), Munich-Neuherberg, Germany, 3University Children’s
Hospital Duesseldorf, Department of General Pediatrics, Neonatology
and Pediatric Cardiology, Duesseldorf, Germany, 4University of Ulm,
Institute of Epidemiology and Medical Biometry, ZIBMT, Ulm, Germany
Objectives: To estimate updated age- and sex-specific time trends of
childhood type 1 diabetes (T1D) in children 0–14 years of age in
North Rhine-Westphalia, Germany, in the period 1996–2014 with an
average risk population of 2.687 million children.
Methods: Newly diagnosed T1D cases were ascertained by means
of three data sources: a prospective hospital-based active surveillance system (ESPED), annual inquiries among practices, and a
computer-based documentation system for quality control and scientific research in diabetes care (DPV). Completeness of ascertainment was estimated by the capture-recapture-method. Point and
interval estimates (95% CI) of incidence rates (per 100,000 personyears) were based on Poisson distribution. Age- and/or sexstandardized rates were estimated by the direct method using equal
weights. Poisson regression analysis was applied to assess time
trends.
Results: Between 1996 and 2014, 11,774 newly diagnosed children
with T1D aged 0–14 years (6,209 boys, 5,565 girls) were registered.
Ascertainment was estimated to be 99.1% complete. The overall incidence rate was 22.8 (22.3-23.2). The incidence among boys was
higher than among girls (23.4 vs. 22.1, p = 0.002). Age-specific estimates for age groups 0–4, 5–9, 10–14 years were 15.9, 25.6, 26.8,
respectively (p < 0.001). The average annual incidence increase was
estimated at 3.0% (2.7%-3.4%) with no difference between boys and
girls (3.1% vs. 2.9%, p = 0.412). Age-specific trends were similar
among boys (0–4, 5–9, 10–14 years: 2.5%, 3.3%, 3.3%, p = 0.407)
but varied significantly among girls (0–4, 5–9 and 10–14 years: 3.1%,
3.6% and 2.0%, p = 0.023).
Conclusions: This study confirmed the incidence of childhood T1D in
Germany to increase steadily. Interestingly, differential trends between
sexes were observed among 10–14 year-old children. Further research
is needed to identify causes of the continuous rise of diabetes incidence
and in particular of differential trends between sexes.
143
POSTER TOURS
P298
The onset age of type 1 diabetes in Polish children
from Wielkopolska province has become younger
E. Niechcial1, B. Skowronska1, I. Krzysko-Pieczka1, A. Gertig-Kolasa1,
W. Stankiewicz1, M. Michalak2, P. Fichna1
basal-bolus insulin regimen. The average ratio of rapid acting insulin
to long-acting insulin was 1.55 +/− 0.65.
Conclusion: This study is the first of its kind ever conducted in the only
residential diabetes camp in Mauritius. Data compiled on the diabetic
camp by T1Diams has established the benchmark for future studies.
1
Poznan University of Medical Sciences, Department of Paediatric
Diabetes and Obesity, Poznan, Poland, 2Poznan University of Medical
Sciences, Department of Informatics and Statistics, Poznan, Poland
Objectives: In Poland, the first epidemiological register was conducted in Wielkopolska (1970–1985), where the estimated average
incidence rate was 4.4/105 in children aged 0–16 years. The next
data (1998–2003) showed the growing trend with incidence rate
around 11.2/105 in children aged 0–14 years and with highest incidence peak in children aged 10–14 years. We aimed to assess the
current incidence of type 1 diabetes (T1DM) in children aged 0–14
years from Wielkopolska, Poland.
Methods: The analysis involved new cases of T1DM that were
recorded in Childhood Diabetes Registry from 2008 to 2014. The
denominator for the analysis were children ≤14 years with permanent residency in the study area. Total, sex-, and age-specific incidence rates per 100,000 person-years were calculated for each
calendar year. A direct standardization method was used to estimate age and sex standardized rates. The 95% CI was calculated
using the Gaussian approximation to the Poisson log-likelihood.
The demographic date was obtained from the Statistical Office in
Poznan.
Results: 695 new cases of T1DM: 309 girls and 386 boys were identified from 2008 to 2014. The mean age was 9.0 4.4 years. The
trend for increased incidence of T1DM has been observed in children
aged 0–14 (2008: 15.6/105, 95% CI: 8.6-22.4; 2014: 22.9/105, 95%
CI: 17.9-27.9). The highest annual incidence was reported among
those aged 5–9 years (2008–22.8/105- 95% CI: 15.6-30.0;
2014–28.8/105- 95% CI: 21.1-36.2). The fastest incidence increase
was found in the youngest age group
(2008–7.1/105, 95% CI: 3.2-11.0; 2013–17.4/105 , 95% CI: 11.523.2; 2014–13.9/105 , 95% CI: 7.9-19.9).
Conclusions: The incidence of T1DM raised up in Wielkopolska, predominantly in the younger age-groups. The highest incidence peak
was observed in children aged 5–9 years. Such rapid increase in very
short period rather is associated with environmental factors than
changing in genetic background.
P299
Characteristics of type 1 diabetic patients attending
a winter diabetic camp in Mauritius
P.K. Guness1, A. Dustagheer2, D. Jean Pierre2
1
Private, Saint Clothilde, Réunion, 2NGO/ T1Diams, Vacoas, Mauritius
Introduction: Diabetic camps have become an integral part in the life
of people with type 1 diabetes and a different setting to improve
DSME (Diabetes Self-Management Education).
Aim: To determine the characteristics of type 1diabetics attending a
winter diabetic camp in Mauritius.
Methods: During a 7-day camp, organised by T1Diams (Type 1 diabetes mellitus support) non-governmental organisation, the epidemiological data of 27 Type 1 diabetic patients was collected and
compiled on a personal computer. The data was analysed on Microsoft Excel®. Clearance was obtained from the managing committee of
the organisation.
Results: 27 patients attended all the 7 seven days. 11 male and
16 female patients were present with mean age of 16.3 years (
16.5 years male and 16.1 years male).The mean age of onset of diabetes was 9.96 +/− 4.5 years. On average they attended the camp
4.4 times during the last 8 years. Mean weight was 52.1 +/− 10.7 kg,
height 160 +/− 8 cm and a BMI 20.3 +/− 3.68. No patient on insulin
pump, 1 patient was on a twice daily insulin injection and the rest on
P300
Association of rs7093069- IL2RA and rs7647305SFRS10 polymorphisms with diabetes type 1 in
children
A. Bossowski1, A. Polkowska1, J. Goscik2, N. WawrusiewiczKurylonek3, W. Mlynarski4, A. Kretowski3
1
Medical University of Bialystok, Dep. of Paediatrics, Endocrinology,
Diabetology with Cardiology Division, Białystok, Poland, 2Medical
University of Bialystok, Centre for Experimental Medicine, Białystok,
Poland, 3Medical University of Bialystok, Dep.of Endocrinology,
Diabetology with Internal Medicine, Białystok, Poland, 4Medical
University of Lodz, Dep. of Pediatric,Oncology, Hematology and
Diabetology, Lodz, Poland
Background: The etiology of diabetes type 1 is multifactorial and
involves genetic and environmental factors. Family and population
studies confirmed the strong genetic influence and inheritability in
the development of these diseases. Most papers evaluating the relationship of rs7093069 and rs7647305 polymorphisms with lipid
metabolism and obesity. Possible differences in overexpression of the
IL2RA, SFRS10, ETV5 and DGKG genes polymorphisms on diabetes
type 1 remain unclear.
Objective and hypotheses: To identify the association between polymorphisms of IL2RA, SFRS10, ETV5 and DGKG genes and diabetes
type 1.
Method: The study was performed in 94 patients with diabetes type
1 and 160 healthy volunteers. The two single nucleotide polymorphisms (SNPs): rs7093069 - IL2RA and rs7647305 - SFRS10, ETV5 and
DGKG were genotyped by TaqMan SNP genotyping assay using the
real-time PCR.
Results: Rs7093069 T alleles were more frequent in patients with
diabetes type 1 in comparison to control(p < 0.005 with OR = 2.9).
Rs7647305 T alleles were more frequent in patients with type 1 diabetes in comparison to control (p < 0.005, OR = 2.5).
Conclusion: Rs7093069 T/T and rs7647305 T/T polymorphisms
could contribute to development of diabetes type 1. The main risk
factor for 7093069 is T allele. In case of rs7647305 the main risk factor is also allele T.
P301
Higher C-peptide, higher neutrophil and lower
natural killer peripheral counts at type 1 diabetes
onset - biomarkers for a longer remission phase?
A.L. Fitas1, C. Martins2, G. Nunes2, L. Lopes1, S. Lenzen3,
L.M. Borrego2, C. Limbert1
1
Hospital de Dona Estefânia, Centro Hospitalar de Lisboa Central, EPE,
Pediatric Endocrinology Unit, Lisboa, Portugal, 2CEDOC - Chronic
Diseases Research Center - NOVA Medical School, Immunology
Department, Lisboa, Portugal, 3Hannover Medical School, Institute of
Clinical Biochemistry, Hannover, Germany
Introduction: The natural history of Type 1 Diabetes (T1D) develops
through distinct phases with particular immunologic and metabolic
features. In remission phase a partial and transient restoration of
endogenous insulin production occurs.
Objective: To identify clinically useful biomarkers for longer remission phase.
Methods: Prospective evaluation of 28 T1D children in three disease
time-points (T1-onset; T2-remission phase; T3-established disease).
Patients and 28 age-matched controls PB samples were analyzed by
144
flow cytometry. Metabolic data were prospectively collected. In this
data subset, relations between cellular populations, metabolic data
and remission phase duration were explored.
Results: 28 T1D children aged 5-16y (mean 10 2,6y), 46% male. T1
samples were collected 4 2 days after diagnosis (mean SD); T2
occured at 111 45 and T3 at 397 106 days. C-peptide level was
positively related to remission time (r = 0,389; p = 0,05). Children with
C-peptide levels >0,4 at T1 had higher neutrophil counts (p = 0,03). Relative neutrophil count at onset was positively related to remission duration (r = 0,412; p = 0,03). Inversely, NK count in T1 was negatively
related to remission phase duration (r = −0,538; p = 0,003). At remission phase entrance, children with lower C-peptide (<0,4) had significantly lower neutrophil levels (p = 0,02), higher Th1 (p = 0,04) and total
IFN-producing cells (p = 0,05). Neither Th17/Tc17, Th1/Tc1 nor Treg
related significantly with remission phase time.
Conclusions: Higher peripheral neutrophils may signal less pancreatic
infiltration and therefore a less severe initial beta-cell mass destruction. That translates into higher C-peptide levels at disease onset and
eventually a longer remission phase. Lower NK counts may predict a
longer remission phase due to increased pancreatic migration with a
possible protective role in insulitis. Immunologic characterization
along the natural history of T1D may disclose biomarkers to direct
future immune interventions.
P302
Waxing and waning autoimmune measures: are
autoantibodies a useful measure two years after
diabetes diagnosis?
M. Buryk1, V. Arena2, I. Libman2, Y. Huang2, H.-M. Dosch3,
R. Cheung3, M. Pietropaolo4, D. Becker2
1
Naval Medical Center Portsmouth, Portsmouth, United States,
University of Pittsburgh, Pittsburgh, United States, 3Hospital for Sick
Children, Toronto, Canada, 4Baylor College of Medicine, Houston, United
States
2
Objectives: To assess the autoantibody (Ab) status and factors associated with presence or absence of Ab two years after clinical diagnosis of Type 1 Diabetes (T1D).
Methods: T1D patients diagnosed between 12/2004 and 6/2008
with minimum of 3 Ab measured at both onset of T1D and 2 years
after diagnosis were included (n = 141): age 9.5 4 (1.2-18.9) years,
96% Caucasian, 59% male. Measures of T-cell autoreactivites to
10 analytes, Ab (GADA, IA-2A, IAA, ICA) and BMI percentile at onset
and 2 years were collected. IAA only drawn within 7 days of beginning insulin therapy.
Results: At baseline 11 (8%) of those with clinically diagnosed T1D
were negative for all measured Ab [ 21 (15%) 1 Ab+; 46 (33%) 2Ab+;
50 (35%) 3Ab+; 13 (9%) 4Ab+]. Two years after diagnosis 3/11 (27%)
of those originally Ab negative were positive for one Ab. Of those
with positive Ab at baseline, 40/130 (30%) were negative for an Ab
that was measured positive at baseline. Those individuals who lost at
least one Ab were more likely to be younger age; 8 4 years (lost
Ab) vs. 11 4 years (no change Ab) (p = 0.01). There was no difference in gender, race or BMI in those with unchanged Ab compared
with those losing Ab. Twelve subjects (8%) were Ab + at baseline but
negative at 2 years (all of these individuals were positive for diabetes
associated T-cells). GADA was Ab that most commonly converted
from positive at baseline to negative at 2 years (26/141 (19%)) [IA2A (10/141 (7%)), ICA (13/141 (9%))].
Conclusions: The autoimmune process in T1D is continuously evolving, even after T1D diagnosis. Those who are younger at diagnosis
tend to have more rapid conversion to negative Ab, possibly supporting the concept that the autoimmune process evolves more rapidly in
this young group. Given that 10% of patients with clinical T1D and
positive responses to T1D associated T-cells were Ab negative at
2 years indicates that Abs may not be useful tool to assess diabetes
"type" more remote from the time of diagnosis.
POSTER TOURS
P303
Corelation among whole genome methylation
status and line-1 expression in various age grouop
of diabetic rat brain
S. Mukherjee1, D. Sharma1, K.C. Upadhyaya1
1
Jawaharlal Nehru University, School of Life Sciences, New Delhi, India
Objectives: Emerging data suggest that epigenetics also play a key
role in the pathogenesis of diabetes. LINE 1 is an autonomous, nonLTR retrotransposon and the L1 retrotransposons constitute around
17%, of the human, mouse and rat genomes respectively. Transposable elements make up sizeable components of all eukaryotic genomes, varying from 14% to over 80%. Retroelements constitute a
predominant class of elements in eukaryotic genomes and subdivided
into two categories: LTR elements and non LTR elements. The mammalian genomes contain a preponderance of non-LTR retroelements.
Under normal physiological conditions, the retroelements remain by
and large transcriptionally silent but are activated in response to
biotic and abiotic stress conditions. Our objectives were to study the
transcriptional expression of L1Rn elements in different brain regions
of epileptic rats and correlate with corresponding DNA methylation
levels.
Methods: Real time PCR analysis using RNA isolated from various
brain regions and various tissues from old and young wistar rats of
both diabetic and control rats was carried out to determine the
change in L1 transcripts. DNA methylation assay was performed
using COBRA method.
Results: There was no significant change in the expression of L1Rn
in various brain regions of 2 month old and 18 month old rats except
cerebral cortex.
Conclusion: In conclusion, the degree of hypomethylation in promoter CpG islands in LINE-1 repetitive sequences do play essential
role in LINE-1 element expression. Besides tissue specific factors do
play pivotal role in LINE-1 expression.
P304
The efficacy of vitamin D supplementation on the
improvement of serum 25-hydroxyvitamin D3
status and HbA1c levels in pediatric patients with
type 1 diabetes mellitus
J. Chin1,2, S. Chan-Cua2, L. Abad2
1
Vicente Sotto Memorial Medical Center, Pediatrics, Cebu City,
Philippines, 2University of the Philippines Manila- Philippine General
Hospital, Pediatrics, Metro Manila, Philippines
Background: Recently, studies have outlined clinical evidence on the
non-classical role of vitamin D in type 1 diabetes mellitus (T1DM).
Multiple studies have suggested a link between vitamin D deficiency
in early life and the development of T1DM later in life. Local data has
shown a significant proportion of T1DM patients with Vitamin D
inadequacy.
Objective: This study aims to study the effect of Vitamin D supplementation on the Vitamin D status and HbA1c levels of T1DM pediatric patients with vitamin D inadequacy.
Subjects and Methods: A prospective cohort, interventional study of
34 subjects with Type 1 diabetes mellitus ( 21 females, 13 males ),
with mean age of 14.5 ( SD 5.23, 11.07-18.49 ), with mean duration
of T1DM of 5.74 years. All subjects had
(1) a diagnosis of diabetes following the ISPAD guidelines diagnostic criteria,
(2) had baseline measurements of 25(OH)D, HbA1c, ALT, Creatinine, and Sun Exposure Score,
(3) received Vitamin D supplementation, and
(4) had post-supplementation measurements of 25(OH)D, HbA1c
and Sun Exposure Score.
145
POSTER TOURS
Results: At baseline, Vitamin D deficiency was noted in 100% of the
subjects. Further, 64.71% of the subjects had poor glycemic control.
Post-supplementation, Vitamin D levels improved, with 11.76% of
subjects having sufficient levels and 58.82% having insufficient levels.
However, 61.76% of subjects still had poor glycemic control. There
was an increase in 25(OH)D level post-supplementation ( p < 0.01 ).
However, no significant change in HbA1c levels was noted (
p = 0.32 ).
Conclusion: Vitamin D deficiency is prevalent in patients with Type
1 Diabetes Mellitus. Vitamin D supplementation was associated with
a statistically significant increase in 25(OH)D levels. Despite this,
there was no statistically significant change in the HbA1c levels of
the subjects. There is a need to look at other factors contributing to
the glycemic control of these subjects.
P305
Clinical profile and outcome of children with
diabetic ketoacidosis: type 1 diabetes mellitus a real
challenge for low income Nation
1
P. Kanodia
1
Nepalgunj Medical College, Department of Pediatrics, Nepalgunj, Nepal
Background: The objective of the study was to study clinical profile
and outcome of DKA children in Nepal. Nepal is a poor and developing nation and childhood diabetes is a real challenge.
Methods: We retrospectively analysed the case records of 30 children (17 boys and 13 girls) with type 1 diabetes mellitus admitted to
our hospital from January 2010 to August 2015. They were managed
using a standard protocol including intravenous fluids and insulin
infusion. Data was analysed by using SPSS version 21.
Results: The median age at presentation was 9 years. Among 30 diabetic children 21 were presented with severe diabetic ketoacidos.
Polyuria with polydipsia was the commonest clinical presentation.
All of them had elevated HbA1C levels and length of stay in the
paediatric intensive care unit was 3.9 days. The median time for the
arterial blood gases to become normal was 20 hours and for urinary
ketones to become non-detectable was 26 hours. Severity of diabetic ketoacidosis was significantly associated with the presence of
infection, history of omission of insulin, poor compliance, and presence of shock at time of presentation, length of stay in the hospital,
final outcome (p < 0.01 for each of these associations). Only one
child was expired due to DKA and rest all children were doing well
on follow up.
Conclusion: The outcome of active management of diabetic ketoacidosis in children is rewarding. Parents should understand the importance of the need for regular insulin injections and regular monitoring
of blood glucose.
Keywords: Type 1 diabetes mellitus, DKA, blood glucose.
P306
Clinical profile and outcome of Type 1 diabetes
mellitus in tertiary care centre of Eastern Nepal
L. Shah1, S. Sanyal1, G.S. Shah1, M. Bhatta1
1
B. P. Koirala Institute of Health Sciences, Pediatrics, Dharan, Nepal
Ojective: The objective of this study was to study the clinical profile
and outcome of patients admitted with Type 1 diabetes mellitus in
tertiary care centre of Eastern Nepal.
Method: A prospective descriptive study was carried out in the
Department of Pediatric and Adolescent medicine, at BPKIHS,
Dharan, which is a tertiary care centre in Eastern Nepal from
January 2014 to February 2015. Details of socio-demographic,
clinical, laboratory, treatment and outcome parameters were
recorded in a pre-designed proforma. Data was analysed using
SPSS version 21.
Results: Out of 24 samples, median age was 11.5 yrs(range = 4–18
yrs). Females were 58.3%. 66.7% were admitted with DKA. Most
patients were from lower socio-economic status and rural background. The classical symptoms were polyuria, polydipsia and polyphagia were present in all cases. 46% were newly diagnosed. 37.5%
presented with DKA at onset.
Conclusion: Type 1 diabetes mellitus though not curable is a treatable disease. Besides compliance to insulin, self monitoring of blood
glucose, dietary restrictions and regular follow-up, compassionate
counseling plays a major role in achieving good glycemic control is
important to avoid life threatening complications like Diabetes
ketoacidosis.
Keywords: Type 1 diabetes mellitus, DKA, blood glucose
P307
Maximising diabetes care in resource poor setting
J.N. Menang1, S. Njimogu2
1
CALMEF Health Centre, Diabetes, Tiko, Cameroon, 2St. Louis University
of Medicine and Health Sciences, Research, Bamenda, Cameroon
Background: Diabetes mellitus disease now at global epidemic
proportions with developing nations to shoulder as much as 75%
of the global diabetes burden by 2035 portrays a developing
nations diabetes emergency on the horizon. Sub-Saharan - the
worst hit by HIV/AIDS on the globe also records high prevalence
and deaths from either diabetes or both. HIV therapies are known
to influence obesity and predispose clients to obesity and diabetes whereas HIV/AIDS itself damages the immuno-neurological
processes over time, leading to AIDS associated dementia and
others.
Methods: Pilot study from December 2014 of identifying the diabetic foot neuropathy needs in diabetics with immuno-compromised
disease and addressing them amid several complex disorders by conducting routine bi-monthly neurological assessment using tools like
10 g monofilament, hand held doppler, thermometer and blood pressure cuff. The study anticipates incorporating annual routine HIV
testing to all 68 registered diabetic clients and providing timely and
appropriate interventions.
Results: The study is ongoing with no results yet, but the complexity
of enormous health issues point to an urgent need of addressing diabetes in HIV/AIDS.
Conclusion: HIV/AIDS and diabetes are serious interwoven health
complications that enormously weigh down poor family funds, overstretch already burdened health care by many other diseases, few
staff and limited funds. The main goal of this study is prioritising neurological assessment of all registered diabetics so as to enhance quality of life of diabetics especially in HIV.
P308
Risk factors for poor metabolic control and
mortality in diabetic children in Cameroon
S. Sap1,2, M. Dehayem3, E. Sobngwi3,4, A. Chiabi5, J.C. Mbanya3,5,
P.O. Koki2,5
1
University of Yaounde I, Pediatrics, Yaounde, Cameroon, 2Mother and
Child Center, Yaounde, Cameroon, 3Yaoundé Central Hospital, Yaounde,
Cameroon, 4University of Yaounde I, Endocrinology and Diabetology,
Yaounde, Cameroon, 5University of Yaounde I, Yaounde, Cameroon
Introduction: Although the management of diabetes in children is
free of charge in Cameroon, majority of children followed have a
poor metabolic control. To address that issue, the present work
aimed to identify factors related to poor metabolic control to see
either there are modifiable or not.
Methods: A cross sectional study, including diabetic children followed for at least a year in the 9 clinics of the country. Socio demographic, education and nutritional variables were studied, related to
HbA1c through a logistic regression. Incomplete files and rare diabetes (e.g. lipoatrophic) excluded. Data were analysed through Excel
and Epi info software.
146
POSTER TOURS
One hundred and fifteen patients were included from which
83 boys. Median age was 17 years. Low mother educational level,
been orphan, living far from the clinic appeared to be the most relevant risk factor for poor glycaemic control.
Conclusion: Poor glycaemic control is found mostly in situation of
precarity, suggesting a more intensive and educational strategy for
children living in that condition in a holistic approach.
P309
60 hours hybrid-closed-loop (HCL) in everyday life:
the DREAM5-study
T. Biester1, I. Muller2, K. Remus1, I. Gottwald1, S. Bläsig1, E. Atlas2,
R. Nimri3, K. Dovc4, N. Bratina4, T. Battelino4, M. Philip3,
O. Kordonouri1, T. Danne1
1
Children’s Hospital ’Auf der Bult’, Diabetes-Center for Children and
Adloescents, Hannover, Germany, 2DreaMed Diabetes Ltd., Petah
Tikvah, Israel, 3Schneider Children’s Medical Center of Israel, Petah
Tikvah, Israel, 4Department of Pediatric Endocrinology, Diabetes and
Metabolic Diseases, University Children’s Hospital, UMC Ljubljana,
Ljubljana, Slovenia
Introduction: Previous DREAM studies showed the safety of the CEmarked closed loop (DreaMed Substance Administration System©) in
overnight use (1 night, adolescents) at a Camp and at home
(4 nights, all age groups).
The actual aim was to evaluate the system for a 60 hours continuous use, weekend time at home without remote monitoring.
Methods: All subjects had in randomized order one weekend with
sensor-augmented pump therapy (SAP) or HCL: in the intervention
arm only the amount of carbohydrate was entered into the bolus calculator, the rest of insulin dosing was delivered automated and wirelessly by a tablet computer.
Primary endpoint was the percentage of glucose values between
70–180 mg/dl.
Results: 5 adults, 5 adolescents, 5 children (10f, 5 m) experienced in
sensor use were included: (median, [IQR]): age 16.8y [12.9-18.5], diabetes duration 10.66y [7.1-13.8], pump use 10.7y [5.3-12.6], HbA1c
7.6% [7.2-8.2].
After evaluating adolescents and adults, glucose (mean[IQR]) was
173[163,186] mg/dl vs. 156[141,184] mg/dl, SAP vs. HCL, p = NS).
Percentage of time in 70–180 mg/dl was 50.2% [44, 67] vs. 67.8%
[44, 75], p = NS).
No events of ketosis or severe hypoglycemia were observed.
7 events < 60 mg/dl in SAP- and 8 in HCL-use occurred.
Discussion: The results confirm the security of this HCL in an
„around the clock“-use. The system is safe and effective in use as well
as in administration of automated corrections.
The “missing” remote monitoring did not lead to a worsening of
results or rising of dangerous events.
SAP
HCL
Time in 70–180 mg/dl [%]
50.2 [44, 67]
67.8 [44, 75]
Mean Sensor
Glucose STD [mg/dl]
173 [163,186]
156 [141, 184]
Mean SMBG [mg/dl]
211.60[173, 250]
146.14 [137, 181]
Area_Above 250 mg/dl
[mg/dl*min]
12822.5 [4250,
40607]
8874.75 [1740,
11565]
Area_Below63 [mg/dl*min]
175.0 [0, 350]
179.9 [0, 1495]
Time in 80–120 mg/dl [%]
16.4 [8, 21]
23.9 [16, 37]
[Comparison of Periods]
P310
Virtual pump clinic toward diabetes home care
model for children and their families
B. Bassoy1, G. Margabanthu1, Pump Patients
1
Kettering General Hospital, Kettering, United Kingdom
Aims: The aim of the project was to study impact of virtual pump
data analysis on glycaemic control, patient satisfaction to enable
patient empowerment and better home management of diabetes.
The impact of the practice on acute glycaemic events and hospital
admissions were analysed.
Methods: A prospective analysis was performed on virtual pump
clinic consultations over a period of 6 months.
The families were advised to upload the pump data at least once
between clinics. The data was analysed by the Paediatric Diabetic
MDT on twice weekly open basis on Tuesday and Friday pm. The
families would either text, email or call the team to alert them with
their list of concerns, analysis and solutions to the issues for the
MDT to address.
The families were asked to attempt adjust dose regimes first which
was reviewed and validated or altered by the MDT team. This
enabled patient empowerment and a very satisfying patient
experience.
Results: 31 children were on pumps out of the 140 patients. The
maximum change in HbA1C was 36 mmol/l. The average A1C was
55.6 mmol/l with a median change in A1C of 3. 43-mmol/l. There
was a reduction in the number of calls to the MDT with poor compliance in the study period. There were no admissions with acute complications like DKA in that period. The confidence of the patients
using the service improved dramatically.
Conclusions: Virtual pump clinic is an innovative approach to patient
care embracing the evolving technology for empowering patients
toward self management of the children’s diabetes by their families
from the comfort of their homes. Confidence in approaching their
own care and continuing care is the key to achieving better health
standards and this was reflected in the mean A1C at 55.6 mmol/mol
(national average 75 mmol/mol). The reduction in acute admissions
with DKA delivered better care and had cost saving benefit. Patient
experience had tremendously improved in this big leap toward home
care diabetes model.
P311
Use of professional continuous glucose monitoring
in children with type 1 diabetes mellitus: an open
label randomized control trial
K. Raviteja1, R. Kumar1, D. Dayal1, N. Sachdeva2
1
Post Graduate Institute of Medical Education and Research, Pediatrics,
Chandigarh, India, 2Post Graduate Institute of Medical Education and
Research, Endocrinology, Chandigarh, India
Objective: To assess efficacy of insulin dose adjustments, based on
data from p-CGM and SMBG, in improving glycemic control when
compared to SMBG alone.
Methods
Participants: Children (2–10 years) with Type 1 diabetes mellitus
(T1DM) for at least 6 months, on basal-bolus insulin regimen and self
monitoring of blood sugars (SMBG). Children having DKA within
2 months prior to enrolment were excluded.
Intervention: Children in Intervention group underwent professional
continuous glucose monitoring (p-CGM) (iPro®2 Professional CGM,
Medtronic, USA) for 3–5 days along with SMBG. Control group had
only SMBG.
Objective: To assess efficacy of insulin dose adjustments, based on
data from p-CGM and SMBG, in improving glycemic control when
compared to SMBG alone.
Outcome: Change in HbA1c 3 months after p-CGM.
147
POSTER TOURS
Randomization: It was done using computer generated random number list. Group allocation was concealed from investigator and participants using opaque sealed envelopes.
Results: Numbers randomized: Out of 310 patients screened for eligibility a total of 68 patients were randomized, 34 each to either arms.
Recruitment: closed
Numbers analyzed: Thirty children in intervention group and 33 in
control group. Intention to treat analysis was also performed.
Outcome: There was more decrease in unit change in HbA1c, percentage of low sugar records and total insulin requirement per day,
after 3 months follow-up, in intervention group when compared to
controls. However, they were not significant except for total insulin
Units/kg/day (p value 0.014). In sub-group analysis of children with
baseline HbA1c > 7.5%, there was a significant mean fall of HbA1c
by 1.27%.
Harms: Two patients had premature removal.
Conclusions: Addition of p-CGM along with SMBG may help in
adjusting insulin dose more effectively especially in children with
higher baseline HbA1c.
Trial registration: Clinical Trial Registry of India (CTRI) (REF No 2015/
04/008867).
Funding: None
P312
CGM-based treatment decisions with the Dexcom
G5 Mobile CGM System is safe and effective for
both adult and pediatric type 1 patients
L. Dunn1, K. Leone2
1
Dexcom, Inc., Clinical Affairs, San Diego, United States, 2Dexcom,
Professional Education, San Diego, United States
Objective: The objective of this human factors study was to conduct
a validation test on critical knowledge related to replacing selfmonitoring blood glucose testing for diabetes treatment decisions
with the Dexcom G5 Mobile CGM System and to evaluate the ability
to support safe and efficacious training of the system.
Methods: The study included a total of 49 participants with diabetes and divided in 3 user groups using intensive insulin therapy adults (≥ age 18; n = 16); self-managing children/ adolescents (age
12–17; n = 17); caregivers (n = 16). A risk assessment was completed to identify the highest risk tasks when using the Dexcom G5
as well as non-adjunctive use. Several scenarios were tested - stacking insulin using SMBG and when to use/not use CGM to determine
a treatment decision. Each participant used the tutorial for selftraining or 1:1 training with their healthcare professional for their
instruction. A small sample of CGM experienced participants (n = 9)
received no training and then all participants were tested on their
knowledge.
Results: The results of the study suggested that there were no
significant differences between the two formal training methods:
self-training and 1:1 training. Participants who were formally
trained achieved a 99.5% success rate across the high risk scenarios using CGM for treatment decisions. 7 failures were
observed in the scenario related to insulin stacking with SMBG,
showing that insulin stacking is not a unique risk to using CGM.
Participants who did not receive formal training achieved a 91%
success rate across the high risk scenarios using CGM for treatment decisions.
Conclusions: Based on the usability testing performed in the Summative Usability Study, the critical knowledge is effectively communicated in the training and Instructions for Use, and non-adjunctive
use risks of the Dexcom G5 are largely mitigated. Thus, safe and
effective use of the Dexcom G5 for CGM-based decision making is
concluded.
P313
Safe hypoglycaemia prevention in children with
type 1 diabetes by using SmartGuard™ algorithm in
sensor-augmented pump therapy: post suspension
glycaemic control depends on users behaviour
T. Biester1, O. Kordonouri1, M. Holder2, K. Remus1, T. Wadien2,
D. Kieninger-Baum3, T. Danne1
1
Children’s Hospital ’Auf der Bult’, Diabetes Center for Children and
Adolescents, Hannover, Germany, 2Olgahospital, Klinikum Stuttgart,
Stuttgart, Germany, 3Universitätsmedizin Mainz, Mainz, Germany
Background: Sensor-augmented insulin pump (SAP) with MiniMed®640G system features the SmartGuard algorithm which stops
insulin delivery based on predicted sensor glucose levels. This offers
prevention of hypoglycaemia.
Methods: The prospective, multicenter study in pediatric patients
assessed 6 weeks of SmartGuard use after a 6 week run-in phase
with SAP (without automated suspension). The setting for SmartGuard was “suspend before Low 70 mg/dL” Primary outcome was
the potential reduction in the frequency of hypoglycemic episodes
and hypoglycemic intensity (AUC and time < 70 mg/dl). Post suspension glycemic values were evaluated in context to management during hypoglycemia.
Results: 24 Patients (age:11,7 5,1y; T1D duration 7,2 4,2y,
CSII:5,9 4,4y, CGM:0,8 2,0y; HbA1c:7,5 0,6%,BMI:19,2 2,5
kg/m2) took part of whom 18 followed strictly the protocol.3.15
1.03 predictive suspensions per day were observed, no severe
hypoglycemia occurred. Time in suspension was 155 47 min/d, In
comparison number of excursion ≤ 70 mg/dL/d (1,02 0,52 to
0,72 0,36;p = 0,027), AUC < 70 mg/dL [mg/dl*d] (0,76 0.73 to
0,38 0,24;p = 0,027),time/day ≤ 70 mg/dl
(73 56 min
to
31 22 min) were lower in phase 2.
The table shows the superiority of non-acting when SmartGuard is
triggered.
Conclusion: SmartGuard is a safe approach to reduce the risk of hypoglycaemia in pediatric age; best results are met without human intervention. This approach should be included in future education sessions.
[: Average values at / during / after activation o]
Glucose value at
begin of insulin
suspension [mg/dl]
Glucose value at
resume of insulin
infusion [mg/dl]
Minimal Glucose
value during
suspension
[mg/dl]
Glucose value 1 h
after resume of
insulin
infusion [mg/dl]
Time of
suspension
[min]
24 hours (all)
105,0 7,5
103,4 11,1
85,1 13,8
162,0 15,1
58,8 7,1
During day (08 am - 10 pm)
105,6 8,7
104,3 10,4
84,3 15,0
174,4 17,7
54,1 8,1
During night (10 pm - 08 am)
102,4 5,4
101,4 12,1
87,4 12,0
137,3 13,8
67,9 13,1
Without meal during/after suspension
106,6 3,6
104,0 10,7
83,4 8,5
138,7 10,3
66,3 8,2
With meal during/after suspension
109,5 3,0
109,5 3,0
81,0 10,6
190,8 26,5
50,7 11,4
148
POSTER TOURS
P314
Physical activity (PA) in youth with type 1 diabetes
(T1D): variable impact on metabolic outcomes
E. Giani1,2, L.K. Volkening1, S.N. Mehta1, L.M. Laffel1
1
Joslin Diabetes Center, Pediatric, Adolescent and Young Adult Section;
Section on Clinical, Behavioral and Outcomes Research, Boston, United
States, 2University of Milan, V. Buzzi Children’s Hospital, Pediatric
Endocrinology, Diabetes and Metabolism, Milan, Italy
Objectives: PA is often associated with favorable metabolic parameters due to enhanced insulin sensitivity and higher lean body mass.
We studied associations of frequency and amount of PA with metabolic measures in 136 youth aged 8–17 y/o with T1D.
Methods: Youth reported frequency, amount, and type of PA in a
typical week; moderate and vigorous PA (4 and 8 METs, respectively)
were combined. Youth were compared by frequency of PA (0–5 vs
6–7 days/week (d/wk)). Blood was assayed for glycemic control (A1c;
1,5-anhydroglucitol (1,5-AG)) and lipids. Body composition was
assessed by DXA. Clinical data (e.g., insulin dose, zBMI, BP) were
obtained by chart review.
Results: Youth (49% male) were 12.8 2.6 y/o, with T1D for
5.9 3.1 yrs, A1c 8.1 1.0%, 70% pump Rx, BG monitoring
5.7 2.4 X/d. Median PA was 9.5 hours/wk (range 0–42); 6% had
PA 0 d/wk, 17% 1–3 d/wk, 29% 4–5 d/wk, 49% 6–7 d/wk. Youth
with PA 6–7 d/wk were more likely to be male (62% vs 38%;
p = .002), younger (12.3 2.5 vs 13.4 2.5 y/o; p = .01), with
shorter T1D duration (4.8 2.6 vs 7.0 3.2 yrs; p < .0001) than
youth with PA 0–5 d/wk. Many metabolic parameters differed
between PA groups (Table). No variables were significantly correlated
with total hr/wk of PA when adjusting for d/wk of PA.
Conclusions: These data in T1D youth suggest that PA frequency
favorably impacts insulin resistance, body composition, lipids, and
possibly glycemic excursions (1,5-AG). Further research is needed to
PA 0–5 days/week PA 6–7 days/week
(n = 70) (51%)
(n = 66) (49%)
zBMI
Fat mass (%)
0.8 0.7
30
0.5 0.9
25
P value
0.05
<0.0001
U/kg/day
1.0 0.3
0.9 0.2
0.03
A1c (%)
8.1 0.9
8.1 1.2
0.7
1,5-AG (μg/mL)
2.9 1.8
3.7 2.1
0.02
Total cholesterol
(mg/dL)
169 31
162 24
0.19
Triglycerides
(mg/dL)
118 61
103 50
0.09
HDL / LDL
(mg/dL)
54 13 /
91 26
59 14 /
81 21
0.04 / 0.04
BP (SBP / DBP)
(mmHg)
110 7 / 67 5 108 7 / 66 6
0.07 / 0.3
determine a means to improve A1c with PA.
[Metabolic parameters by frequency of PA]
P315
Detection of common pathogenic genes in children
with special type of diabetes mellitus and its clinical
application
Z. Zhao1, F. Luo1, W. Lu1, R. Cheng1, L. Xi1, X. Li1, R. Ye1, Z. Zheng1,
M. Zhang1, B. Wu1, L. Yang1, Z. Pei1, C. Sun1, J. Ni1
1
Children Hospital of Fudan University, Shanghai, China
Objectives: To explore the clinical value of common pathogenic gene
detection in the diagnosis and treatment in hyperglycemia infants
and children.
Subjects and Methods: Subjects were in-patients with hyperglycemia, age of onset before 1 year-old,or insulin antibody negative and
with family history of diabetes. Gene sequencing for ABCC8, KCNJ11,
INS and GCK were performed and potential mutations were analyzed.
The patients with ABCC8 and KCNJ11 gene mutations were treated
with sulfonylurea, patients with GCK mutations were given the lifestyle intervention and others with insulin.
Results: Total 21 patients were enrolled, 15 patients were found
with pathogenic gene mutations, 52.4% in ABCC8 gene and KCNJ11
gene (11/21). The patients with KCNJ11 or ABCC8 gene mutation are
with average age 2.01 1.62 months or 2.52 2.60 months,
respectively. GCK gene mutations were detected in children with age
of onset more than or equal to 12 months, at 58.33 43.02 months
of age. There existed significant statistical difference among the
onset ages of the three genetic variants, P = 0.001. The onset random blood glucose levels were significantly higher in the patients
with INS gene mutation (66.70 mmol/L) than those of GCK gene
mutation patients (9.73 + 1.97 mmol/L, P = 0.003). 11 patients with
ABCC8 or KCNJ11 gene mutation were treated with sulfonylurea and
9 patients reached euglycemia.
Conclusions: Mutations in potassium channel related genes (KCNJ11
and ABCC8) were the most common cause of neonatal diabetes in
Chinese. Sulfonylurea therapy was effective and euglycemia were
reached in most of the patients with the mutations in KCNJ11 and
ABCC8. Patients who were diagnosed hyperglycemia before 1 yearold,or with negative antibody testing and family history of diabetes
were referred for gene testing, even by targeted next-generation
sequencing of all known related genes. The target therapy based on
gene diagnosis is more effective and improvement of life quality.
P316
The timing of blood glucose monitoring or
urinalysis may lead to under reporting of
hyperglycaemia and the prevalence of transient
diabetes in childhood acute lymphoblastic
leukaemia
S. Drew1, H. Gordon1, R. Margetts1, P. Patel1, A. Pillay1, C. Peters1
1
Great Ormond Street Hospital, London, United Kingdom
Introduction: Hyperglycaemia is a well-documented common complication of L-Asparaginase and glucocorticoids in the treatment protocol of childhood acute lymphoblastic leukaemia (ALL). Children on the
oncology unit routinely have first morning urine glucose monitoring.
We report the prevalence of transient diabetes (TD), risk factors and
diabetic ketoacidosis (DKA).
Method: Data was collected from the electronic prescribing system
of patients who had received this treatment regimen and also
required insulin therapy. Clinical data collected included gender, age,
ethnic origin, BMI, insulin units/kg/day, fasting blood glucose (BG),
urinalysis and incidence of DKA.
Results: Between April 2013-April 2016, 155 children received this
treatment regime in a paediatric oncology centre. TD was seen in
7 cases, of which 6 were female. DKA was documented in 1 patient
and ketosis seen in 2 others. Timing of BG testing or urinalysis was
reviewed; 6 children with symptoms of polyuria and/or polydipsia were
hyperglycaemic with morning fasting BG testing. One child was found
to be hyperglycaemic with normal morning fasting glucose. Insulin
requirements had a mean 1.3 units/kg/day with a range 0.6-2.2 units/
kg/day. The mean age was 7.9 years with a range of 2–12 years. 2 had
a BMI ≥91st centile. 5 were from African or Asian ethnicity.
Conclusion: Our data suggests that it is uncommon for children to
be diagnosed with TD requiring insulin therapy and that DKA is a rare
complication. Risk factors are similar to that of Type 2 diabetes
including ethnicity and elevated BMI. Screening for hyperglycaemia
appears to be adhoc with morning urinalysis.
We question whether the number of TD observed is a true representation of this patient group due to inadequate BG monitoring
unless symptomatic and whether this figure could be higher. Prospective studies are required to look at a change in timing and sampling
of BG or urinalysis in order to capture incidence of hyperglycaemia
(>11.1 mmol/L).
149
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P317
Two novel cases of permanent neonatal diabetes
mellitus caused by homozygous mutations in the
glucokinase gene
N. Elbarbary1, M. Salem1, E. De Franco2, S. Ellard2
1
Pediatric Diabetes Unit, Faculty of Medicine, Ain Shams University,
Department of Pediatrics, Cairo, Egypt, 2Institute of Biomedical and
Clinical Science, Peninsula Medical School, University of Exeter, Exeter,
United Kingdom
Background: Permanent neonatal diabetes (PND) caused by homozygous mutations in the glucokinase gene (GCK) is rare and only few
cases have been reported so far. Heterozygous GCK mutations cause
maturity-onset diabetes of the young (MODY2).
Case report: We report two girls, first cousins, 1st in order of birth,
born to consanguineous parents. Both were born full-term with intrauterine growth-retardation after an uneventful pregnancy. Both
patients presented with persistent hyperglycaemia and glycosuria
within the first two days of life and were treated with insulin. They
both tested negative for anti-insulin and islet cell antibodies at the
age of 4 months. Excluding diabetes, both are otherwise healthy children with no diabetes-related chronic complications and good glycemic control. Both fathers have non progressive, impaired fasting
glucose and slightly elevated HbA1c values. The mothers were found
to be mildly hyperglycaemic and both had gestational diabetes during
their subsequent pregnancy. Genetic analysis using PCR and direct
sequencing found a novel homozygous missense mutation, p.H50D,
in exon 2 of the GCK gene in both patients. This C > G mutation at
nucleotide 148 (c.148C > G) results in the substitution of the amino
acid aspartic acid (acidic charged polar) for histidine (basic charged
polar) at codon 50 (p.His50Leu). Current evidence suggests this mutation is likely to be pathogenic. The parents were heterozygous for the
mutation.
Conclusion: We report two PND cases caused by a novel homozygous missense mutation in the GCK gene in two families with
MODY2. Coexistence of PND, parental consanguinity and a family
history of mild hyperglycaemia should always prompt testing of the
GCK gene since heterozygous carriers have a mild phenotype
(MODY2) and homozygotes present with PND. As MODY2 is usually
a silent disorder, fasting blood glucose testing in the parents of every
infant with PND should be a must, even if there is no family history
of diabetes.
P318
Kearns-Sayre syndrome with co-occurring insulindependent diabetes mellitus in the 10-year-old girl:
a case report
K. Indulska1, M. Grzechnik-Gryziak1, S. Łuczak2, D. Piekutowskaska3, A. Szypowska1
Abramczuk2, K. Szyman
1
Medical University of Warsaw, Department of Pediatrics, Warsaw,
Poland, 2Children’s Memorial Health Institute, Department of Medical
Genetics, Warsaw, Poland, 3Medical University of Warsaw, Department
of Developmental Psychiatry, Warsaw, Poland
Kearns-Sayre syndrome is a rare mitochondrial disease with a diabetes as one of the symptoms.
10-year-old girl was admitted to our department with symptoms of
polyuria, polydipsia, weight loss of approximately 1 kg, without
ketoacidosis. Insulindependent diabetes mellitus, with negative antiGADA, IA2, ICA antibodies, was diagnosed. In addition, deficiency of
body weight and height, ptosis, limitation of eye movements,
decreased muscle tone, poorly expressed deep tendon reflexes and
cognitive disorders were found. Girl reported also headaches. MRI of
the head showed changes characteristic for spongiform group of
mitochondrial diseases.
Due to the phenotypic and abnormal imaging studies karyotype
was performed (result was normal). The patient during follow up
develop tremors of the head and limbs, and intensified headaches..
From July 2014, seizures were observed in the form of gibberish
speech, balance disorder, the prevalence of scotoma and headaches.
These seizures always occurred during normoglycemia. Treatment
with lamotrigne was performed due to abnormal EEG. Kearns-Sayre
syndrome was suspected. Genetic testing was performed. DNA sample obtained from muscle and urine showed reduced by 40-50% level
of ligation probes located in the area m.7120_m.14068 including
genes MTCOX1, MTCOX2, MTATP6, MTCOX3, MTND3, MTND4
iMTND5. The heteroplasmy of these mutations in the blood and buccal epithelia were lower (<30%).
Identified deletion corresponds to the range of the so-called common deletion, which according to the literature data is responsible for
about 90% of cases of KSS.
Currently, the patient receives insulin with the insulin pump, the
daily insulin requirement of 0.63 units per kg and with mean HbA1c
of 7.4%. Insulin dependent diabetes mellitus may be accompanied by
the typical symptoms of Kearns-Sayre syndrome.
P319
Rare genetic conditions related to diabetes in low
income country: is there a solution?
S. Sap1,2, A. Chiabi3, M. Dehayem4, P.O. Koki2,3
University of Yaounde I, Pediatrics, Yaounde, Cameroon, 2Mother and
Child Center, Yaounde, Cameroon, 3University of Yaounde I, Yaounde,
Cameroon, 4Central Hospital Yaounde, Yaounde, Cameroon
1
Introduction: Congenital generalized lipoatrophy or Berardinelli Seip
syndrome is a rare genetic disorder characterized by absence of subcutaneous fat with various lesions including severe hyperinsulinism
(diabetes in advanced stage), dysmorphic features, hepatic and cardiac involvement. The prevalence is around 1/ 1 million births. Diagnosis and management of this condition is not easy in low income
countries. To describe some of these difficulties and solutions
approach, we report the present cases.
Cases: Two not related adolescents, aged 15 and 16 years old, were
referred from 2 peripheral diabetes clinics for management of diabetes. They presented polyuropolydypsic syndrome associated with
high blood glucose (17.6 mmol for the first and 16 mmol/l for the
second). They had normal birth weight but a peculiar appearance. On
physical examination they had a thin skin, hepatomegaly and delay
puberty (B1P1R0). Although high insulin doses (3.8 and 3.5 UI/Kg/
day), they presented persistant hyperglycemia, with increased HbA1C
(14%), increased blood lipids. Diabetes, thin skin, delay puberty and
disturbance of lipid profile linked to the diagnosis of congenital
lipoatrophy.
The 3rd case is a 5 months old infant, brought for peculiar appearance. Borned at term, she has a voracious appetite contrasting with
stunting. On physical examination she has a very thin skin, hepatomegaly. She has 535 mg/L of triglycerides. We also conclude to congenital lipoatrophy. Futher management includes a particular diet
(medium chain polyunsaturated fatty acid) and a carefull follow up to
early identify complications.
Conclusion: No molecular analysis was done and no leptin is available for the girls with diabetes. What is the future of these patients
and their family? To answer some of family questions, a precised
diagnosis is necessary. As for neonatal diabetes, international collaborative studies to improve understanding, management of affected
patients may be helpful.
P320
Successful sulfonylurea treatment in three patients
with neonatal diabetes mellitus associated with
novel inherited ABCC8 mutations
A. Aoui1, A. Zennaki1, S. Niar1, M. Naceur1, M. Gharnouti1,
K. Bouziane-Nedjadi1, M. Touhami1
1
University Hospital, Pediatrics, Oran, Algeria
150
Neonatal diabetes is a rare genetic disorder. Intellectual disability,
epilepsy and congenital abnormalities are not uncommon features. A
genetic defect is detected in more than 70% of case. It concerns,
6q24 abnormalities, activating mutations in KATP channel subunits
(KCNJ11 or ABCC8genes) and less frequently in INS.Several reports
demonstrated that the effect of gain mutations affecting KATP channel can be reversed using sulfonylurea. We report on three patients
including two siblings: Serine and Ines who developed neonatal diabetes before 3 months of age. Genetic testing identified two novel
mutations in ABCC8 gene; a paternal inherited mutation for the two
siblings and a maternal mosaic mutation for the third patient Ashraf.
Interestingly the father that transmitted the deleterious mutation
developed diabetes in adulthood.When epilepsy with congenital urinary tract defect were occurred in one patient: Ashraf. First treatment with insulin was not very effective for all patients. The
introduction of Glibenclamide, a sulfonylurea molecule after the cessation of insulin, was remarkably efficient .The first dose engendered
an instant increase of C-peptide. At day-7 of treatment for Serine
and day-15 for Ines, and allowed the establishment of a good diabetes control for the all. These cases confirm the Glibenclamide efficiency in the treatment of neonatal diabetes by mutation of ABCC8
gene and illustrate the benefit of a genetic investigation for the diagnostic, treatment and prognosis of this disease.
Keywords: neonatal diabetes mellitus, ABCC8,sulfonylurea
treatment.
P321
Clinical characteristics and therapeutic issues in two
sisters with Berardinelli-Seip syndrome
R. Savova1, M. Archinkova1, O. Slavcheva1, M. Konstantinova1
1
Iniversity Pediatric Hospital, Department of Diabetes, Sofia, Bulgaria
Aim: To present two cases with insulin resistant diabetes and generalized lipoatrophy -Berardinelli-Seip syndrome.
Index case 1: A girl aged 18 years, birth weight 2600 g, normal
development, first hospital admission for lymphadenomegaly at age
of 11 years. Berardinelli-Seip syndrome was diagnosed with normal
glucose tolerance but insulin resistance (HOMA IR 12.1). At the age
of 15 years she presented non-autoimmune, insulin resistant diabetes: HbA1c - 14,03 % (4-6%), C-peptide - 1022 pmol/L (196–960),
cholesterol - 9,2 mmol/L, HDL-cholesterol - 0,6 mmol/L, triglycerides
- 4,9 mmol/L. Specific phenotype included: acromegaloid athletic
body, phlebomagaly, triangle face with prominent chin, dry brownish
coloured skin, acanthosis nigricans on the rubbing skin surfaces, generalized lipoatrophy, hypertrichosis, enlarged soft lymph nodes on the
posterior neck, umbilical hernia. Height 162,5 cm, weight 49,6 kg.
Treatment with insulin and metformin 1.5 to 2.4 g started. An year
later poor control persisted with HbA1c 12%, highly variable triglycerides up to 46 mmol/L. Insulin was discontinued and replaced with
Lipanthyl 200 mg, Pioglitazone 30 mg, Simvastatin 20 mg, Metformin
3 g. Atherogenic lipid profile and elevated HbA1c > 10% persisted all
the time in spite of adding insulin again. At present she has hepatic
steatosis, oligomenorrhea, arterial hypertension and initial
nephropathy.
Index case 2: The younger sister (b.w. 2300 g) was diagnosed with
Berardinelli-Seip syndrome at age of 13 years (the same phenotype
and kyphoscoliosis). Under metformin she keeps subclinical diabetes
up to now (15 years) and near normal lipids, but she has hepatic steatosis (ASAT 112 U/l, ALAT 197 U/l) and no menarche. Recently Pioglitazone was added to the therapy.
Conclusion: We present lipoatrophic insulin resistant diabetes with
therapeutic issues. The prognosis of both girls is obscure. Recombinant leptin or regular plasma lipids extraction were discussed for
alternative treatment.
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P322
Glicemic control in patients with Cushing
syndrome - comparison to age and BMI matched
healthy controls
ska, M. Wysocka-Mincewicz
E. Moszczyn
The Children’s Memorial Health Institute, Department of Endocrinology
and Diabetology, Warsaw, Poland
Introduction: Patients with Cushing syndrome frequently have problems with glicemic control or even diabetes. In children this disease
is very frequent and is lack of studies about glicemic control of this
group. The aim of the study was to check the glicemic control and
compare it with age and BMI matched control.
Material and Methods: We retrospectively studied data of 22 children with Cushing syndrome (mean age 13,4 +/− 3,1 lat, BMI 24,84
+/− 5,1) than surgically confirmed. Glicemic control analysis (OGTT,
HbA1c) were compared with BMI and age matched health control
(mean age 12,89+/− 2,2. BMI 25,63 +/− 2,1, both p = 0,5). We analyzed data from glicemic and insulinemic curve in OGTT, HbA1c, and
AUC for glicemia and insulinemia. After checking normality of distribution data were analyzed t-students test in Statistica 6,0, taking as
significant p value under 0,05.
Results: The groups were not statistically different in any glicemic
parameter , AUC and HbA1c. We observed very significant differences in every time points in insulinemic curve and AUC (respectively
0’ 24,04+/−9,3 vs 14,04+/−6,08 IU/ml p < 0,0001, after 30’OGTT162,56+/−63,65 vs 101.4+/−61,78 IU/ml p < 0,003, after 60’230,44+/−192,5vs 129,54+/− 85,3 IU/ml p < 0,03, after 90’- 286,56
+/− 289,92 vs 118,28+/−67,01 p < 0,01, after 120’ -271,88
+/−242.08 vs 122,87 IU/ml p < 0,006 and AUC 1007,31+/− 772,79
vs 486,14 p < 0,003).
Groups were statistically different in height (studied group 145,86
+/− 15,5 vs 160+/− 10,8 cm, p < 0,0005) and weight (respectively
52,24+/− 13,8 vs 66,61+/− 13,33 kg).
Conclusions: Children with Cushing Syndrome have the same glicemic profile as overweight children, but significantly higher insulinemic
curves. What was unsurprised children with Cushing Syndrome were
significantly shorter.
P323
Neonatal insulin pump patients - diagnostic,
practical and safety aspects of using insulin pumps
and continous glucose monitoring in a clinical series
of eight cases of neonatal diabetes
T. Torbjörnsdotter1, E. Marosvari Barna1, E. Henckel2, M. Corrias2,
S. Norgren1, A. Janson1,3
1
Karolinska University Hospital, Pediatrics, Stockholm, Sweden,
Karolinska University Hospital, Neonatology, Stockholm, Sweden,
3
Karolinska Institutet, Women´s and Children´s Health, Stockholm,
Sweden
2
Objective: Treatment of neonatal diabetes including practical and
safety aspects of using insulin pumps and continous glucose monitoring (CGM) in patients with neonatal diabetes.
Methods: We collected data from all cases of diabetes with an onset
within the first 6 months of life treated at our clinic from Jan 1998 May 2016 in a clinical observation study.
Results: Eight patients were included, see Table. All patients were
treated with intravenous insulin and 7 were put on subcutaneous
insulin pumps. All patients could terminate insulin treatment. Until
now one patient been diagnosed with diabetes again, at age
4,5 years.
151
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Gestatonal age
(Weeks + days)
Sex
Birth
Weight
(gram)
Small for
Gestational
Age
Age at start of
insulin (days)
Age at start of
insulin pump (days)
Age at termination of
insulin (weeks)
Mutation
26 + 0
F
872
No
11
/
2
?
30 + 0
M
1455
No
4
7
20
ABCC8
38 + 3
F
2200
Yes
4
9
8
6Q24 Paternal
Duplication
39 + 3
M
2355
Borderline
value
5
5
3,5
6Q24 Paternal
Duplication
26 + 1
M
777
Yes
12
54
7,5
?
42 + 0
M
3500
No
41
43
15
ABCC8
34 + 4
F
1881
Borderline
value
2
13
2,5
ABCC8
24 + 2
M
641
No
0,5
32
Ongoing
Ongoing
[Table: Patient Characteristics]
A mutation (monogenic diabetes) was diagnosed in 5 children (analyses in Exeter, UK). In two patients no mution was identified, and in
one the analysis is ongoing.
7 patients were treated with a subcutaneous insulin pump
(Medtronic Veo) using diluted insulin 10 U/ml, and the smallest
patient was put on treatment with pump at a weight of 938 grams.
Continous glucose montoring (MiniLink or DexCom4/DexCom5) was
used. Adaptations to currents guidelines were made to ensure safety.
Conclusions: Prompt and safe treatment of neonatal diabetes is crucial for further growth and development of the affected child. Use of
insulin pumps and CGM was very useful in these patients. A knowledge of the technical limitations of the equipment as well as a good
cooperation between physicians and nurses of both departments,
including adaptation of diabetes guidelines to the setting of the neonatal intensive care unit was important.
P324
Sodium pyruvate treatment improved endogenous
insulin secretion in a patient with mitochondrial
diabetes
T. Ayabe1, T. Inoue2, Y. Oto2, N. Murakami2, Y. Koga3, R. Sakuta2
1
National Research Institute for Child Health and Development, Tokyo,
Japan, 2Dokkyo Medical University Koshigaya Hospital, Koshigaya,
Japan, 3Kurume University Graduate School of Medicine, Department of
Pediatrics and Child Health, Kurume, Japan
Objectives: Mitochondrial diabetes is a rare form of diabetes mellitus, and reveals progressive decline in endogenous insulin secretion.
Sodium pyruvate treatment has been reported to be a potential therapeutic choice for fatigability in patients with mitochondrial diseases.
However, the effect of sodium pyruvate treatment for glucose intolerance in patients with mitochondrial diabetes remains to be clarified.
Case presentation: Water-based sodium pyruvate solutions (0.5 g/
kg/day) were administrated orally to a 32-year-old Japanese man
with mitochondrial diabetes and myopathy caused by the m.14709
T > C mutation. At the age of 20, he was diagnosed with diabetes
mellitus and started insulin self-injection. He did not have any kind of
islet autoantibodies. To evaluate therapeutic effects, we measured
urinary C-peptide, hemoglobin A1c (HbA1c) and total daily insulin
dose (TDD) 6 months later. His urinary C-peptide level improved
from 4.3 to 17.2 μg/day after 1 day and to 30.2 μg/day after
6 months of sodium pyruvate treatment. He experienced no adverse
event such as diarrhea resulting from sodium pyruvate treatment,
except episodes of mild hypoglycemia. To avoid hypoglycemia, his
TDD could be reduced from 33 Units/day to 20 Units/day. Despite
reduction of TDD, his HbA1c declined from 6.5% to 5.9%.
Conclusions: Sodium pyruvate treatment improved endogenous insulin secretion and resulted in reduced TDD in a patient with
mitochondrial diabetes. Sodium pyruvate treatment may be a potential therapeutic choice for patients with mitochondrial diabetes.
P325
The importance of awaring monogenic diabetes in
Chinese pediatric population - a case series
L.K. Lee1,2, W.C. Wong2,3, H.C. Yau1,2, W.Y. Tsang1,2, Y.P.L. Yuen4,5,
W.K.G. Wong1,2
1
Prince of Wales Hospital, Pediatrics, Hong Kong, Hong Kong, China,
Chinese University of Hong Kong, Pediatrics, Hong Kong, Hong Kong,
China, 3Alice Ho Miu Ling Nethersole Hospital, Pediatrics, Hong Kong,
Hong Kong, China, 4Prince of Wales Hospital, Chemical Pathology, Hong
Kong, Hong Kong, China, 5Chinese University of Hong Kong, Chemical
Pathology, Hong Kong, Hong Kong, China
2
Objectives: To estimate the period prevalence, and review the clinical presentation, genetic diagnosis and its impact on management of
monogenic diabetes in the Chinese pediatric population.
Methods: A retrospective review of Chinese patients with monogenic diabetes aged from birth to 18 years under the care of the
2 major pediatric departments of the Hong Kong New Territories
East Cluster (NTEC) of Hospital Authority from 1/1/2010 to 31/12/
2015 and determination of period prevalence.
The Electronic Patient Record System was employed to retrieve
the following data: age at presentation, Sex, presenting symptoms,
any family history, Initial working diagnosis, body mass index at presentation, HbA1c at presentation, genetic result, Time from presentation to genetic diagnosis, any alteration in clinical management after
genetic diagnosis.
Results: 10 Chinese patients, aged one day to 15-year-9month were
identified. The period prevalence of Chinese patients with monogenic
diabetes, aged below 15 years, from 1/1/2010 to 31/12/2015 in
NTEC was 65.8 per 1,000,000 populations. 2/10 patients were
related. Seven patients were MODY 2, two MODY 3, one with paternal uniparental disomy at 6q24 locus. The female : male ratio was
1.6. Family history positive in 8 patients. All the patients were nonobese, no acanthosis nigricans and no ketoacidosis. The mean time
from presentation to genetic diagnosis ranged 1.5-52months. The
presenting HbA1c ranged 5.3% to 7.7%. Anti-islet antibodies were
negative in all 4 tested. The heterozygous GCK c.1132_1133delGC
was the most common mutation.
Conclusion: Our finding highlighted the important role of pediatric
endocrinologist in early detection of monogenic diabetes in Chinese
pediatric patients. The period prevalence aged under 15 years was
comparable to all-aged period prevalence reported in UK. The earliest
time of 1.5 months from presentation to diagnosis suggested awareness was the key to early detection.
152
P326
Hyperglycaemia and metabolic syndrome: not
always synonymous of T2D
J. Galhardo1, C. Limbert1, L. Lopes1
1
CHLC - Hospital de Dona Estefânia, Diabetes and Paediatric
Endocrinology Unit, Lisboa, Portugal
Background: MODY encloses a group of disorders caused by autosomal dominant mutations in genes linked to pancreatic ß-cell function.
Usually it presents as a non-ketotic hyperglycaemia, in patients under
25y that miss both T1D and T2D features.
Case report: We report a 15y Caucasian girl, admitted for nonketotic hyperglycaemia detected after one month of polyuria and polydipsia. There was no history of chronic medication or pancreatic
insult. Apart from central obesity and severe facial acne, her examination was unremarkable.
She was born LGA and is obese since toddlerhood. Her menarche
was at 9y, with irregular cycles ever since. Her sister, mother, and
maternal grandfather had diabetes classified as T2D from their 20’s,
when all were lean.
Fasting bloods revealed HbA1c 7.4%, C-peptide 2.5 ng/dL, glucose
194 mg/dL, triglycerides 164 mg/dL, HDL 32 mg/dL, ALT 67U/L;
autoimmune markers, hyperandrogenism and thyroid dysfunction
were absent. Pelvic and abdominal US were normal. MODY genetic
screening panel was also performed.
She was started on basal-bolus insulin and norm caloric diet. Her
compliance was erratic, with progressive weight gain and HbA1c
increase to 10.6%.
Nine months into diagnosis, genetic testing revealed HNF1A c.89
T > C heterozygous variant, to our knowledge not yet described in
the literature. Gliclazide (30 mg/day) was then started and doubled
on wk2; metformin (850 mg/day) was introduced on wk3 and
doubled on wk4; in parallel, insulin was progressively withdrawn and
stopped on wk5. During the first month of follow-up glycaemia has
been between 90-140 mg/dL.
Discussion: Worldwide there is an increasing prevalence of youth
obesity and T2D. However, even in the presence of metabolic syndrome and the lack of autoantibodies, an important history of diabetes in direct relatives, especially when they are lean and young at
diagnosis, should put us on the track of MODY, as this is important
for both treatment, prognosis and family genetic counseling.
P327
Novel glucokinase mutation in a boy with MODY
2 followed by continuous glucose monitoring
M. Kocova1, J. Lebl2, A. Tasevska1, L. Dustakova2
University Children´s Hospital, Skopje, Macedonia, the Republic of, 22nd
Faculty of Medicine, Charles University in Prague University Hospital
Motol, Prague, Czech Republic
1
Glucokinase (GCK) deficiency (MODY 2) is among the most common
forms of MODY variants. It can be detected randomly in young children when glycemia is checked for other reasons such as surgical
intervention or infection, or if a parent of the child has been diagnosed with MODY previously. No MODY patient has been described
so far in the Republic of Macedonia.
Case report: A 2.5 year old lean boy (BMI = 16.8 kg/m2) presented
with epistaxis, polyuria and polydypsia during an upper respiratory
infection. He had hyperglycemia (7.7-9.4 mmol/l), no ketonuria or
glucosuria. Family history revealed diabetes type 2 in a paternal
grand-father since the age of 36 years who is on metformin therapy
and in a good metabolic control.
HbA1c was 5.96% (normal range 4.4-6.2%).Blood counts, glucosuria, urea and creatinin were within normal range. Pre-prandial and
post-prandial insulinemia were within the normal range, e.g. 5 and
20 mU/l respectively. C-peptide had normal values 3.82-5.6 ng/ml.
Continuous glucose monitoring (CGMS Guardian system, Medtronic)
confirmed higher measurements of glycemia particularly in the
POSTER TOURS
afternoon and some overnight hypoglycemia. Islet antibodies (GAD,
IA, ICA and IAA2) were negative. DNA analysis of GCK gene tested
by PCR and direct sequencing confirmed heterozygocity for
c.45 + 1G > A in the intron 1. The father of the boy reported higher
glycemia up to 11.2 mmol/l and the same genotype was confirmed.
Paternal grand-father was not available for analysis.
Discussion: GCK mutations cause mild hyperglycemia due to inappropriate glucose sensing by the beta cells. Usually no therapy is
needed since the unfavorable progression of the hyperglycemia and
diabetic complications are extremely rare.
Conclusion: We present a novel mutation not found neither in ExAC,
nor in 1000 Genomes databases of polymorphisms. Prediction software Mutation Taster labeled this variant as disease causing. Continuous glucose monitoring in MODY might help elucidate glycemia
excursions.
P328
Dapagliflozin lowers insulin-requirement by
increasing urinary glucose excretion effectively in
adolescents and young adults with type 1 diabetes
T. Biester1, M. Fath1, B. Aschemeier1, M. Frey2, M.F. Scheerer3,
O. Kordonouri1, T. Danne1
1
Children’s Hospital ’Auf der Bult’, Diabetes-Center for Children and
Adolescents, Hannover, Germany, 2Alcedis GmbH, Giessen, Germany,
3
Astra Zeneca GmbH, Wedel, Germany
Objectives: Youth with type 1 diabetes (T1D) infrequently achieve
HbA1c targets. This is the first study to assess the safety, tolerability,
and pharmacokinetics of a SGLT-2 inhibitor as add on to insulin in
relationship to HbA1c in youth.
Methods: In a placebo-controlled, randomized, double blind, crossover study, the effect of a single dose of 10 mg dapagliflozin (DAPA)
on the insulin dose administered i.v. during a glucose-infusion for the
ensuing 24 hours with blood glucose kept between 160–220 mg/dl
was studied.
Results: 33 participants (14 males, age: 16 (12–21) [median(range),
years], diabetes duration 8 years (2–16) with n = 33 equally stratified
in 3 HbA1c groups (in target: 5.5-7.5%, moderately elevated: 7.69.0% and clearly elevated: >9.0-12.5%) took part.
DAPA reduced mean i.v. insulin dose by 13.6% (P < 0.0001 by
ANOVA). This was irrespective of baseline HbA1c (mean [CI 95%]
DAPA vs. Placebo: in target: 0.87 [0.81-0.92] vs. 0.99 [0.93-1.05]
U/kg/24 h; moderately elevated: 0.90 [0.81-0.92] vs. 1.02 [0.951.09] clearly elevated: 0.99 [0.91-1.06] vs. 1.17 [1.09-1.25]). Urinary
glucose excretion was overall increased by 610% (143.12 [128.39157.84] vs. 22.40 [7.68-37.13]; P < 0.0001). 6 independent episodes
in 6 patients with plasma ß-hydroxybutyrate (BHB) levels between
≥0.6 and < 1.0 mmol/l have been observed, 5 episodes in the DAPA
and 1 in the placebo group. There was no correlation between the
amounts of meal intake (6 ml/kgBW, maximum of 360 ml) compared
to excess of BHB.
Conclusions: In youth with T1D, DAPA led to a significant reduction
of insulin needed to achieve target glucose by triggering glycosuria.
In the present study, slightly elevated BHB levels were seen with
DAPA, far below those associated with clinical diabetic ketoacidosis.
The amount of standardized meal intake or baseline HbA1c had no
influence on BHB levels. This study provides a proof of concept for
adjunct SGLT-2 inhibitor therapy in the pediatric age group.
P329
Effect of metformin on endothelial function in
overweight adolescents with type 1 diabetes (T1D)
K. Nadeau1, K. Miller2, B. Nathan3, F. Bacha4, M. Katz5, J. Simmons6,
M. Gottschalk7, E. Tsalikian8, M. Tansey8, K. Copeland9, D. Linda10,
M. Cree-Green11, I. Libman12, M. Haller13, for the T1D Exchange
Clinic Network Metformin RCT Study Group
153
POSTER TOURS
1
Barbara Davis Center for Diabetes / Children’s Hospital Colorado,
Aurora, United States, 2Jaeb Center for Health Research, Tampa, United
States, 3University of Minnesota, Minneapolis, United States, 4Baylor
College of Medicine, Houston, United States, 5Joslin Diabetes Center,
Boston, United States, 6Vanderbilt University Medical Center, Nashville,
United States, 7University of California San Diego, San Diego, United
States, 8University of Iowa Children’s Hospital, Iowa City, United States,
9
University of Oklahoma, Oklahoma City, United States, 10Indian
University School of Medicine, Indianapolis, United States, 11Children’s
Hospital Colorado, Aurora, United States, 12Children’s Hospital of
Pittsburgh, Pittsburgh, United States, 13University of Florida, Gainesville,
United States
Objectives: Overweight youth with T1D are at greater risk for future
cardiovascular disease. Metformin’s impact on endothelial function in
this group is unknown. The aim of this study was to assess the effect
of metformin on endothelial function among overweight adolescents
with T1D.
Methods: Seventy overweight adolescents from 10 diabetes clinics
(mean age 15.8 years [range 12–19 yrs], mean T1D duration
6.7 years, 51% female, 87% non-Hispanic white) were randomly
assigned to metformin (up to 2000 mg/day) or placebo. EndoPAT, a
non-invasive surrogate of peripheral microvascular endothelial function, was used to measure reactive hyperemic index (RHI) scores at
baseline and 13 weeks. Linear mixed models of the natural log
(ln) transformation for the RHI score were used to obtain tests of significance with adjustment for clinic center and baseline score.
Results: Mean baseline RHI score was 1.8 0.6 in the metformin
group (N = 41) and 1.7 0.6 in the placebo group (N = 29). At
13 weeks, there was no significant change from baseline in the ln RHI
scores (+0.1 in metformin vs. -0.0 in placebo, P = 0.08). However,
when stratified by gender, there was a modest improvement in endothelial function among males (Figure).
Conclusions: Although no treatment effect was observed amongst
overweight T1D adolescents overall, metformin may improve endothelial function in overweight T1D males. Further study is needed to
confirm these findings and explore mechanisms for gender specific
differences.
[Figure 1]
P330
Prevalence of anemia in type I Indian diabetics
M. Saiyed1, F. Patel1, D. Hasnani1, B. Saboo1
1
Diacare-Diabetes and Hormone Clinic, Ahmedabad, India
Randomly 200 numbers of Type I subjects were selected aged below
10 years with history of diabetes more than 2 years with normal
growth. Blood sample were drawn for CBC, S creatinine, TSH.
Out of 200 subjects, 60% (n = 120) had low level of hemoglobin
(below 10 g/dL) remaining had normal levels of hemoglobin. And the
level of Glycosylated hemoglobin varied according to individual
adherence.
Further, these subjects were screened for ferritin, iron and TIBC
levels which were on lower side and treated accordingly. Iron supplements were initiated for deficient subjects for a period of time till the
target was achieved. (Children below 10 years 11.5 to 13.5 g/dL).
To conclude, Anemia is a prevalent finding in Type I Indian Diabetics, probably unrecognized. In our practice we make sure that each
individual kid is supplied with iron supplements, before it is detected
deficient.
The probable reason for this deficiency in India can be mal nutrition,
poor socioeconomic background or recurrent parasitic infections.
P331
Medium-term effect of a process of nutritional
education on metabolic control in adolescents with
type 1 diabetes
A. Lorubbio1, T. Timpanaro2, D. Benevento1, P. Ciampalini1,
M. Matteoli1, I.P. Patera1, M. Cappa1, R. Schiaffini1
1
Bambino Gesù, Diabetes Unit, Roma, Italy, 2Policlinico G. Rodolico
Catania, Biancavilla, Italy
Introduction: Medical nutritional therapy is one of the cornerstones
of diabetes care in children and adolescents with type 1 diabetes mellitus (T1DM). Carbohydrate counting, which is a more flexible nutritional method, has become popular in recent years. Imprecise
carbohydrate counting as a measure to guide the treatment of diabetes may be a source of errors resulting in problems in glycemic control. Adolescence is a critical period in which glucose control is
frequently deteriorated due to pubertal development and psychosocial issues. The aim of this study was to investigate the medium-term
effects of a process of nutritional education on metabolic control and
serum lipids levels in adolescents with T1DM.
Methods: A total of 48 T1DM adolescents from the Diabetes Unit Bambino Gesù Children’s Hospital (26 female and 22 male) were
enrolled in the study. Exclusion criteria were duration of
diabetes < 1 year, obesity, celiac disease and chronic complications.
Patients were divided into Nutritional Education Group (n = 24) and
Control Group (n = 24) and were observed for 1 year (T1). Demographic characteristics, body measurements, insulin requirement,
HbA1c and serum lipids were evaluated at T0 and T1. In the Nutritional
Education Group a structured nutritional program including basal nutritional care and CHO counting was given at 3 months intervals.
Results: The results are reported in the table attached. In the nutritional Education Group HbA1c(T0) 69 (mmol/m) vs HbA1c
(T1) 55 (mmol/m) , IR (T0) 1.2 IU/kg/die vs IR(T1) 0.7 IU/kg/die.
BMI significantly decreased during the observation period
21(T0) vs 19(T1). No differences were observed in serum lipids levels
and BP values.
Conclusion: Structured Nutritional Education including and CHO
counting is a useful method in order to obtain a better glucose control due to improving of eating habits and an healthier lifestyle in
adolescents with T1DM.
T0
T1
T0
T1
HBA1C
69.3
55.8
68.16
69.33
IR
1.24
0.70
0.80
0.80
BIR
0.37
0.36
0.33
0.33
BMI
21.15
19.06
20.5
21.04
TC(mg/dl)
115.37
146.45
154.86
164.82
HDL(mg/dl)
58.45
63.15
61.6
59
LDL(mg/dl)
92
91.8
82.18
82.41
TG(mg/dl)
65.8
64
75
74.3
BP: sis/dias mmHg
115/65
109/65
116/61
117/71
[NEG AND CONTROL GROUP]
154
P332
The longitudinal relationship between parental
well-being and adolescents’ glycemic control
M. Eilander1, M. de Wit1, J. Rotteveel2, H.J. Aanstoot3, W. Bakkervan Waarde4, M. Houdijk5, R. Nuboer6, P. Winterdijk3, F. Snoek1,7
1
VU University Medical Center, Medical Psychology, Amsterdam,
Netherlands, 2VU University Medical Center, Department of Pediatrics,
Amsterdam, Netherlands, 3Diabeter, Center for Pediatric and Adolescent
Diabetes Care and Research, Rotterdam, Netherlands, 4UMCG,
Department of Pediatrics, Groningen, Netherlands, 5HAGA Hospital,
Department of Pediatrics, Den Haag, Netherlands, 6Meander mc,
Department of Pediatrics, Amersfoort, Netherlands, 7Academic Medical
Center, Medical Psychology, Amsterdam, Netherlands
Objectives: Parents are of great importance when it comes to the
self-care of youth with type 1 diabetes. Research to date suggests
that parental depressive symptoms, stress and diabetes specific criticism associate with worse HbA1c. Little is known about the complex
relationship between parental factors and glycemic outcomes over
time. Using longitudinal data we examined A) the relationship
between parental well-being and glycemic control over time, and B) if
this association is mediated by diabetes parental behavior and parental diabetes stress.
Methods: Parents of youth 8-18y with type 1 diabetes (N = 174 on
T0) participating in the DINO study completed questionnaires at
three points in time each with a 1 year interval. Generalized Estimating Equations (GEE) analyses were performed to examine the relationship between parents’ well-being (WHO-5) and HbA1c over time,
with either supportive or nonsupportive diabetes parental behavior
(DFBC+ and DFBC- scales) and diabetes stress (PAID-Pr) as mediators, corrected for parents’ education level, parents’ gender, and adolescents’ age, gender and diabetes duration.
Results: No relationship was found between WHO-5 and HbA1c
(β = −0.052, p = 0.656). Neither between WHO-5 and DFBC+
(β = −0.042, p = .36). WHO-5 was related to DFBC-(β = −0.174,
p < .01) and PAID-Pr (β = −0.669, p < .01). DFBC+, DFBC- and
PAID-Pr in their turn related to HbA1c (β = −0.261, p = .01;
β = 0.376, p = .02; β = 0.287, p < .01).
Conclusions: Over time parental well-being was not related to adolescents’ HbA1c. However, worse parental well-being was associated
with increased levels of nonsupportive diabetes parental behavior
and parental diabetes stress. Both variables in turn were related to
less optimal glycemic control. Interventions aimed at parents should
focus on reducing negative diabetes parental behaviors -such as
criticism- and diabetes distress.
P333
Illness identity in youth with type 1 diabetes: a
person-centered approach
L. Oris1, P. Moons2, L. Goubert3, I. Weets4, K. Luyckx2
1
KU Leuven, Faculty of Psychology and Educational Sciences, Leuven,
Belgium, 2KU Leuven, Leuven, Belgium, 3Ghent University, Ghent,
Belgium, 4UZ Brussel, Brussels, Belgium
Objectives: An important task for adolescents and emerging adults
with type 1 diabetes is integrating diabetes into one’s identity. Four
so-called illness identity dimensions have been identified: engulfment,
rejection, acceptance, and enrichment. To examine individual differences in these illness identity dimensions, the present study focuses
on configurations of these four illness identity dimensions and how
they relate to diabetes-specific and psychological functioning.
Methods: A sample of 575 patients (14–25 years of age) with type
1 diabetes completed questionnaires on illness identity, psychological
functioning, and treatment adherence. HbA1c-values were collected
from patients’ medical records. Cluster analysis was used to identify
different configurations. Analyses of variances were used to identify
differences among the clusters in diabetes-specific and psychological
functioning.
POSTER TOURS
Results: Five clusters were retained and this solution was rather stable across sex (Cohen’s kappa = 0.77): Engulfment-Rejection (13.0%
of the sample), Rejection (17.8%), Engulfment-Enrichment (18.7%),
Acceptance (25.0%), and Acceptance-Enrichment (25.5%). No differences in age, illness duration, or sex were found among the clusters.
The Engulfment-Rejection showed the least optimal profile (i.e., high
on depressive symptoms, low on satisfaction with life, low on treatment adherence, and high HbA1c-values). Acceptance and
Acceptance-Enrichment showed the most optimal profile (i.e., low on
depressive symptoms, high on satisfaction with life, high on treatment adherence, and low HbA1c-values).
Conclusions: Five clusters were identified, each characterized by
their own unique profile scores on the illness identity dimensions.
These clusters were differentiated on diabetes-specific and psychological functioning. Hence, these clusters provide clinically meaningful
profiles.
P334
High prevalence of disordered eating behavior in
adolescents with type 1 diabetes in a central region
of Italy
L. Ferrito1, R. Gesuita2, E. Skrami2, A. Iannilli1, V. Cherubini1
1
Azienda Ospedaliero-Universitaria Ospedali Riuniti, Division of Pediatric
Diabetes, Ancona, Italy, 2Centre of Epidemiology and Biostatistics,
Politecnical University of Marche, Ancona, Italy
Objectives: To assess the prevalence of disordered eating behaviours
(DEB) in adolescents with type 1 diabetes (T1D) living in the Marche
region of Italy.
Methods: Basing on the regional registry for T1D, a total of 163 subjects with diabetes duration ≥ 1 year, aged 11–20 years, were
recruited during November 2015-May 2016 (response rate 74,5%).
All subjects completed the revised Diabetes Eating Problem Survey
(DEPS-R) and the mSCOFF questionnaire. Clinical, metabolic, socioeconomic and familial data were also collected. Positive screening for
DEB was defined as total score ≥20 on DEPS-R or ≥2 on mSCOFF.
DEB prevalence was evaluated as punctual and 95%CI estimates.
Fisher exact test and Wilcoxon rank sum test were used for comparisons between subjects with or without DEB.
Results: 56 out of 163 adolescents (34.4%; 95%IC: 27.1%-42.2%)
had a positive screening for DEB. 41.7% [95%CI 31.0-52.9] of
females and 26.6% [95%CI 17.3-37.7] of males scored ≥20 on DEPSR; 57.1% [95%CI 45.9-67.9] of females and 51.3% [95%CI 39.7-62.8]
of males scored ≥2 on mSCOFF. 46.4% of subjects reported using
not enough insulin and 9.8% reported skipping the insulin dose completely after overeating, at least occasionally (DEPS-R items 2, 8);
29.6% were identified as “insulin restrictors” on the mSCOFF (question 5). DEB was significantly associated with higher zBMI, HbA1c,
total cholesterol, triglycerides, insulin doses and more sedentary lifestyle. No significant association was found between DEB and parental education, socioeconomic status, family structure, and type of
insulin treatment.
Conclusions: A high prevalence of DEB and insulin restriction,
related to higher HbA1c and BMI, was found among T1D adolescents
of both genders in the Marche region. DEB diagnosis is difficult, and
insulin purging could hide the weight gain of binge eating disorders.
Further validation of disease-specific screening tools and early detection of DEB are needed to provide appropriate intervention.
P335
Health related quality of life and glycaemic control
of children with type 1 diabetes mellitus in Ireland
E. Hennessy1,2,3, C. Cronin1, A. Bradfield1, M. Bradley1, O. Neylon4,
A. Khan5, D. Bux6, P. Leahy2, S. O’Connell1, S. O’Riordan1
1
Cork University Hospital, Cork, Ireland, 2University College Cork, Cork,
Ireland, 3HRB Clinical Research Facility - Cork, Cork, Ireland, 4Sligo
155
POSTER TOURS
General Hospital, Sligo, Ireland, 5Tralee General Hospital, Tralee, Ireland,
6
University Hospital Waterford, Waterford, Ireland
Background: In type 1 diabetes mellitus (T1D) monitoring quality of
life (QoL) of children and adolescents in clinical practice is important.
Objectives: To assess the clinical utility of available generic and diabetes specific QoL questionnaires suitable for use in an Irish cohort
of children and adolescents with T1D.
Methods: The Paediatrics QoL Inventory (PedsQL; Varni, 1999) measures health-related quality of life in children and adolescents with
acute and chronic health conditions. The PedsQoL Measurement
Model integrates both generic core (physical, emotional, social and
school functioning) scales and disease-specific modules (physical
symptoms relating to diabetes, treatment concerns, worries about
diabetes and communication problems) into one measurement
system.
Results: As a part of 2 year prospective longitudinal study 80 children
with T1D (37 males) aged 4–18.5 years (mean 12.5 3.3) were analysed. Child Generic PaedsQoL total score was lower in the group of
patients with poor glycaemic control (HbA1c > 75 mmol/mol) vs
group with suboptimal control (HbA1c 58–75), p = 0.03, and vs
group of children with optimal control (HbA1c < 58), p = 0.053.
Physical and social functioning as a part of Child Generic PaedsQoL
module had lower score in patients with poor glycaemic control vs
patients with suboptimal control (p < 0.05), while emotional wellbeing was scored lower in children with HbA1c > 75 vs HbA1c < 75
(p < 0.03). Child Diabetes PaedsQoL revealed lower score for treatment barriers and adherence in group of children with poor control
vs HbA1c < 75 (p < 0.01). Treatment adherence score as a part of
Parent Diabetes PaedsQoL module was higher in patients with optimal and suboptimal control vs patients with poor control (p < 0.02).
Conclusions: QoL is a useful adjuvant in routine diabetes care. The
mean QoL score agrees with main HbA1c categories of glycaemic
control levels (optimal, suboptimal and poor/high risk) according to
ISPAD guidelines.
P336
Quality of life, psychological functioning and
positive affect in children and adolescents with
type 1 diabetes
J. Laridaen1, E. De Bruyne1, E. Van Hoecke1, C. Van Herzeele1, S. Van
Aken2, R. Heyse3, M. Cools2,4, L. Goubert5
1
Ghent University Hospital, Pediatric Psychology, Ghent, Belgium,
Ghent University Hospital, Dept. of Pediatric Endocrinology, Ghent,
Belgium, 3Ghent University, Ghent, Belgium, 4Ghent University, Dept. of
Pediatric Endocrinology, Ghent, Belgium, 5Ghent University, Dept. of
Experimental-Clinical and Health Psychology, Ghent, Belgium
2
Objectives: Type 1 diabetes (T1D) is a chronic disease that significantly affects the life of children and their parents. Literature shows
inconsistent results regarding the impact of T1D on quality of life
(QoL) and psychological functioning. Identifying protective factors
such as positive affect are important to understand why some children and adolescents adapt more easily to the challenges associated
with diabetes than others.
The objectives of this study were: A) to evaluate QoL and psychological functioning in pediatric patients with T1D, as reported by
patients and their parents (proxy-report), and B) to examine the association between positive affect and QoL and psychological
functioning.
Methods: Fifty-nine youngsters with T1D between 8 and 18 years
old and 44 parents participated in this study (mean age: 12.2 yrs;
58.3% boys; mean HbA1c: 7.6%). Children and their parents completed questionnaires regarding general QoL (PedsQLTM 4.0),
diabetes-specific QoL (PedsQLTM 3.0 Diabetes Module), psychological
symptoms (SDQ) and positive/negative affect (PANAS).
Results: Children with T1D reported similar general QoL compared
to a matched sample of healthy children. No correlation was found
between self and proxy-report for general as well as diabetes-specific
QoL. Parents reported more psychological difficulties (proxy-report)
than their children (t = −2.2, p = 0.03).
Positive affect (measured by positivity ratio) was significantly associated with better self-reported child functioning. Positive affect
explained 28% of variance in general QoL, 40% of diabetes-specific
QoL and 28% of psychological problems.
Conclusions: Children and adolescents with T1D have comparable
overall QoL than healthy children. As parents report more psychological problems, multi-informant information seems important. Positive
affect seems a promising protective factor for resilient outcomes,
suggesting novel targets for intervention in this population.
P337
Maternal anxiety, stress, worries and depression in
the context of their child’ s type 1 diabetes (T1D):
association with child outcomes and the
moderating role of maternal emotion regulation
C. Van Gampelaere1, T. Vervoort1, N. Decoene1, L. Goubert1
1
University of Ghent, Experimental Clinical and Health Psychology,
Ghent, Belgium
Objectives: Previous research has shown that parents of children
with T1D experience high levels of stress, anxiety and depression,
which contribute to maladaptive child outcomes. To date, little is
known about mechanisms that may buffer the adverse impact of
these parental variables. The current study had two objectives. First,
we examined the contribution of maternal anxiety, depression, stress
and worries in explaining child anxiety, depression and functional disability. Secondly, we investigated whether maternal emotion regulation moderated the relationships between maternal and child
variables.
Methods: Participants consisted of a sample of 43 children with type
1 diabetes between 8–15 years and their mothers, recruited through
Ghent University Hospital.
Results: Linear regression analyses, controlling for child age and gender, indicated that mothers evidencing higher levels of maternal worries had children with more fear and functional disability. Further, a
significantly positive association was observed between maternal fear
and child depression scores. The positive association between maternal depression and child fear was found to be marginally significant.
Finally, maternal emotion regulation (i.e., positive reappraisal) was
found to significantly moderate the relationship between maternal
depression and child anxiety, such that the relationship was less
strong when mothers reported high levels of positive reappraisal. A
similar, yet marginally significant, moderating effect of maternal refocus on planning was observed for the relationship between maternal
worries and child anxiety.
Conclusions: In line with previous research, the current findings indicated that higher levels of maternal worries, fear and depression were
associated with adverse child outcomes in the context of T1D. However, maternal emotion regulation strategies may buffer some of
these negative relations, attesting to the critical role of targeting
parental emotion within treatment.
P338
Sexual behaviors and knowledge in Greek
teenagers with type 1 diabetes mellitus (T1DM)
B. Kandyla1, A. Tsitsika2, C. Tzavara2, K. Karavanaki1
1
National and Kapodistrian University of Athens School of Medicine,
Diabetes Unit, Second University Department of Pediatrics ’P. &
A. Kyriakou’ Children’s Hospital, Athens, Greece, 2National and
Kapodistrian University of Athens School of Medicine, Adolescent Health
Unit, Second University Department of Pediatrics, “P. & A. Kyriakou”
Children’s Hospital, Athens, Greece
Background: Adolescents with type 1 diabetes mellitus (T1DM) may
differ from their healthy peers in respect to sexual behaviors.
156
POSTER TOURS
Aims: We aimed to explore the sexual behaviors of T1DM adolescents in comparison with healthy peers.
Materials and Methods: Fifty eight T1DM adolescents (mean SD
age 16.3 2.0 years, disease duration 6.7 3.5 years and
HbA1c:8.0 1.3%) were compared to 116 healthy controls (matching 1:2 for school, class and gender). Anonymous, self-reported questionnaires were used to evaluate sexual education and behaviors.
Results: T1DM adolescents tended to believe that they were more
adequately informed on sexual education and contraceptive use compared to controls (77.4% vs 64.0%). For both groups the primary
sources of information on contraceptives were parents and friends.
Both groups had the same knowledge regarding the reason of requiring contraception during sexual intercourse. T1DM teenagers knew
that HIV is a sexually transmitted disease (STD) in significantly lower
percentage compared to controls (82.4% vs 95.4%, p = 0.013), with
no difference regarding the knowledge of other STDs. T1DM adolescents had a sexual experience in a significantly lower percentage than
healthy peers (74.1% vs 87.4%, p = 0.033).
The average age of first sexual intercourse was similar for both
groups (15.2 1.5 years vs 15.9 1.5 years for T1DM and controls
respectively). Intoxication by alcohol prior to sexual contact was
reported in relatively fewer cases in T1DM adolescents. (4.3%
vs. 20%, p = 0,046). The number of sexual partners was similar for
the two groups, while 52.4% of T1DM teenagers vs 58.7% of controls used condoms in every sexual contact.
Conclusion: T1DM adolescents showed no appreciable differences,
regarding sexual experience. Furthermore, they presented similar
level of knowledge concerning sexual issues and also presented
almost similar proportions of risky sexual behaviors in comparison
with healthy controls.
P339
Health related quality of life and psychosocial risk
in children with type 1 diabetes in Ireland
E. Hennessy1,2,3, C. Cronin1, A. Bradfield1, M. Bradley1, O. Neylon4,
A. Khan5, D. Bux6, P. Leahy2, S. O’Connell1, S. O’Riordan1
1
Cork University Hospital, Cork, Ireland, 2University College Cork, Cork,
Ireland, 3HRB Clinical Research Facility - Cork, Cork, Ireland, 4Sligo
General Hospital, Sligo, Ireland, 5Tralee General Hospital, Tralee, Ireland,
6
University Hospital Waterford, Waterford, Ireland
Background: Psychosocial factors may be essential in explaining poor
glycaemic control in children with Type 1 diabetes (T1D). Monitoring
quality of life (QoL) of children and adolescents with T1D is important in clinical practice.
Objectives: To examine the association of scores on two screening
tools measuring psychosocial risk and emotional distress with quality
of life in an Irish cohort of children with T1D.
Methods: The Risk Index for Poor Glycaemic Control (RI-PCG) is the
screening tool to assess psychosocial risk (low risk score 0–1, moderate =2, high risk ≥3). The Paediatric Index of Emotional Distress (PIED) was used for emotional distress assessment. The Paediatrics QoL
Inventory (PaedsQoL) contains generic (physical, emotional, social
and school functioning) scales and disease-specific modules (physical
Rank Youth-reported strengths (DSTAR items)
n, %
symptoms relating to diabetes, treatment concerns, worries about
diabetes and communication problems).
Results: As a part of 2 year longitudinal study 103 children with T1D
(53 males) aged 3–18 years
(mean 12.3 3.4) were analysed. 63.5% of patients had a low
score (0–1) on the RI-PGC, 15.7% had a moderate score (=2), 20.8%
had high scores (≥3). 8.7% of patients were at high risk for emotional
distress (PI-ED > 20).
The group of patients with RIPCG ≥ 3 (high risk) compare to children at low and moderate risk showed lower PaedsQoL scores for
parents and for children (p < 0.05) in Generic and Diabetes module.
Patients at high risk for emotional distress (PIED > 20) had lower
PaedsQoL total score vs low risk: Generic questionnaire (parent
p < 0.01; child p < 0.01), Diabetes questionnaire
(parent p < 0.01; child p < 0.01).
Conclusions: PaedsQoL is significantly lower in T1D children with
high psychosocial risk and risk for emotional distress. Routine QoL
assessment may be helpful in guiding mental health referral.
P340
Diabetes strengths profiles: a characterization of
what is going well for adolescents with type
1 diabetes (T1D)
M.E. Hilliard1, S.S. Eshtehardi1, S. Wheat1, R. Klenk1, C. Sanders1,
S. Gunn1, B.J. Anderson1
1
Baylor College of Medicine and Texas Children’s Hospital, Pediatrics,
Houston, United States
Objectives: To enhance T1D outcomes, new strategies are needed
that build on teens’ and families’ capacities and successes. In a
strengths-based pilot intervention, diabetes providers gave brief, supportive feedback during routine care visits based on “diabetes
strengths profiles” derived from teen and parent reports of positive
T1D-related behaviors and attitudes. Adolescents’ baseline strengths
profiles are described.
Methods: 62 youth (age 14–18, M = 15.3 1.8; 44% male; M
A1C = 8.5% 1.6) completed the Diabetes Strengths and Resilience
measure (DSTAR) and parents completed the Diabetes SelfManagement Profile Parent-Report (DSMP). Strengths profiles were
created using algorithms created by endocrinologists and psychologists to highlight ≥6 of each family’s highest rated positive diabetesrelated behaviors and attitudes.
Results: Profiles had a mean of 6.1 2.3 youth-reported strengths
and 4.1 1.6 parent-reported youth adherence behaviors. All
12 DSTAR items and 10 of 24 DSMP items appeared on profiles. The
most frequent strengths and adherence behaviors are summarized in
the Table.
Conclusions: Adolescents with T1D had unique patterns of diabetesrelated strengths, which commonly reflected feeling supported, having confidence about self-management, and engaging frequently in
both routine and urgent management tasks. Strengths-based interventions based on profiles tailored to teens’ and families’ unique
capacities may benefit outcomes during this challenging developmental stage.
Parent-reported youth adherence behaviors (DSMP items)
n, %
1
There is someone I can always ask for help with my diabetes. 44, 71% In the last 3 months, teen completed most boluses or shots
(missed once a week or less).
55, 89%
2
Tie: My parent(s) help me take care of my diabetes. I can ask
for help with my diabetes management when I need to.
38,61% Teen keeps something handy in case of low blood sugar.
52, 84%
3
I am able to take care of my diabetes pretty well.
37, 60% Teen checks blood sugar 4 or more times daily.
39, 63%
4
Tie: I am good at responding to high or low blood sugars. If I
try hard to do everything I need to do for my diabetes, it
makes a difference.
35, 58% Teen usually or always does ketone test when sick, once or
more times per day.
26, 42%
5
I am good at figuring out what to do for my diabetes when
problems come up.
32, 52% Teen or parent treats low blood sugars with prescribed
16, 26%
amount of carbs, with or without recheck 15 minutes later.
157
POSTER TOURS
[Top 5 youth- and parent-reported T1D strengths]
P341
Understanding the relationship between anxiety
and blood glucose management in children with
type 1 diabetes
D. Rudaizky1, C. MacLeod1, T. Jones2, E. Davis2, A. Hunt3, N. Chen1,
W. Radcliffe2, A. Lin3
1
University of Western Australia, School of Psychology, Perth, Australia,
Princess Margaret Hospital, Perth, Australia, 3Telethon Kids Insititute,
Perth, Australia
2
Objectives: Children with Type 1 Diabetes (T1D) experience anxiety
at much higher rates than their non-T1D counterparts. This elevated
anxiety is also known to interfere with optimal management of blood
glucose. Attentional biases that favour the processing of negative
information have been shown to causally underpin anxiety. In the
present study we sought to determine
1) whether anxiety in children with T1D is associated with biased
attentional processing of negative information and
2) whether these biases in attentional processing also contribute to
control of blood glucose levels.
Methods: 62 children (33 female) with T1D who attended the Diabetes Clinic at Princess Margaret Hospital participated in the study.
Mean age was 15.62 (SD = 1.63). Participants completed the Trait
Anxiety Inventory and the dot-probe task to assess patterns of attentional processing of negative information. HbA1c measurements were
extracted from standard clinic data collection. Correlational analyses
were employed to determine whether or not anxiety was related to
poorer control of blood glucose and whether attentional processing
of negative information contributed to this association.
Results: Trait anxiety was positively correlated with HbA1c levels.
Importantly, measures of attentional processing of negative information were negatively correlated with trait anxiety levels, suggesting
that higher levels of anxiety are associated with a pattern of attentional avoidance of these types of information. When controlling for
attentional processing, the correlation between anxiety and HbA1c
becomes non-significant.
Conclusions: These findings suggest that attentional processing of
negative information makes a critical contribution to the relationship
between anxiety and control of blood glucose levels. Future research
will focus on developing attentional training procedures to concomitantly reduce anxiety and increase control over blood glucose levels.
P342
Evaluating the impact of the diagnosis and
management of a child with type 1 diabetes on
parents
C. McCormick1, S. Millar2
Objectives: Glycaemic control can be adversely affected by family
conflict derived from regular parental input in the management of
diabetes and the negative psychological impact of the disease upon
parents. Our objective is to identify potential parental psychological
stressors and thus interventions deemed useful to provide additional
support to parents with an overall objective of improved patient metabolic control.
Methods: 252 children were identified from outpatient diabetic
records. Two copies of the Paediatric Inventory Questionnaire for
Parents were sent to each household. The questionnaire is designed
to identify stressors among parents of children with chronic disease.
The questionnaire consists of 43 questions divided into four categories: communication, medical care, emotional distance and role
function. Each question is rated across a 5 point scale to assess frequency and difficulty. Two parent focus groups were then held to
identify key parental concerns and possible interventions.
Results: 123 questionnaires were returned. 1 questionnaire was discounted as it was incorrectly completed with blank spaces. The category emotional distance scored the largest numbers of high scores
with 70% and 69% of parents scoring greater than 50% of the possible total maximum score for that category across the two domains of
frequency and difficulty respectively. Role function had the least
number of high scores with 37% and 39% of parents scoring greater
than 50% of the possible total maximum score for that category
across frequency and difficulty respectively. Themes emerging from
the focus groups included parental concerns regarding the relentless
´24´ hour care of caring for a child with diabetes and impact upon
their own social life, relationship with partner and other children.
Conclusion: Caring for a child with diabetes has a significant psychological impact upon parents and further psychological support and
interventions are necessary.
P343
Psychological status of urban T1DM adolescents
(Delhi, India)
S. Puri1, A.K. Vedwal2, A. Virmani3
1
Jamia Millia Islamia, Social Work, Delhi, India, 2Yog Dhyan Foundation,
Selhi, India, 3Max Hospitals, Endocrinology, New Delhi, India
Objective: To assess psychological status in urban T1DM adolescents using MY-Q (Mind Youth Questionnaire for self-evaluation on
general QOL, social/ emotional life, and diabetes management).
Methods: We administered MY-Q to 16 M, 29 F adolescents in
Delhi. 28 come to a private clinic; 17 go to government hospitals, and
are part of a Group which meets weekly, also offers financial support
and Yoga. 23 answered English version; 22 version translated into
Hindi (which also reflects lower SES).
Results: All clinic families know of the Group, but only those needing
financial support attend meetings regularly. In answering MY-Q,
42 (93%) expressed overall optimism (ladder question), but on specific
questions, often had scores indicating distress in the following areas.
1
Antrim Area Hospital, Lisburn, United Kingdom, 2Southern Health and
Social Care Trust, Paediatrics, Newry, United Kingdom
Total
n = 45(%)
Boys
n = 16
Girls
n = 29
English (upper
SES) n = 23
Hindi
(lowerSES)n = 22
No Group
Support n = 22
Group
Support n = 23
Family
36(80)
14(87)
22(76)
21(91)
15(68)
18(82)
18(78)
Self
26(58)
7(44)
19(66)
15(65)
11(50)
12(55)
16(70)
Leisure
12(27)
6(38)
6(21)
8(35)
4(18)
6(27)
5(22)
Diabetes
Related
12(27)
6(38)
6(21)
9(39)
3(14)
8(36)
4(17)
School
9(20)
5(31)
4(14)
5(22)
4(18)
7(32)
2(9)
Friends
5(11)
2(13)
3(10)
3(13)
2(9)
3(14)
2(9)
[Table 1]
158
Family issues were common; boys and girls were equally affected.
Self image problems were more in girls; leisure and diabetes related
issues were more in boys. In spite of poverty, those with Group support had distress levels comparable to well off families. Specific problem areas included handling hyperglycemia (15/45), deciding what to
eat (15), handling hypoglycemia (12), injecting insulin (12) and selftesting (10/45).
Conclusions: Specific questions are needed to elicit areas where psychological distress exists. Family issues predominate in our cohort.
Group support (psychological and financial) can help reduce distress.
Well off families resist participating in such activities, and may need
different forms of incentives.
P344
Family caregivers of pediatric patients with type
1 diabetes mellitus: keys for their well-being
J.J. Alcon Saez1, F. Moreno Macian2, I. Tarazona3, S. Casaña Granell4,
L. Lacomba Trejo4, M. Perez Marin4, I. Montoya Castilla4
1
Consorcio Hospital General Universitario de Valencia, Department of
Pediatrics, Pediatric Endocrinology Unit, Valencia, Spain, 2Hospital
Universitario y Politécnico La Fe, Department of Pediatrics, Pediatric
Endocrinology Unit, Valencia, Spain, 3Hospital Clínico Universitario,
Department of Pediatrics, Pediatric Endocrinology Unit, Valencia, Spain,
4
Faculty of Psychology, University of Valencia, Personality, Assessment
and Psychological Treatments Department, Valencia, Spain
Objectives: Our objective was to study, in main family caregivers of
pediatric patients with DM1, their main psychological, family and
adjustment to illness features.
Methods: 44 main family caregivers of 44 pediatric patients with
type 1 DM, were assessed in a single moment of evaluation. Patients
were between 8–15 years old (Mean age 12.41 SD: 1.64). The time
of diagnosis of the disease ranges from 3 months to 14.83 years. At
least, 50% of patients had been diagnosed 5 or more years before.
For the evaluation of psychological variables, the following questionnaires were used:
- Hospital Anxiety and Depression Questionnaire (HADS)
- Questionnaire of Stress produced by Pediatric disease Situations (PIP)
- Family Cohesion and Adaptation Scale (CAF)
- Adult Attachment Questionnaire (CAA)
Descriptive statistical analyses were conducted using IBM
SPSS v20.
Results: In our sample of family caregivers we found mainly mothers
(82%). A significant percentage of caregivers reported a clinical problem of emotional distress (77%), with high rates of anxiety (55%) and
depression (25%). They also had a difficulty adjustment to the illness
of their children, showing moderately high levels of stress produced
by situations of caretaking. There is a positive relationship between
emotional distress (anxiety and depression) and stress.
Almost 30% of caregivers had low self-esteem, showing a tendency
to get angry easily, being more reserved and displayed no communication (aspects related to an insecure attachment style). In our sample
we found predominantly families struggling to feel connected emotionally in a healthy way (68%) although most families have shown
some flexibility to respond adequately to the problems (66%).
Conclusions: Our study highlights the importance of considering the
family system as a whole unit of attention and care in the presence
of a chronic condition in one of its members.
P345
Prevalence of disturbed eating behavior in Dutch
adolescents with type 1 diabetes: 1 year follow up
M. Eilander1, M. de Wit1, J. Rotteveel2, H.J. Aanstoot3, W. Bakkervan Waarde4, M. Houdijk5, R. Nuboer6, P. Winterdijk3, F. Snoek1,7
1
VU University Medical Center, Medical Psychology, Amsterdam,
Netherlands, 2VU University Medical Center, Department of Pediatrics,
POSTER TOURS
Amsterdam, Netherlands, 3Diabeter, Center for Pediatric and Adolescent
Diabetes Care and Research, Rotterdam, Netherlands, 4UMCG,
Department of Pediatrics, Groningen, Netherlands, 5HAGA Hospital,
Department of Pediatrics, Den Haag, Netherlands, 6Meander mc,
Department of Pediatrics, Amersfoort, Netherlands, 7AMC, Medical
Psychology, Amsterdam, Netherlands
Objectives: The prevalence of disturbed eating behaviors (DEB) in
youth with type 1 diabetes peaks at age 17–19: 49% of girls and
15% of boys report DEB. Previously we examined the prevalence of
DEB in Dutch 11-16yo adolescents: 45.6% was at risk for DEB and
7.8% scored above cut-off, indicating DEB. No gender differences
were found. Using 1 year follow-up data we examined if the prevalence of DEB changes and if gender differences become visible.
Methods: Using a stepwise approach DEB were assessed in adolescents (11-17yo) participating in the DINO study: only those who
reported dieting activities or body dissatisfaction (step 1) completed
the Diabetes Eating Problems Scale-Revised (DEPS-R) (step 2). Four
sub-groups were identified: ’No DEPS-R’; ’Low’; ’Medium’; ’Above
cut-off’. Prevalence of DEB on T0 and T1 were compared descriptively. Gender differences were examined using χ2test.
Results: Of the 103 participating on T0, 82 enrolled in follow-up.
Mean DEPS score on T0 was higher for drop outs (T = 2.8,
p = 0.008). Gender was not associated with DEB (χ2 = 0.31,
p = 0.86). As presented in Table 1, for 22% DEPS scores increased,
60% remained stable and for 18% scores decreased.
Conclusions: In this sample female gender was no predictor for DEB
and for the majority DEB proved to be stable. However, more DEB
on T0 were found in the dropout group suggesting an under estimation. Screening for DEB risks using a stepped approach is feasible.
[Table 1: Prevalence of DEB at T0 and T1]
P346
Chronicity of type1 diabetes mellitus in youths and
quality of life and psychopathology: an interplay?
F.G. Bascialla1, D. Gklavas2, O. Konstantinidou3, A. Kleisarchaki2,
I. Maggana2, K. Mouzaki2, E. Efstratiou2, A. Galli-Tsinopoulou2
1
Aristotle University,Medical School,Faculty of Health Sciences, 1st
Department of Psychiatric, General Hospital Papageorgiou, Thessaloniki,
Greece, 2Aristotle University,Medical School,Faculty of Health Sciences,
4th Department of Pediatrics, General Hospital Papageorgiou,
Thessaloniki, Greece, 3Aristotle University, Department of Psycology,
Thessaloniki, Greece
Objectives: Type1 diabetes (T1D) is a chronic illness and the most
common metabolic disease in childhood. We aimed to examine the
relationship between glycemic control through HbA1c, age of onset
of diabetes, gender and psychological distress, overall well-being of
quality of life among a sample of Greek adolescent outpatients
with T1D.
Methods: Forty-eight adolescents outpatients with T1D aged 13–18
years were enrolled. Glycemic control was evaluated through HbA1c
at study enrollment. Good control considered with HbA1c levels <
7.5%. To assess psychosocial factors, the following questionnaires
were used: Pediatric Quality of life Questionnaire 4.0 Generic Core
Scales(PedsQL4.0 GCS), Ego Identity Scale(EIS), Beck Depression
Inventory(BDI II),Beck Anxiety Inventory(BAI). One-wayANOVA and
independent samples t-test have been applied to examine differences
between groups.
159
POSTER TOURS
Results: Patients have been divided according their age of onset of
T1D into 3 groups: < 6 yrs (25.0%), 6-12 yrs (58.3%) and >12 yrs
(16.7%). Mean HbA1c level was 7.94%. The mean Generic Score was
80.5, functioning: Physical 85.9/Emotional 74.4/Social 87.1/School
74.7 and Psychosocial health 236.1, but none of these factors is correlated with age of onset and glycemic control. Statistically significant
difference has been found for the ’Competence vs Inferiority’ domain
of the EIS between the groups 6–12 and >12 (p = 0.034). Statistically
significant differences were found between groups regarding depression (p = 0.019) and anxiety (p = 0.010). The age group of onset < 6
has greatest average of depression symptoms (15.18 13.12) and
anxiety (18.08 10.50).
Conclusions: Youths with onset disease at age >12 have more feelings of inferiority and worst competence. A service for adolescent
outpatients should offer a multidisciplinary approach aimed to
decrease diabetes related stress, increase self-efficacy and support
the family as a whole.
P347
The implementation of a specific validated semistructured questionnaire assessing self-care in
children and adolescents with type 1 diabetes
G. Tzitzika1, I. Maggana2, I. Kyrgios2, A. Kleisarchaki2, E. Kotanidou2,
K. Mouzaki2, E. Efstratiou2, K. Kazakos1, A. Galli-Tsinopoulou2
1
Alexander Technological Educational Institute of Thessaloniki,
Thessaloniki, Greece, 2Aristotle University,Medical School,Faculty of
Health Sciences, 4th Department of Pediatrics, General Hospital
Papageorgiou, Thessaloniki, Greece
Objectives: Knowledge of the characteristics that affect selfmanagement in patients with Type 1 Diabetes Mellitus (T1DM) is valuable for achieving better glycemic control, avoiding complications
and having a high quality of life. Aim of the present study was to
investigate the parameters that may have an effect, positive or negative, on the self-management in children and adolescents with T1DM.
Methods: A specific validated semi-structured questionnaire, the
Diabetes Self-Management Questionnaire (DSMQ), was administered
to 93 children and adolescents with T1DM, aged 2.5-18 years-old
(52.7% were boys, 83.9% used a multiple injection regimen). The
questionnaire was composed of 16 items, subdivided into 4 subscales:
glucose management (GM) (5 items), dietary control (DC) (4 items),
physical activity (PA) (3 items) and health-care use (HCU)’ (3 items),
whereas one item referred to an overall evaluation of self-care.
Results: The mean item-total-correlation was 0.38 (>0.3 for most
items) and the total internal consistency was acceptable (Cronbach’s
alpha 0.773, which is >0.7). Similar findings were obtained when analysis was performed separately for each subscale, except HCU
(Cronbach’s alpha 0.22). Each subscale score was found to be significantly negatively correlated with age (except for HCU), diabetes duration (except for PA and HCU), and treatment type (except for HCU),
but not with sex or HbA1c (p > 0.05 in all cases). No differences in
subscale scores between groups of different glycemic control were
noticed as well (p > 0.05).
Conclusions: This study suggests that younger children and those
with short diabetes duration have higher scores of self-care, possibly
due to stricter parental supervision. Adolescence and long disease
duration seem to result in poorer self-care, attributed to the revolutionary nature of that age. However, patients with better glycemic
control do not present higher scores of self-care. These findings
remain to be confirmed by larger studies.
P348
Psychosocial profile, glycemic control and well
being in poverty associated type 1 diabetes mellitus
[T1DM] adolescents in India
R. Manjunath1,2,3, S. Malhotra4,5, V.A. Rao6, L. Reddy2, B. Reshma4,
G.S. Rao4, S. Srikanta3, V. Nath4, C.S. Muralidhara Krishna1,
B. Sunitha3, S.M.H. Owais1, R. Ashok3, T. Deepak1, A. Sharda1,
Diabetes Collaborative Study Group: Samatvam Jnana Sanjeevini
1
Samatvam Endocrinology Diabetes Center, Endocrinology Diabetes,
Bangalore, India, 2Disha Dosti Free Diabetes Clinic for the Poor,
Diabetes, Community Health, Bangalore, India, 3Jnana Sanjeevini
Medical Center and Diabetes Hospital, Endocrinology Diabetes,
Bangalore, India, 4Jnana Sanjeevini Medical Center and Diabetes
Hospital, Diabetes, Community Health, Bangalore, India, 5Jain University,
Psychology, Bangalore, India, 6Samatvam Endocrinology Diabetes Center,
Diabetes, Community Health, Bangalore, India
Objectives: To analyse psychosocial determinants of glycemic control in economically underprivileged T1DM adolescents in India.
Methods
DISHA: Since 1987, 3000 children provided free insulin, syringes,
health counseling, 24 h helplines. Since 2006, BG meters, 5–10
strips/month added. Basal bolus insulin 100%.
DISHA + CDiC/LFAC: 2011-ongoing: [Changing Diabetes in Children and Life for a Child with Diabetes] 292 children receiving
enhanced support −100 BG strips/ month, quarterly HbA1c, annual
urine albumin: creatinine ratio, TSH].
Psychosocial evaluation: 84 adolescents (age 10-18y; mean age
15.4y ; age onset 9.83y; duration 5.5y; 37% boys; 52% urban/semiurban). Tools: HADS 1983; Self Care Inventory-R SCI-R 2001; PAID
2006; KIDSCREEN-272004; Multidimensional Scale of Perceived
Social Support 1991; Self-Esteem 1965; Emotional Regulation 2003;
General Health Questionnaire-28; ACOPE 2001; FAD 1983.
Results:
Glycemic
Control
HbA1c %
Range
N
HbA1c
% Mean
Anxiety
Score
Depression
Score
Better
<9.1
22 8.04
6.59
6.64
Intermediate
9.1-11
33 10.13
6.97
6.39
Poor
>11
29 12.60
7.38
5.62
[HbA1c Anxiety Depression]
Better control (A1c < 9.1) was associated with lower anxiety, lower
hypochondriasis, higher adherence, and lower family dysfunctional
behavior. Poor control (A1c >11) was associated higher anxiety,
higher hypochondriasis, lower adherence, and higher family dysfunctional behavior. Depression scores were highest in “Better” control
group, compared with “Poor” control group.
In subgroup analysis, adolescents with “Good” control (A1c < 8.1)
had lowest anxiety scores (5.56); whereas those with “Worst” control
(A1c >12) had lowest depression scores (5.05) ? “careless, and happygo-lucky” attitude.
In the “Better” control group, there was relative preponderance of
girls and urban/semi urban adolescents.
Conclusion: Optimal psychosocial environment and support are
important determinants of better glycemic control and well-being in
T1DM, even in resource limited settings.
P349
Family Factors and metabolic control in ethnic
minority youth with type 1 diabetes
A. Delamater1, K. Niel1, E. Pulgaron1, J. Sanchez1
1
University of Miami, Pediatrics, Miami, United States
Objectives: Ethnic minority youth with type 1 diabetes (T1D) are at
increased risk for poor metabolic control. The aim of this study was
to identify family factors associated with metabolic control and regimen adherence (RA) in minority youth with T1D.
Methods: The sample included 91 youth (24% White, non-Hispanic,
46% Hispanic, 30% Black) (mean age = 13.6 years, duration = 5.4
years, 64% girls) and their parents. Participants completed standardized measures of general life stress, family cohesion and conflict;
diabetes-related supportive, non-supportive behaviors, and family
responsibilities; and RA. A1c and DKA were recorded from the
160
medical record. Multiple regressions identified predictors of A1c,
DKA, and RA with demographic (age, gender, SES, marital status),
general family (parent life stress, cohesion and conflict), and diabetesrelated (supportive and non-supportive family behavior, responsibilities for diabetes management) family variables.
Results: Higher A1c was predicted by single-parent status (p = .05),
older age (p = .01), and more life stress (p = .02). DKA was predicted
by lower SES (p = .01), more life stress (p = .02), lower family cohesion (p = .01), and more diabetes tasks that no one had responsibility
for (p = .001). Lower youth-rated RA was predicted by older age
(p = .01), more life stress (p = .05), less cohesion (p = .01), more tasks
with no responsibility (p = .03), and less supportive family behavior
(p = .02). Lower parent-rated RA was predicted by older age
(p = .04), less cohesion (p = .001), and more non-supportive (p = .03)
and less supportive family behavior (p = .001). ANOVAs indicated
that Black and Hispanic parents reported more life stress than White
parents (p = .01); Black youth reported less family cohesion than
White youth (p = .04); Hispanic youth had fewer diabetes responsibilities than White or Black youth (p = .01).
Conclusions: Poor metabolic control and RA in ethnic minority youth
is associated with greater parental life stress and less family cohesion.
P350
Screening for depression in adolescents with
diabetes by medical social workers: a quality
improvement initiative
G. Bethany1, K.M.C. Hong1
1
Nationwide Children’s Hospital, Social Work/Endocrinology, Columbus,
United States
Objectives: Screen adolescents with diabetes to identify their risk
for depression and compare depression risk with glycemic control.
Methods: Youth completed the Patient Health Questionnaire 9 (PHQ-9). Social workers scored the PHQ-9 and made referrals as
needed. Referrals were made to Nationwide Children’s Hospital
(NCH) for counseling or the patient´s local mental health agency.
Data on A1C was collected when the PHQ-9 was scored initially, and
at 3 month-intervals for a year. Data was also collected for adolescents who were referred (NCH/ non-NCH) and whether the adolescents followed through with counseling (three visits or more).
Results: 449 adolescents with diabetes were seen in scheduled social
work appointments during that time period. Among that population
the mean A1C was 8.9% with the range of 6.2 to >14%. Out of the
449 potential patients who were seen at social work visits during that
time, 367 patients actually completed the PHQ-9 (82%). 58% (19/33)
who met criteria for depression were referred to counseling, 18%
(6) declined, and 24% (8) were already linked. 78% improved in glycemic control who received a referral and followed through
(Intervention). 31% improved in glycemic control who either did not
follow through with a referral or declined (Did not receive Intervention). 50% improved in glycemic control who were already linked with
counseling prior to the screening.
Summary: Adolescents who met criteria for moderate to high risk
(≥10) depression had higher A1C compared to those who met criteria
for low risk (≤9) of depression. This indicates that early identification
of depression symptoms is important.
There was a significant improvement in A1C among adolescents
who met criteria for moderate to high risk (≥10) for depression and
followed through on counseling referral compared to those who did
not follow through, indicating psychotherapy has the potential to
impact A1C.Adolescents with diabetes are at higher risk for depressive symptoms.
POSTER TOURS
P351
Type 1 diabetes mellitus in pediatric patients: keys
to their well-being and adjustment to disease
J.J. Alcon Saez1, F. Moreno Macian2, I. Tarazona3, S. Casaña Granell4,
L. Lacomba Trejo4, M. Perez Marin4, I. Montoya Castilla4
1
Consorcio Hospital General Universitario de Valencia, Department of
Pediatrics, Pediatric Endocrinology Unit, Valencia, Spain, 2Hospital
Universitario y Politécnico La Fe, Department of Pediatrics, Pediatric
Endocrinology Unit, Valencia, Spain, 3Hospital Clínico Universitario,
Department of Pediatrics, Pediatric Endocrinology Unit, Valencia, Spain,
4
Faculty of Psychology, University of Valencia, Personality, Assessment
and Psychological Treatments Department, Valencia, Spain
Objectives: The main objective was to study, in a group of children
and adolescents with type 1 diabetes mellitus, their main psychological, family and adjustment to disease characteristics.
Methods: 44 pediatric patients(43.2% girls) from 8–15 years old
(mean age 12.41, SD 1.64) of three different hospitals, were assessed
in a single moment of evaluation.The time of diagnosis of the disease
ranges from 3 months to 14.83 years. At least, 50% of patients were
diagnosed 5 or more years before the study.
For the evaluation of psychological variables, the following questionnaires were used:
- Self-Esteem Questionnaire of Rosenberg (CSR)
- Qualities and Difficulties Questionnaire (SDQ)
- Scale for assessing educational style of parents of teenagers (EP)
- Scale of Psychological Well-Being (BIEPS-J)
- Hospital Anxiety and Depression Questionnaire (HADS)
All descriptive and statistical analyses were conducted using IBM
SPSS 20.00.
Results: Data showed that 73% of our patients have a non-adaptive
response to DM1.
Diabetic children highlighted by the presence of anxiety symptoms
in 16% of cases. Remarkable levels of difficulty in motor activity
(23%), emotional symptoms (11%) and behavioural problems (9%)
were also observed. In our sample, depression levels were not clinically relevant.
Regarding psychological well-being, 9.1% of patients had major difficulties in areas such as: ability to find a meaning to his/her life,
sense of control and self-competence.Related to the perception that
adolescents have about the parenting style of their parents, our data
showed that parents of our sample mostly have healthy educational
styles and high behavioural control. These parental features are usually beneficial in diseases like DM1 with a demanding regimen
treatment.
Conclusions: Our study highlights the need for psychological counselling in these patients, given the important relationship between
their emotional and behavioural discomfort and worse adaptation
to DM1.
P352
Experience of pressure in informal caregiving in
parent(s)/caregiver(s) of a child with T1DM. It takes
a village to raise a child’
A.M.J. Neijens1
1
Hogeschool Utrecht, FG, Utrecht, Netherlands
Aim: Diabetes mellitus T1 in a child touches all family members. Children and their parents have to deal with a disease which requests
attentiveness, specific knowledge and skills, and this care is hard to
hand over (Almeida, 2012; Butler, 2008). T1DM in children leads in
>40% to overstressed parents, dysfunctioning families (Piazza-Waggoner, 2008; Rohan, 2015) and worse long term outcome of T1DM.
An intervention might prevent predictable pressure in families (Beck,
2012). Is it possible to avoid predictable stress, and how?
Method: Systematic literature review; semi structured interviews
with professionals; questionnaire Experience of Pressure in Informal
Caregiving (EDIZ, Pot, 1995; n = 51); systematic implementing
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POSTER TOURS
diagnosis (van Linge, 2004). Options for intervention analysed in the
PRECEDE-PROCEED Model (Green, 1974).
Results: There’s a correlation between the overloaded parents and
T1DM in their child. Parent(s)/caregiver(s) accept the situation and by
overoptimistic beliefs (Freckleton, 2014) they cannot foresee impact
on social life (Landolt, 2005; Lewin, 2006; Rintala, 2013; Roth, 2014)
and childs’ health perspective (Tsiouli, 2013; Missotten, 2013). Professionals see the need (Werkgroep Kind & Diabetes, 2016).
Conclusion: Although the impact of T1DM in a child is predictable,
diabetes teams cannot solve the gap between formal and informal
care. The lack of breather threatens all family members (Chapell, Reid
en Dow, 2001). Current services for family support lack the competencies, capacity, continuum and access to keep up families functioning (Eilander et al, 2015; Movisie, 2015).
Recommendation: There is a broad support for a collaborational
innovation for diabetes support that seamlessly connects to diabetes
care (medical axis) and a healthy neighbourhood approach (Alles is
Gezondheid, 2016). Though the need for informal support this innovation deserves a careful implementation to remain the status of a
trustworthy supplement of integrative diabetes care.
P353
The mental health of adolescents with type1
diabetes: associations with HbA1c
W. Radcliffe1, D. Rudaizsky2, T. Jones3,4, E. Davis3,4, A. Hunt4,
C. MacLeod2, A. Lin4
1
Nationwide Children’s Hospital, Social Work/Endocrinology, Columbus,
United States, 2Ohio State University, Endocrinology, Columbus, United
States, 3Nationwide Childrens Hospital, Pediatrics, Endocrinology,
Columbus, United States
Objectives: To identify the impact of a recently established Type
1 diabetes mellitus transition program (T1DM-TP), with an adult
endocrinologist in a pediatric endocrinology setting, on a pediatric
provider team’s attitudes regarding the transition process. The provider team studied was comprised of Registered Dietitians (RD),
Endocrinologists (MD), Advanced Nurse Practitioners and Physician
Assistant (APN/PA-C), and Social Workers (SW).
Methods: A 19 item cross-sectional survey using a 5-point Likert
scale was developed based upon prior transition literature to evaluate
provider attitudes and barriers with regard to transition from pediatric to adult care among diabetes patients. The survey was distributed
to providers prior to implementation of the T1DM-TP and then
repeated 12 months later.
Results: Factor analysis revealed a positive change in provider attitudes toward the transition process. The results from the pre-survey
(N = 28; 13 MD, 4 APN/PA-C, 3 RD, 5 DNE, 3 SW) and post- survey
(N = 22, 9 MD, 3 APN/PA-C, 2 RD, 4 DNE,
4 SW) revealed changes in provider attitudes toward the transition
process. Among several notable findings, there was an increased frequency of discussion with patients regarding transition and a
decreased concern in several areas of the transition process, including
access to care and affordability of care.
1
Child and Adolescent Health Service, Princess Margaret Hospital,
Paediatric Consultation Liaison Program, ACUTE Child and Adolescent
Mental Health, Perth, Australia, 2University of Western Australia, Centre
for the Advancement of Research on Emotion, School of Psychology,
Perth, Australia, 3Princess Margaret Hospital, Department of
Endocrinology and Diabetes, Perth, Australia, 4University of Western
Australia, Telethon Kids Institute, Perth, Australia
Background: Young people with Type1 Diabetes are at heightened
risk for poor mental health and this can be associated with diabetesrelated variables, such as HbA1c and history of severe hypoglycaemia. In the current study we investigated the mental health of adolescents with Type1 and associations with their diabetes history.
Methodology: 62 adolescents with Type1 (52.4% female) aged
12–18 years participated in the study. They all completed the wellvalidated self-report measures of general psychopathology
(Achenbach Youth Self-Report, YSR), anxiety and depressive symptoms, perceived stress and fear of hypoglycaemia. Average HbA1c
over the last year was used as an index of metabolic control. Severe
hypoglycaemia was defined as any convulsion or hospitalisation for
hypoglycaemia.
Results: The mean age of participants was 15.62 (SD 1.93), with
16.7% reporting depressive symptoms in the elevated range. A notably high proportion of participants reported somatic complaints and
thought difficulties (on YSR) in the clinical range. Of the group 9.7%
reported deliberately trying to hurt or kill themselves and 14.5%
thinking about killing themselves.
All symptom scores were positively correlated with average HbA1c
in the past year. There were no significant associations between mental health and history of severe hypoglycaemia, age of diabetes onset
or fear of hypoglycaemia.
Conclusions: Adolescents with Type1 experience significant rates of
mental health problems and these are associated with metabolic control. Care for mental health is likely to improve metabolic control.
P354
Provider attitudes: the impact of the
implementation of a pediatric T1DM transition
program
B. Glick1, E. Buschur2, L. Nahata3, M. Kamboj3
[Provider survey]
P355
Assessment of the efficacy of a psychological
intervention aiming at improving the quality of life
in patients with diabetes mellitus type 1 and their
families
M. Zavattoni1,2, C. Maffoni1,2, R. Cardani2, A. Trettene3,
A. Salvatoni2,3
1
ADIUVARE - onlus, Varese, Italy, 2ASST-Settelaghi, Mother & Child
Department - Pediatric Unit, Varese, Italy, 3University of Insubria,
DSCM-Pediatric Unit, Varese, Italy
Objectives: To assess the efficacy of a psychological intervention at
disease onset in pediatric patients with T1DM and their families.
Methods: Two groups of 14 patients matched for age and gender
were compared: A (newly diagnosed patients) and B (one year of
disease duration). The patients and their families were assessed
through questionnaire (CBCL) at the time of the diagnosis (T1) in
group A and after one year of disease (T2) in both groups. Since the
beginning of disease and the whole first year group A received a
psychological support treatment. The distribution of anxiety, somatic
and internalization scales of CBCL were compared in groupA at disease onset and after one year and between the two groups at one
year of disease duration. Kruskal-Wallis test was used for statistical
analysis.
162
POSTER TOURS
small sized uterus, bilateral ovaries hypoplastic /agenesis, left hydronephrosis; Age 16: Left minimal hearing loss, Right normal hearing
[Right ear PTA 10db, Left ear 16db]. Short Stature: Height cm: 151;
%ile: 3%; Z-score: −1.87; Weight kgs: 40.2; %ile: 0%; Z-score: −2.89;
BMI-for-age:17.6; %ile: 5%; Z-score: −1.61; Serum Growth Hormone
post clonidine: 7.9 mg/ml.
Conclusion: Hypogonadism may be hypogonadotropic or hypergonadotropic [more reports in males]. Genetic and biologic basis for the
diversity in clinical manifestations [including hypogonadism] in WFS
needs better elucidation. Short stature is common feature.
Results: GroupA showed a significant improvement of the anxiety,
somatic and internalization scales during the first year of disease.
After one year of disease Group A compared to group B showed non
statically significant lower anxiety, somatic and internalization score
(see table).
Conclusions: The study showed that, at the time of the diagnosis
and during the first weeks, patients and their families have a lower
adjustment due to the traumatic experience of the diagnosis. Over
time they seem to better adjust to the situation. The study
was however not able to demonstrate a clear effectiveness of the
psychological support intervention started at the onset of the
disease.
CBCL Components (Scales)
Anxiety
Somatic
N
BL
C
N
BL
C
N
BL
C
A/T1
1(7%)
7(50%)
6(43%)
6(43%)
7(50%)
1(7%)
4(28%)
5(36%)
5(36%)
A/T2
8(57%)
6(43%)
0(0%)
12(85%)
2(15%)
0(0%)
10(72%)
3(21%)
1(7%)
χ2 = 11.52; p < .01
B/T2
5(36%)
8(57%)
χ2 = 1.02; p NS
1
Internalization
Group/Time
χ2 = 5.8; p < .05
1(7%)
8(57%)
6(43%)
χ2 = 5.7; p < .05
0(0%)
χ2 = 2.8; p NS
7(50%)
6(43%)
1(7%)
χ2 = 1.5; p NS
N = normal; BL = borderline; C = clinical
[Results]
P356
Hypergonadotropic hypogonadism in 2 siblings with
DIDMOAD (Wolfram Syndrome - WFS) syndrome
and its associations
R. Manjunath1,2, V.A. Rao3, K.M. Chandrika4, G.S. Rao5, A. Sharda4,
T. Deepak2, L. Reddy2, B. Reshma5, S. Srikanta2, V. Nath5,
C.S. Muralidhara Krishna2, U. Rangaraj5, B.D. Thyagaraj2, A. Hegde2,
Diabetes Collaborative Study Group: Samatvam Jnana Sanjeevini
1
Samatvam Endocrinology Diabetes Center, Endocrinology, Bangalore,
India, 2Jnana Sanjeevini Medical Center and Diabetes Hospital,
Endocrinology Diabetes, Bangalore, India, 3Samatvam Endocrinology
Diabetes Center, Diabetes, Community Health, Bangalore, India,
4
Samatvam Endocrinology Diabetes Center, Endocrinology Diabetes,
Bangalore, India, 5Jnana Sanjeevini Medical Center and Diabetes
Hospital, Diabetes, Community Health, Bangalore, India
Objective: To describe hypergonadotropic hypogonadism in the rare
genetic autosomal recessive WFS syndrome in 2 sisters.
Classic presentation: Insulin-dependent diabetes [non-autoimmune],
optic atrophy, central diabetes insipidus, sensorineural deafness.
Rare: Neurological/ psychiatric; delayed puberty, central hypogonadism, anterior pituitary dysfunctions; urodynamic abnormalities, limited
joint motility, cardiovascular/ gastrointestinal autonomic neuropathy;
heart malformations].
Methods: A. Sibling 1: Full term normal delivery; Age 8: Diabetes
insulin dependent; Age 13: Optic Atrophy; Age 18: Diabetes insipidus; Age 16: Menarche; Age 17: Secondary amenorrhea, Serum FSH
87.5 mIU/ml, LH 29.9 mIU/ml, Testosterone 6.9 ng/dl, US Abdomen:
small sized uterus, bilateral ovaries hypoplastic /agenesis; Age 17:
Bilateral minimal high frequency sloping hearing loss [Right ear PTA
25db, Left ear 23.3 db]. Short Stature: Height cm: 146; %ile: 0%, Zscore: −2.64; Weight kgs: 39.4; %ile: 0%, Z-score: −3.13; BMI-forage: 18.5; %ile: 13%; Z-score: −1.11; Serum Growth Hormone post
clonidine: 6.9 ng/ml.
B. Sibling 2: Full term normal delivery; Age 4: Diabetes insulin
dependent; Age 15: Optic Atrophy; Age 17: Diabetes insipidus; Age
15: Menarche; Age 16: Secondary amenorrhea, Serum FSH
87.8mIU/ml, LH 31.7mIU/ml, Testosterone 16.3 ng/dl, US Abdomen:
P357
Psychosocial need survey - adolescent outpatient
diabetes clinic
T. Johnston-Hoad1, J. Lee1
1
Monash Medical Centre Clayton, Diabetes Ambulatory Care Service,
Clayton, Australia
Aim: To explore patient and carer needs in regards to psychosocial
services in Diabetes Services at Monash Medical Centre for ages
13–18 and to increase involvement and/or support in management
and further understanding of Type 1 diabetes.
Methods: A paper and pen questionnaire based on Likert scaling and
short comments, was given to both carers and adolescents whilst
attending outpatient clinics for Type 1 Diabetes, during a four month
period.
Results: One hundred and thirty three patients were scheduled for
this time and 27% failed to attend. Of the 95 parent surveys
returned, 60% indicated that they would attend workshops on managing diabetes, parenting strategies, stress reduction and promoting
teen independence. 50% indicated an interest in attending support
groups and 40% were interested in their adolescent children attending groups. 78% of carers reported that they would attend groups
at Monash Medical Centre, Clayton.Of the 93 adolescents who
returned their questionnaires, one third failed to answer the majority of the questions. Of those who did complete their questionnaires, 60% responded that they would like to “manage their
diabetes and still have a life”. For workshops 45% responded that
they would not attend if offered, 33% were undecided . Over half
of the adolescents did not answer questions relating to support
groups and the 47% who answered indicated that they would
attend fortnightly or monthly support groups at Monash Medical
Centre.
Conclusion: The survey indicated satisfaction with psychosocial services in DACS, there were mixed results for whether the adolescent
group and their carers would attend or utilise support groups or
workshops, with half of the adolescents not responding. Although
those who did respond, answered positively. There is potenital for
further investigation as to whether there would be future success in
utilising technology for online support groups or workshops as an
alternative to groups at the hospital.
163
POSTER TOURS
P358
Health related quality of life of Egyptian children
and adolescents with type 1 diabetes
A. El-Hawary1, M. El-Ziny1, A. Elsharkawy1, N. Salem1, H. Aboelenin1
1
Mansoura University Children Hospital, Pediatric, Mansoura, Egypt
Objectives: In Egypt, limited evidence exists on HRQoL among children and adolescents with T1DM. Therefore, the present study aimed
to evaluate the HRQoL among Egyptian children and adolescents
with T1DM and their parents taking into account the gender and age
group of the patient.
Methods: This is a cross-sectional study enrolled 102 children and
adolescents with T1DM (54 female/48 male) aged (8 to 18 years old),
had T1DM for at least 12 months. We used Pediatric Quality of Life
Inventory 3.0 (PedsQL™ 3.0) which is a multi-dimensional instrument
of 28 items encompasses 5 scales: diabetes symptoms (2) treatment
barriers (3) treatment adherence (4) worry (5) communication. We followed the methodology commonly used in the translation and validation of HRQoL instruments. Internal consistency was checked by
Cronbach´s alpha coefficient.
Results: There was significant increase of the mean values of the
total score of HRQoL of diabetic patients compared to their parents.
There was no significant difference between male and female
patients in total QoL scores. Female sex was associated with better
total QoL scores and also did better regarding diabetic symptoms,
treatment adherence, treatment barriers, worry dimensions scores.
Male patients were more significantly feel hungry and thirsty than
females (p = 0.009, p = 0.021) respectively. Older children (12–18
years) have significant thirst feelings and frequent urination than
younger group (8–12 years) (p = 0.021, p = 0.016) respectively.
Conclusion: The results of this study indicate that Parents of diabetic
children have poor QoL than their children. There is no effect of gender, age group, or duration of T1DM, on HRQoL. Understanding the
effect of diabetes on quality of life of patients and their parents; male
and female; children and adolescence, is being of great help in clinical
management and to design a public health policy in order to improve
the quality of life and health outcomes of those with T1DM.
to Diabetes care. They enjoyed the discussions and sharing aspect of
the group. Some of the participants used the learned stress management techniques taught within the group. Many of the participants
reported that they have started to allow their adolescents some independence around their diabetes.
Recommendations: The parents suggested that the group run for a
longer period of time.They noted that they would benefit from a psychoeducational aspect to the group. Overall they felt that the Diabetes
team facilitating a group for both parents and patients was beneficial.
P360
Applying the ecological model to understand
factors contributing to psychosocial wellbeing and
health care of children and adolescents with
diabetes mellitus
G. Hapunda1
1
University of Zambia, Psychology, Lusaka, Zambia
Objective: The bioecological model has been shown to be a robust
model for understanding developmental needs of children. To date,
this model has not been applied to specific need for pediatric children
with diabetes mellitus. Therefore, the objective of this study is to discuss the bioecological model of Urie Bronfenbrenner and its application on diabetes care and psychosocial wellbeing of children with
diabetes in Sub Saharan Africa.
Methods: This is a discussion paper that draws its arguments from
empirical literature to demonstrate how the bioecological model can
contribute to our understanding of psychosocial issues and health
care of children and adolescents with diabetes mellitus.
Results: Using empirical evidence, this paper demonstrates that the
bioecological model is a robust theory that can be applied in diabetes
care and psychosocial wellbeing intervention of children. The paper
also discusses clinical and research implications.
Conclusions: The advantage of the bioecological model in diabetes is
that it targets large-scale public health interventions unlike medical
intervention that focus on a single individual.
P359
STAND-support through art and networking for
diabetes parent support group. The opinions of the
parents pre and post group
P361
Whose diabetes is it anyway? Exploring the transfer
of diabetes care responsibility from parents to
children with type 1 diabetes: a study protocol
H. O’Byrne1
J. Aalders1, E. Hartman1, G. Nefs1, H.-J. Aanstoot2, E. van Mil3,
F. Oort4, F. Pouwer1
1
The National Children’s Hospital Tallaght, The Social Work Department,
Dublin, Ireland
Intro: The Diabetes MDT in The National Children’s Hospital Tallaght
set up a 6 week psychology/art therapy led psychotherapy adolescent group for teenagers 16–19 years old who attend our service.
Alongside this the Medical Social Worker (MSW) facilitated a support
group for the parents.The purpose of the parent support group was
to provide a supportive space for the parents to meet others who
have shared experiences and to provide a safe space for them to
open up and share advice. The MSW also provided information and
facilitated discussions in relation to important and relevant topics
related to parenting a young person with Type 1 Diabetes, such as
transitioning to independence, parent–child relationship and stress.
Methodology: Each of the group participants completed a pre and
post group satisfaction survey. 12 participants completed the pre
group survey and as there were 3 drop outs of the group 9 participants completed the post group survey. The surveys were qualitative
and asked the parents about their expectations for the group, their
current struggles, what they gained from the group, whether they
found it improved their input into their teenagers’ diabetes care and
their relationship.
Findings: The outcomes of the surveys were that the participants of
the group gained informal supports that they didn’t previously have.
They felt reassured that other families have similar struggle in relation
1
Tilburg University, Center of Research on Psychological and Somatic
Disorders [CoRPS], Department of Medical and Clinical Psychology,
Tilburg, Netherlands, 2Diabeter, Center for Pediatric and Adolescent
Diabetes Care and Research, Rotterdam, Netherlands, 3Kidz&Ko, Jeroen
Bosch Hospital, ’s-Hertogenbosch, Netherlands, 4University of
Amsterdam, Academic Medical Centre, Department of Medical
Psychology, Amsterdam, Netherlands
Objectives: The transference of diabetes care responsibility from
parents to
children with type 1 diabetes (T1D) is often experienced as stressful by families and clinicians. However, factors that may facilitate or
impede the transference of diabetes care responsibilities from parents to children in different developmental stages or the right timing
and extent of transference for specific families, are yet understudied.
Therefore, the aims of this research project are
a. to identify which factors enhance or impede the transfer of diabetes care responsibilities,
b. to define the right extent of transference in different developmental stages and
c. to develop an explanatory framework (mediation/moderation) that
describes the relation between facilitating and impeding characteristics, the extent of transference of treatment responsibilities and
health outcomes.
164
Methods: First, a qualitative focus group study will be conducted to
a. examine which factors facilitate or impede a smooth transfer of
diabetes responsibilities and
b. to identify the right extent of transference.
Based on Belsky’s Process Model (Belsky, 1984), the identified
facilitating and impeding factors will then be categorized into parent,
contextual and child domains. Next, a large-scale cross-sectional
study (N ~ 200) will be conducted to test the explanatory framework
linking parent/child/contextual factors to diabetes care transference
and health outcomes.
POSTER TOURS
Results: It is expected that the results of this project will disentangle
associations between child/parent/context characteristics, the extent
of care transference and diabetes-outcomes in different developmental stages.
Conclusion: The previously outlined project aims to help families to
optimize blood glucose control and quality of life by providing them
with family-tailored advice about the right extent and timing of the
transference of treatment responsibilities.
DOI 10.1111/pedi.12452
AUTHOR INDEX
A
Alessandrelli M.C. P052
Aalders J. P122, P361
Alexander C. P231
Atik Altinok Y. P199
Aanstoot H.J. P009, P246, P332, P345
Alexander V. P247
Atkinson M. P090
Aanstoot H.-J. O41, P054, P122, P361
Algazir N. P184
Atlas E. O02, P309
Abad L. P304
Alghar H. P191
Atwa H. P278
Abbas Q. P025
Ali B. P201
Autio R. O36
Abd El Fattah M. P222
Alimova N.U. P295
Avann C. P021
Abd El-Aziz Ahmed A.S. P280
Allen J.M. P047
Aversekar S. O06
Abd El-Tawab K.A. P286
Alnhdi A. P191
Ayabe T. P061, P100, P103, P324
Abdel Ghaffar H. P280
Aloi C. O40, P181
Ayyagari M. P205
Abdellatif M. O54
Åman J. P088, P254
Azad K. O64, P090, P120
Abo Bakr A.S. O26
Ambler G. O05, O59, P195
Abo El-Asrar M. O26
Amed S. O14, P156
Abo Elwafa R. P222
Amemiya S. P007, P061, P100, P296
B
Aboelenin H. P358
Ameyaw E. P030
Bacha F. P329
Abourazzak S. P204
Amin R. P013
Bächle C. P123
Abraham M.B. O46
Amr N.H. P286
Baechle C. P160, P297
Abul M. P183
Anderson B. O48, P020, P050, P053,
Bailey T. O03, O04
Accogli A. P181
P193, P194
Athayde D.A.M. P182, P230
Baker C. O17
Anderson B.J. P340
Baker E. P086
Acerini C.L. P018, P047, P185, P253
Anderson D. P085
Bakker-van Waarde W. P074, P332, P345
Adamczyk P. P015
Anderson D.G. INV6
Baloch R. P227
Adan Lanceta V. P045
Anderson S. O03, O04
Balu P.S. P206
Adly A. O25, P004, P214
Anderson V. P231
Banach A. P216
Adolfsson P. P033, P080, P210
Anderzén J. P008
Baquer N. P048
Agarwal S. O51
Andrés De Llano J. P094
Barat P. O21
Agwu J.C. P171
Anicet F. P143
Barcenilla H. O33
Ahad F.B. P082
Annan F. INV1, P262
Bardtrum L. P189
Ahmadov G. O61, P090
Antosik K. P060
Barker P. P145
Ahmed N. O64
Antunes A. P217
Barnes N. O63
Ahmed S. P059, P249
Aono M. P261
Barnett T. P091
Ahmedani M.Y. P257
Aono S. P261
Barni F. P111
Ahmedani Y. P090
Aoui A. P093, P320
Barrett T. P208
Ajaltouni Z. P223
Arbab S. P025
Bartlomiejczyk M. P058, P060
Akatsuka J. P007
Arbelaez A.M.INV10
Bascialla F.G. P346
Akesson K. P013
Arcano S. P097
Basit A. P257
Åkesson K. O12, P008, P056, P066,
Archinkova M. P259, P321
Bassoy B. P040, P150, P310
Arena V. P302
Bastida J.L. P014
Al Aaraj N. P251
Ares J. P291
Bath L. O52
Al Ashmawy A.A. P280
Armengol E. P110
Bath L.E. P012
Al Ghazawy A. O25
Aroian K. P127
Battelino T. O02, P309
Al Khalifah R. P191, P221
Arslanian S.INV3
Batticciotto A. O28
Al Yafei F. P251
Asante Bediako E. O63
Baumgartner A. O27
Alanazi M. P191
Aschemeier B. P328
Bayman E. O52
Albert B. P075
Ashford J. P253
Bayman E.M. P012
Albin A.-K. P098
Ashok R. P032, P041, P348
Bazdarska Y. P252
Alcon Saez J.J. P344, P351
Asscherickx W. P276
-Skowronek I. P157
Ben
Acerini C. P245
P137, P215
Pediatr Diabetes October 2016; 17 (Suppl. 24): 165–176
wileyonlinelibrary.com/journal/pedi
© 2016 The Authors.
Pediatric Diabetes © 2016 John Wiley & Sons A/S
165
166
Beauloye V. P162
AUTHOR INDEX
Bossowski A. P096, P104, P157, P216,
Beccaria A. P285
P241, P266, P300
Carrascosa A. P110
Carson M. P085
Bechtold - Dalla Pozza S. P283
Botta E. O56
Carson M.E. P018
Bechtold -Dalla Pozza S. O31
Bouk’hil K.S. P240
Carvalho S. P217
Bechtold-Dalla Pozza S. P234
Bouziane-Nedjadi K. P093, P320
Casalini E. P003, P077, P111
Beck R. O48, P020, P034
Boyadzhiev V. P259
Casaña Granell S. P344, P351
Becker D. P302
Boyko V. P084
Casanova J.-L. P071
Bekkat Berkani D. P240
Boyle C.T. O29
Casas R. O33
Benevento D. P331
Brack C. P095
Cassanello M. O40
Bensenouci A. P240
Bradfield A. P335, P339
Castañeda J. O41
Ben-Skowronek I. P096, P241
Bradley M. P335, P339
Castano L. O55
Beran D. P043
Bratina N. O02, O10, P309
Casteels K. P071, P162, P167, P198, P276
Berg C. P163
Brazg R. O03, O04
Castell C. O10
Berger G. P139
Brennan A.A. P159
Castillo K. P123, P297
Bergeron A. O21
Brett C. P082
Castillo-Reinado K. P160
Berget C. O07, O42
Brites F. O56
Castro-Correia C. P011
Berry C. P180
Brossaud J. O21
Cattelani C. P078
Bersom R. P201
Brown A. O05
Cawley V. P277
Bertholt Zuber M.L. P094
Brown F. P250
Cebi A.H. P183
Besancon S. O47, O61, P090
Brownlee W. O46
Cenciarelli V. P281
Bethany G. P350
Bruno G. P140
Cerqueiro Bybrant M. P098
Bevilacqua E. P131
Brunzell C. P017
Cetin H. P083
Bhatta M. P306
Bruzzi P. P078, P186, P281
Chan-Cua S. P304
Bianco V. P078
Buckingham B. O03, O04
Chandrika K.M. P106
Bierła J. P225
Buckingham B.A. O07
Chang N. P200
Biester T. O02, P139, P178, P309,
Buckingham D. P269
Channon S. P161
P313, P328
Budzynska E. O35
Chao S. P162
Bijl J. P152
Bull L. P262
Charalampopoulos D. P013
Bilbao L. P110
Burling K. P145
Charemska D. P096, P157, P216, P241
Binder E. O31
Burlot K. P119
Chatzakis C. P142
Bingley P. O10
Buryk M. P302
Chavda V. P294
Birkebæk N. P013, P073, P235
Buschur E. P354
Chawla M. O06, P076
Birkebaek N. P215
Busiah K. INV7
Chen N. P341
Birnie E. P246
Butler A.M. P121
Cheng R. P315
Bishar Abdirahman S. P082
Bux D. P335, P339
Cheon C.K. P101
Bishop F. P146
Cherif N. P240
Bismuth E. P119, P143
Chernenkov Y. P232
Bjarnason R. P215
C
Cherubini V. P052, P334
Bjornstad P. O27
Caballero E. P158
Chetana K.L. P032, P041
Blasco González L. P044
Caetano L.A. P062
Cheung R. P302
Bläsig S. P309
Cain C. O42
Chiabi A. P308, P319
Bodansky H.J. O15, P176
Caldwell C. P127
Chin J. P304
Bode B. O03, O04
Calliari L.E. P108, P170
Chobot A. P015
Boero L. O56
Cameron F. P117
Choi L. P132
Boettcher C. P081
Cameron F.J. O05
Christensen L. P215
Bohn B. P203
Campbell F. P022
Christian P. P001, P059
Bolli G. P147
Campbell F.M. O29
Christie D. INV11
Bollow E. P283
Campbell K. O42
Christoforidis A. P113, P165
Boncompagni A. P281
Campos A. P110
Christopoulos-Timogiannakis E. P092
Bonvicini F. P078
Campos J. P237
Chrousos G. P067, P092
Borkenstein M. P144
Candela G. P177
Chua C. O53
Borowiec M. O35, P060
Cappa M. P220, P331
Church D.S. P012
Borrego L.M. P301
Cardani R. P105, P115, P190, P355
Ciampalini P. P331
Bosch B. P071
Cardona-Hernandez R. P290
Ciancanelli M. P071
Bosco A. P190
Carlsson A. O09, P008, P098
Cianfarani S. P220
167
AUTHOR INDEX
Ciborowski M. P060
Davis E. O46, P341, P353
Dovc K. O02, P290, P309
Cinek O. O10, O36
Davis E.A. P153
Dozza A. P281
Claes L. P197
Davis L. P124
Dreher-Preis L. O43
Clark S. P117
Dayal D. P311
Drew S. P179, P316
Clarke C. P012
Dayan C. O11
Driscoll K. P146
Clarkson Fletcher M. O05
Dayashankar U. P041
Driscoll K.A. O07, O42, P039
Clarson C. P284
De Beaufort C. O10
Drivvoll A.K. P013, P148, P215
Clemente M. P110
De Bruyne E. P336
Drozd V. P228
Clements M. P013
De Franco E. P317
Drummond L. P021, P208
Codner E. P138
De Kerdanet M. P079
D’Souza N. O17
Cody D. O24
De Keukelaere M. P276
Du Bose S. O29
Coe G. O27
De La Cuesta A. P158
Dudzik N. P228
Coeckelberghs M. P162
De Long N.E. P221
Duijndam E. P174
Colino E. P010
De Mendonca Lindström T. P210
Dulude H. P129, P130
Collin P. P162
De Percin A. P223
Dumic Kubat K. P258
Commissariat P. P053, P194
De Portu S. O41
Dunger D. P145
Constantinou M. O35
De Vries M. P246
Dunger D.B. P047
Cools M. O23, P336
De Wit M. P152, P332, P345
Dunn L. P312
Copeland K. P329
Declercq P. P131, P236
Dunstheimer D. P081
Corathers S. P126, P231
Decoene N. P337
Dürr R. P070
Corcuff J.-B. O21
Deeb L. P189
Dusatkova L. O38
Corella Aznar E. P089
Deeb L.C. P039, P130
Dustagheer A. P256, P268, P299
Corrias M. P323
Deepak T. P032, P041, P106, P348
Dustakova L. P327
Costa C. P011
Dehayem M. P027, P308, P319
Dykes D. P231
Costas L. P110
Deja G. O08, P241, P244
Dżygało K. P065, P241, P288
Costello A. O64
Del Duca E. P097
Craig M.E. O29, O59, P195
Delaere F. P276
Cree-Green M. O27, P329
Delamater A. P349
E
Criego A. O03, O04
Delgard S. P143
Edge J. P145
Crimmins N. P231
Delis D. P037
Efstratiou E. P346, P347
Cronin C. O57, P335, P339
Demir G. P083
Ehlers M. O45
Crowe C. P133
DeSalvo D. P034, P053
Eilander M. P332, P345
Cukrowska B. P225
Deshpande J. P212
Ekström M. P248
Deshpande R. P212
El Gamal M. P251
Despotova V. P259
El Samahi M. P214
D
Dias R. P208
El Samahy M. P004
Da Rocha Fernandes J. O61
Diaz R. P145
El Sayed N. P251
Daab M. P241
Díaz C. O19
Elawwa A. P251
Dabelea D. O51
Diaz-Naya L. P291
Elbarbary N. O26, O32, P317
D’Agostino Jr. R.B. O51
Dilla T. O44, P014
Elding Larsson H. P008, P098
Dahl-Jørgensen K. O34, P013
DiMeglio L. O22, P034, P053, P194
Elfoly M. P201
Dahlquist G. O10
DiMeglio L.A. O07
El-Hawary A. O54, P358
Daley J. P277
Dimitriadou M. P113, P165
Elkabbany Z. O32
Damaceno N. P108
Dmenska H. P219
Elkelany A. P278
Damiani D. P182, P230
Dobrovolskiene R. O39, P263
El-Khaleegy H. O54
Daniilidou K. P165
Dobrzyn A. P060
Ellard S. P317
Danilova L. P228
Doggen K. P162
Ellsworth S. P231
Danne T. O02, O43, O48, P020, P070,
Dolezel Z. P109
Elsharkawy A. P358
Domínguez A. P158
El-Ziny M. P358
D’Annunzio G. O40, P181, P285
Donaghue K.C. O59, P195
Eroğlu N. P173
Danyte E. O39
Dong F. P099
Ersoy B. P173
Darcan S. P083, P199
Dooms L. P162
Eshtehardi S.S. P340
Datz N. P178
Dorchy H. P102
Esteban M. O55
Davies Y. O17
Dosch H.-M. P302
Evans K. P141
Davis B. P231
Dost A. P283
Evans M. P124
P178, P189, P309, P313, P328
168
AUTHOR INDEX
Evans-Cheung T.C. O15, P176
Frederiksen F. P098
Goksen Simsek D. P199
Evsyukova E. P046
Fredheim S. P013, P073, P235
Golmayo L. P010
Ewen M. P043
Freire P.V. P170
Gomes M.M. P217, P170
Ez-Elarab H. P286
Frey M. P328
Gomes da Costa M. P170
Ezzat Y. O32
Frier B.M. P147
Gonynor C. P193
Fritsch M. P154
González-Martínez S. P291
Fröhlich-Reiterer E. O29, P144, P154, P279
Góralczyk A. P104
F
Frohnert B. O13
Gordat M. O50
Fajkusova L. P109
Frumkin Ben-David R. P084
Gordon H. P179, P316
Fall C. O64
Fu J. INV4
Goscik J. P104, P300
Farid Konsouh M.M. P280
Fukami M. P061, P100
Gottschalk M. P329
Farrell K. P133
Fulcher G.R. P147
Gottwald I. P309
Fath M. P178, P328
Fürst-Burger A. P139
Goubert L. O23, P333, P336, P337
Fatima A. P031
Fusco L. P220
Goutbeek A.-M. P152
Fawwad A. P090, P257
Govender D. P090
Feder C.K.R. P170
Goverde M. P152
Fegan-Bohm K. P121
G
Govoni V. O64
Feldhahn L. P283
Gad K. P278
Graf-Bar-El C. P084
Feldman M. P124
Gaete X. P138
Graham S. P275
Feltbower R.G. O15, P176
Gagnum V. O16
Grandemange M. P079
Fendler W. P058, P060, P266
Gahl J. P231
Greco F. P220
Feo S. P239
Gajewska K. O24
Green A. O10
Fernandes S. P011
Galhardo J. P289, P326
Green N. P273
Fernandes V. P217
Gallagher D. P161
Gregory J. O11, P161
Fernandez Rodriguez S. P234
Gallagher K. P185
Griffiths B. P151
Fernell E. P056
Gallego P. O46, P141
Groele L. P065, P229
Ferrari M. O28, P118
Gallego P.H. P284
Grosser S. P247
Ferreira M. P237
Galler A. P139
Groszek A. P225
Ferrer M. P239
Galli-Tsinopoulou A. P346, P347
Grulich-Henn J. O43, P081
Ferrer Lozano M. P045, P089
Gangadharan A. P180
Grzechnik-Gryziak M. P318
Ferrito L. P052, P334
Ganguli B. P026
Guasti M. P111
Fichna P. P118, P298
Gao L. P147
Guitteny M.-A. P079
Fieuws S. P276
García Maset L. P044
Gulisano M. P003, P077
Fijak-Moskal J. O35
Gardiner M. P151, P267, P273, P274
Gumeniuk O. P232
Findlay C. P275
Garg S. O03, O04
Guness P.K. P256, P268, P299
Finer S. O64
Garnett S. O59, P195
Gunn A. P075
Finken M. P152
Gartner S. P110
Gunn E. P075
Firmino S.L. P182
Gasbarro A. P177
Gunn S. P340
Fisch-Shvalb N. O47
Gawel W.B. O08
Gupta P. O06
Fitas A.L. P301
Gehr B. P019, P293
Gustafsson A. P098
Florez I.D. P191, P221
Gerling I. O34
Gustafsson J. P056
Fontoura M. P011
Gertig-Kolasa A. P298
Guy C. P145
Formankova R. O38
Gesuita R. P334
Guzman C.B. P129, P130
Fornari E. P005
Gharnouti M. P093, P320
Gys I. P131
Forsander G. O01, P008, P080, P112,
Giani E. P290, P314
P137, P149
Giannella M.L.C. P182
Forsman S. P210
Gilbertson H. P117
H
Foster N. O22, P013, P034
Girard C. P223
Haas J. P056
Fottrell E. O64
Gklavas D. P346
Haas N.A. P234
Fouquaert C. O23
Glick B. P354
Habiba M. P079
Francia P. P003, P077
ska-Olszewska B. P216, P266
Głowin
Haerst J.E. P018
Franco D. P189
Godbole T. P212
Hagrasy H. P278
Frappin G. O50
Goethals E. P167, P198
Hahn E. O43
Freckmann G. P033
Goksen D. P083
Haller M. P329
169
AUTHOR INDEX
Hamilton N. P141
Hofer S.E. O29
Islam N. O14, P156
Hanas R. O48, P013, P020, P080,
Hogendorf A. O35
Ismail E. O25, O26, O32, P004, P214
Holder M. P019, P293, P313
Ismailov S.I. P295
Hanberger L. O12, P008, P013, P066, P215
Holec V. P169
Isom S. O51
Hanck L. P128
Holl R. O29
Ito S. P230
Hanes S.J. O07
Holl R.W. O31, O43, P013, P068, P070,
Iturralde E. O07
P189, P248
Hannonen R. P164
Hanson F. P022
P081, P095, P123, P139, P144, P160,
Iughetti L. P052, P078, P186, P281
P203, P283, P297
Ivarsson S.A. P008
Hapunda G. P360
Holle R. P160
Haq A. P025
Holman N. O29
Harkin J. P277
Holst K. P235
Härkönen T. O37
Home P.D. P147
J
Harrington K. P194
Hong K.M.C. P350
ska J. P216
Jabłon
Hartman E. P122, P361
Hood K.K. O07
Jacobson J.G. P129
Harvey J. O11
Hoshino T. P007
Jaja T. P168
Hasanbegovic S. P270
Hotta Y. P024, P261
Jakubiuk-Tomaszuk A. O35
Hashem N. O32
Houdijk M. P332, P345
Jali M.V. P282
Hashimoto T. P024, P261
Houdon L. P119
Jali S.M. P282
Hashimura K. P024, P261
Houdon Nguyen L. P143
Jałowiec I. P096, P157, P241
Hasnani D. O20, O47, P294, P330
Hovorka R. P047
Jamiołkowska M. P096, P157, P241
Hattersley A. P072
Howards A. P158
Janikiewicz J. P060
Haug C. P033
Huang Y. P302
Janson A. O60, P323
Haynes A. P153
Hughes C. P161
Jara F. O19
Hecht Baldauff N. P016
Humayun K.N. P072, P207
Jarocka-Cyrta E. P216
Hegde A. P032, P041, P106
Humphrey L. O22
Jarosz-Chobot P. O08, O10, P241,
Heger S. P178
Hunt A. P341, P353
Iversen H.H. P148
P244, P015
Heidtmann B. O31
Hutter, Ben P001
Jaser S. O22, P132
Heineking B. P234
Hunter C. P146
Jasinskiene E. P263
Helm N. P210
Hwang J.W. P069, P172
Jasser-Nitsche H. O31, P144, P279
Henckel E. P323
Hynes L. P133
Jean Pierre D. P256, P268, P299
Henderson K. P001
Hyöty H. O36, O37
Jefferies C. P075
Jelleryd E. O60
Henderson M. P091
Hendrieckx C. INV12, P122
Jenkins A. O05
Hennessy E. P335, P339
I
Jennane F. P204
Herbst A. P070, P095
Iannilli A. P052, P334
Jeronimo T. P230
Hermann J. P068, P070, P160
Ibañez L. INV5
Jiménez Olmos A. P045
Hermann J.M. P013, P081
Ibrahim M. P036, P226
Johannesen J. P073, P235
Hernández Marco R. P044
Ibrahim M.G. P286
Johansen A. P013, P073, P215, P235
Hertel T. P235
Icks A. O43, P203
Johnson S.B. P039
Hettema W. O50
Iferghas A. P204
Johnston-Hoad T. P357
Heyse R. P336
Ignasiak K. P288
Jolly M. P231
Hicks J. P151
Ihe C. P249
Joner G. O16
Hiermann P. O18
Ihle P. P203
Jones T. O46, P341, P353
Higashide T. P024, P261
IJzerman R. P152
Jones T.W. O29, P153
Hilgard D. O18, P139
Ikomi C. P231
Jönsson B. P098
Hill D. P284
Ilany J. O03, O04
Joo M. P261
Hilliard M. P053, P194
Iliev D. P238
Jorch N. O43
Hilliard M.E. P121, P340
Ilonen J. O36, O37
Jorge A.A.L. P062
Hindmarsh P. P087, P250, P264, P271
Ilvered R. P137
Josefsson A. O09
Hirose M. P024, P261
Imane Z. P204
Joshi A. P026
Hirschler V. O55, O56
Indulska K. P065, P318
Hitman G. O64
Inoue T. P324
Hodnekvam K. P148
Ionescu-Tirgoviste C. O10
K
Hoey H. P159
Iori A. P281
Kachalia S. O06
Hofer S. P013, P144, P154
Iotova V. P252, P259
Kącka A. P216
170
AUTHOR INDEX
Kadłubiska A. P266
Knip M. O37
Lahilla L. P239
Kakkat F. P090
Kockum I. P008
Laimighofer M. O13
Kaleva N. P259
Kocova M. O10, P327
Laing R. P043
Kallinikou D. P002
Koga Y. P324
Laliena Aznar S. P089
Kamala T. P032
Koki P.O. P308, P319
Lamari F. O58
Kamboj M. P354
Koleva R. P259
Landgraf W. P147
Kamboj M.K. P269
Kolomina I. P046
Landwehr S. P123
Kamecke U. P033
Konecna P. P109
Lane V. P171
śka H. P244
Kamin
Konopka E. P225
Lang M. P119
Kaminska H. P241
Konrad K. O43, P095
Lange K. P019, P123, P293
Kanaka-Gantenbein C. P002, P067, P092
Konstantinidou O. P346
Lanzinger S. O43, P139
Kandyla B. P338
Konstantinova M. P238, P259, P321
Laranjo G. P237
Kanodia P. P305
Koprivarova K. P259
Laridaen J. O23, P198, P336
Kapellen T. O18, P095
Kordonouri O. O02, P178, P309,
Larsen J. P149
Kapellen T.M. P068
P313, P328
Larson H. P269
Karagüzel G. P183, P233
Kosta K. P142
Larsson K. P098
Karaiskou A. P113
Kosteria I. O47, P067, P092
Lathia T. P212
Karavanaki K. P002, P338
Kotanidou E. P347
Latroch C. P093
Karges B. P068, P070, P203
Kourti A. P037
Lawrence J.M. O51
Kasahara Y. P100
Kovacic R. P283
Le Tallec C. P223
Kashihara Y. P024, P261
Kovil R. P076
Leahy P. P335, P339
Kaspers S. O49, O50
Kramna L. O36
Lebl J. O38, P327
Kastendieck C. P095
Krasinska A. P118
Lee C.-T. P049
Katsuyuki M. P292
Kretowski A. P060, P104, P300
Lee D.-Y. P069, P172, P202
Katz M. P329
Kristensen K. P235
Lee J. P127, P357
Kaufman F. O03, O04
Kristiansen K. P073
Lee K. O05
Kawada Y. P103
Krnic N. P258
Lee L.K. P325
Kawamura T. P024, P061, P100, P103,
Krogvold L. O34
Lee S.H. P255
Krone R. P021, P208
Lee-Barkley Y.H. O31
Kawasaki E. P103
Krumsiek J. O13
Leen M. P071
Kayserova J. O38
Krzysko-Pieczka I. P298
Leete P. O34
Kazakos K. P347
Kuddus A. O64
Leivada I. O58
Kerr S. P180
Kulkarni C. P212
Lemay J.-F. P139
Kershaw M. P021, P208, P243
Kulkarni R. O41
Lemiere J. P198
Ketchum K. O42
Kulkarni S. P076, P212
Lenzen S. P301
Keyes-Elstein L. O45
Kumar P. P048
Lenzi L. P105, P111
Khan A. P335, P339
Kumar R. P311
Leone K. P312
Khan A.K.A. O64
Kumaran A. P243
Lepej D. O02
Kichler J. P126, P146
Kummernes S.J. P013
Lerário A.M. P062
Kieninger-Baum D. P313
Kuraeva T. P107, P211
Lerner-Geva L. P084
Kiff S. O52
Kuß O. P160
Lernmark Å. P008
Kiff S.E. P012
Kyllo J. P017
Levek N. P084
Kikuchi N. P061, P100, P296
Kyrgios I. P347
Levy W. P121
Kikuchi T. P007, P100, P296
Kyriakou A. P133
Li X. P315
P261, P296
Kim M.S. P069, P172, P202
Libman I. P302, P329
Kim Y.J. P202
Lidano R. P097
King B. O29, O57
L
Lilienthal E. P139
Kitchener D. P272
La Grasta Sabolic L. P218
Limbert C. P301, P326
Kittelsrud J. O22
Lacamara N. P010
Lin A. P341, P353
Kjærgaard P. P073
Lacomba Trejo L. P344, P351
Lin C.-Y. P049
Kleisarchaki A. P346, P347
Lacoste A. O21
Lin J. O36
Klenk R. P340
Laffel L. O48, O49, P020, P034, P053, P194
Linda D. P329
Klingensmith G. P189
Laffel L.M. P314
Lindauer S. P070
Klonowska B. P096, P157, P216, P241
Lagges A. O07
Lindell N. O09
171
AUTHOR INDEX
Lindemann N. O18
Małachowska B. P266
Menéndez-Torre E. P291
Lisowicz L. P096, P157, P241
Malhotra S. P032, P348
Mentesidou L. P037
Lockwood-Lee S. P272
Mallon D. P231
Mentink R. P128
Logghe K. P162
Malmusi G. P078
Merino M. O44, P014
Lombardo F. P177
Maltoni G. P023, P186
Messadi W. P240
Lopes L. P289, P301, P326
Mameka I. P142
Metgud D. P282
López P. P138
Mameli C. P290
Meyts I. P071
López Ubeda M. P239
Manca Bitti M.L. P097
Michalak M. P298
López-Siguero J.P. O44, P014
Manjunath R. P032, P041, P106, P348
Middlehurst A.C. O61, P090
Lopresti D. P220
Manna T.D. P182, P230
Milenkovic T. P038
Lorubbio A. P220, P331
Mannu C. P140
Miles H. O52
Losada M. P110
Mantravadi M. O07, P053, P194
Millar S. P342
Lou G. P239
Mantuano M. P023
Miller K. P013, P034, P053, P194, P329
Lou Francés G.M. P045, P089
Maouch H. P240
Miller K.M. O29
Louraki M. P002
Marciulionytė D. O10
Miller M. P284
Lovell M. P284
Mara C. P126
Minamitani K. P103
Lowes L. P161
Marciulionyte D. O39
Minhas H. P275
Lu W. P315
Marcus C. P008
Minuto N. O40, P181, P285
Lucaccioni L. P281
Margabanthu G. P040, P150, P310
Mitrovic K. P038
Lucisano G. P052
Margetts R. P179, P316
Mladenov V. P259
Łuczak S. P318
Marigliano M. P005
Mlynarski W. O35, P058, P060, P104,
ski W. P216, P266
Łuczyn
Marosvari Barna E. P323
Ludvigsson J. O33, P008
Marquard J. O49, O50
Mochizuki M. P007, P296
Lugani F. O40
Marques O. P217
Mochizuki T. P103
Luís A. P237
Martinez-Badás I. P010
Mockeviciene G. P263
Lundquist K. P248
Martín-Nieto A. P291
Mohamed N. O32
Luo F. P315
Martins C. P301
Mohammadi Z. P251
Lushchyk M. P228
Martins S. P217
Mohanty R. P169
Luyckx K. P163, P166, P167, P196, P197,
Martins T. P108
Moisan M.-P. O21
Maruo Y. P292
Molinari C. O55, O56
Luzuriaga Tomás C. P094
Massa G. P131, P236, P287
Monaghan M.C. P121
Ly T. O03, O04
Mathews C. P185
Mongiardo A. P118
Ly T.T. O07
Mathieu C. O48, P020
Mönkemöller K. O18, O43
Mathieu M.-E. P091
Monteiro M. P170
Matsuura N. P296
Montes Suay F. P044
M
Matteoli M. P331
Montoya Castilla I. P344, P351
Maahs D. P146
Maurice S. O32
Moodambail A.R. P082
Maahs D.M. O07, O29, P013
Maximiliano M. O56
Moons P. P166, P196, P197, P333
Maccallini G. O55
Mayer-Davis E. INV8, P146
Moran A. P017
Macedoni M. O02, P290
Mayoral B. P291
Morandi A. P005
MacLeod C. P341, P353
Mayorov A. P107
Moreau B. O30
Madeo S. P078
Mazur A. P096, P157, P241
Moreno J.O. P014
Madiazaghan S. P041
Mazza C. O47, O48, P020
Moreno Macian F. P344, P351
Madsen M. P073, P235
Mazzoni S. P281
Moretti A. P105, P190
Madzio J. P060
Mbanya J.C. P308
Morgan N.G. O34
Maffeis C. P005
Mbuagbaw L. P221
Morin C. P223
Maffoni C. P115, P355
Mc Darby V. O24
Morrison K.M. P221
Maggana I. P346, P347
Mc Donnell C. P133
Mosaad E. P251
Maghnie M. P285
McCormick C. P342
ska E. P322
Moszczyn
Mahfouz A. P222
McElduff P. O57
Moszczynska E. P224
Mahnin S. P074
McKenna A.M. P159
Mota F. P237
Maier W. P160
Mehta S.N. P314
Mothojakan N.B. P082
Maiza J.C. P143
Meijer J. P174
Mouzaki K. P346, P347
Makaroff L. O61
Meissner T. P297
Mouzouni F.Z. P204
Malachowska B. P058, P060
Menang J.N. P307
Müther S. P070
P198, P333
P244, P300
172
AUTHOR INDEX
Mukai T. P103
Nock V. O49
Oto Y. P324
Mukherjee S. P303
Noiszewska K. P266
O’Toole N. O57
Mul D. O41, P009, P174, P246
Norgren S. P323
Oukrif L. P240
Muller I. O02, P309
Noronha R.M. P108
Overgaard Ingeholm I.M. P073
Muntean W. P279
Norris J. O13
Owais S.M.H. P348
Murakami N. P324
Northam E. INV13
Owens D.R. P147
Muralidhara Krishna C.S. P032, P106,
Northam E.A. O05
Ozen S. P083, P199
Novak D. P149
Ozkaya D. O48, P020
Muramatu L.H. P108
Novak M. P149, P258
Özkol M. P173
Murphy S. P161
Nóvoa Y. P158
Musha I. P007
Noyes K. O52
Mustonen N. O37
Noyes K.J. P012
P
Nuboer R. P332, P345
Paape D. O18
Nunes G. P301
Pacaud D. P070
Nylander C. P056
Padsalge M. P212
P348
N
Naceur M. P093, P320
Pagnini M. P052
Nadeau K. O27, P329
Palenzuela Revuelta I. P094
Nadig A. P206
O
Papagianni M. P142
Nagl K. P068
O Byrne H. P133
Papathanasiou A. P002
Nahar B. O64
O Neill A. P133
Papoutsis J. O05
Nahar J. P120
Obarcanin E. P270
Pappa K. P113
Nahar T. O64
Obermannova B. O38, P213
Parmar K. P294
Nahata L. P354
Obrynba K. P269
Parslow R. O10
Nakamura S. P103
O’Byrne H. P359
Parslow R.C. O15, P176
Narumi S. P061
O’Connell M.A. O05
Partsalaki I. O58
Nath V. P106, P348
O’Connell S. P335, P339
Passanisi S. P177, P220
Nathan B. P329
O’Connell S.M. O57
Passone C. P182, P230
Navardauskaite R. P263
Oestreicher K. O56
Patel F. O20, P294, P330
Nawrotek J. P096, P157, P241
Ogata T. P061, P100, P175
Patel N. P132
Nefs G. P054, P122, P361
Ogle G.D. O61, P090, P295
Patel P. P316
Neijens A.M.J. P352
O’Hickey E. P018
Patera I.P. P331
Nelson B. O22
Ohlsson A. P210
Patouni K. P037
Nelson H. P018
Oikarinen S. O36
Patterson C. O10
Nepom G. O45
Okajima M. P100
Paul E. O30
Neri A.S. P111
Okuno M. P061, P100
Peet A. O37
Nery M. P062
Oliveira J. P011
Pei Z. P315
Neu A. O10, P068
Olives J.-P. P223
Pelicand J. O19
Neylon O. P335, P339
Olsen B. P073
Peraud A. P234
Ng S.P.B. O53
Olsen P. P253
Pereira M.V. P170
Nguyen L. P054
Omar O. P222
Pereyra M. P042
Nguyen N. P209
Onda Y. P175
Perez P. O21
Nhar N. P120
Onur E. P173
Pérez Gordón J. P094
Ni J. P315
Oort F. P361
Perez Marin M. P344, P351
Niar S. P093, P320
Op ’t Eyndt A. P131
Perez-Nieves M. O44, P014
Nicolucci A. P052
Oralewska B. P225
Pession A. P023
Niechcial E. P118, P298
Orchard T. O61
Peterkova V. P107
Niel K. P349
O’Regan M. P159
Peters C. P087, P179, P250, P316
Nieuwesteeg A. P122
Orhan F. P183
Petitti A. P118
Nilsson J. O12
O’Riordan S. O47, P335, P339
Petraitiene I. P263
Nimri R. O02, P309
Oris L. P166, P167, P196, P197, P333
Petrelli A. P097
Nivot-Adamiak S. P079
Orlando Contreras J. P221
Petrova C. P259
Njabou Katte J.C. P027
Örtkvist E. O60
Petruzelkova L. P213
Njimogu S. P307
Örtqvist E. P008, P056, P080
Pham-Short A. O59, P195
Njølstad P.R. O16
Osman M.A. P082
Phatak R. P169
Noble J. P090
Osmond C. O64
Philip M. P309
173
AUTHOR INDEX
Phillip M. O02, O48, P020
Q
Riquetto A.D.C. P062
Piccin B. P003, P077
Quezada R. O19
Robling M. P161
Piccini B. P111
Quinn M. O22
Rocha A. P138
Piché C.A. P129, P130
Quinteiro S. P158
Roche E. O10, P159
Pichierri J. P087, P264, P271
ska I. P096, P157, P241
Rogozin
Pickova K. P213
Rojas Y. P193
Piechowiak K. P065, P125
R
Rojnic Putarek N. O10, P258
Piekutowska-Abramczuk D. P318
Racault A.-S. O41
Roman R. P042, P188
Pierce J. P127
Radcliffe W. P341, P353
Romanisio G. P181
Pietropaolo M. P302
Radji S. P091
Romero P. P138
Pietrowska K. P060
Ragab D. O32
Roncuzzi F. P078
Pigeon Kerchiche P. P119
Raile K. O31, P070, P095
Ros P. P010
Pihoker C. O51
Rajiv K. P032
Rosenbauer J. O10, P068, P070, P081,
Pilgaard K. P073, P235
Rakhimova G.N. P295
Pillay A. P316
Ramadan E. P201
Ross J.L. P127
Pillay K. P155
Ramaiya K. O61
Rothe U. O10
Pinckney A. O45
Ramaker K. P128
Rottembourg D. O30
Pinhas-Hamiel O. P084
Rami-Merhar B. O10, O43, P013, P068,
Rotteveel J. P152, P332, P345
Pinheiro C. P182
P081, P144, P154
P123, P160, P203, P297
Ruas F. P237
Pintaudi B. P052
Ramirez C. P042
Rubic P. P279
Piona C. P005
Ramotowska A. P065, P096, P157, P241
Rubio R. P239
Piotrowicz M. O35
Ramsey M. P163
Rubio Abella M.R. P045, P089
Pistorio A. P285
Ranasinghe A. P001, P059
Rudaizky D. P341
Plager P. P017
Rangaraj U. P041, P106
Rudaizsky D. P353
Rao G.S. P106, P348
Rufiange M. P129
Rao V.A. P032, P041, P106, P348
Ruiz A. P010
Rapini N. P097
Ruiz S. P188
Rassart J. P163
Russell M.A. O34
Raviteja K. P311
Russell W. P132
Raymond J. O42
Russo C. O40
Raymond J.K. O51
Ryaboshtan A. P295
Razanskaite-Virbickiene D. O39
Rychlik K. P055
Razum O. P095
Rydén P. O60
Reddy L. P032, P041, P106, P348
Ryder K.J. P159
Reed K. P117
Rydin A. P248
Plener P. P139
Polat R. P183, P233
Polkowska A. P300
Pontremoli R. P285
Popovic J. P016
Pörksen S. P235
Poschet K. P162
Potts L. P250, P264, P271
Pötzsch S. P070
Pouwer F. P054, P122, P361
Pozas Mariscal S. P094
Pozgaj Sepec M. P016, P218
Praet T. P276
Prashar A. P243
Predieri B. P052, P078, P186, P281
Pretti S. P140
Prikken S. P166, P167, P196
Prinz N. O29, O43, P095
Prochazkova D. P109
Pruhova S. O38
Pruszkowska P. P058
Reed-Screen J. O17
Regensteiner J. O27
Reimer K. O14, P156
S
Reims A. O01
Sabbion A. P005
Reiner B.J. P130
Saboo B. O20, P294, P330
Reiter P. P189
Sachdeva N. P311
Remus K. P309, P313
Sadeghirad B. P221
Reneo I.A. P014
Saiyed M. O20, P294, P330
Reshma B. P041, P106, P348
Sakr M. O54
Resta M. P165
Sakuta R. P324
Retlich S. O50
Salem D. O25
Pryce R. O17
Reusch J. O27
Salem M. O25, P317
Pulgaron E. P349
Reviriego J. O44, P014
Salem N. P358
Pulungan A. P028
Rewers A. P099
Salina A. O40, P181
Pundziute Lyckå A. P066
Rewers M. O13, P099
Salles J.E.N. P170
Purcell L. P017
Reynaert N. P276
Salvatoni A. P105, P115, P190, P355
Puri S. P343
Riaño-Galán I. P291
Salzano G. P177
Pyle L. O27
Richardsson S.J. O34
Samardzic M. O10
Pyrżak B. P096, P157, P241
Rio A. P143
Samudra K. P212
174
Samuelsson U. O09, O12, P008, P066,
AUTHOR INDEX
Sharma D. P303
Standiford D. P146
Sharma V. P116, P265
Stankiewicz W. P298
Sanchez J. P349
Shen T. P129
Stankute I. O39
Sanders C. P340
Sherif E. P286
Steck A. O13
Sanna A. P140
Shin J. O03
Steigleder-Schweiger C. P095
Santana A. P158
Shinkaku H. P261
Stein R. P284
Santana L.S. P062
Shiraishi T. P292
Steinberger D. P178
Santos Silva R. P011
Shukla R. P026
Stene L.C. O16
Sanyal S. P306
Shukla S. P026
Stephenson T. P013, P086
Sap S. P308, P319
Sian E. P072
Stipancic G. P218
Sapin H. O44
Sicard É. P129
Stoicheva R. P252
Sarda A. O62
Siddiqui M. P076
Stompór J. P015
Särnblad S. P066, P137
Siddiqui S. P212
Storr E. P087, P264, P271
Sarzi Puttini P. O28
Sidibe A.T. P090
Streisand R. P121
Sasaki N. P296
Sieniawska J. P096, P157, P241
Strutt B. P284
Savel H. O21
Sierra J. P221
Suárez-Gutiérrez L. P291
Savoldelli R. P182, P230
Silink M. P090
Suga S. P100
Savova R. P259, P321
Siljander H. O37
Sugihara S. P007, P061, P100, P103,
Sayed A. P280
Simell O. O36
Sayed Kamel A. P280
Simmons J. O22, P329
Sullivan C. P209
Scaramuzza A. O28, P118
Simons G. O49
Sumnik Z. O38
Schampers D. O23
Singleton S. P018, P085
Sun C. P315
Scheerer M.F. P328
Sinha S. P265
Sundaram P. P272
Schettler K.F. P234
Sivuda V. P228
Sundberg F. O01
Schiaffini R. P220, P331
Skala-Zamorowska E. P244
Sunitha B. P348
Schiaffino M.C. P181
Skotakova J. P109
Sunni M. P017
Schifano E. P127
Skowronska B. P118, P298
Suo C. P245
Schmidt H. P234
Skrami E. P334
Suppan E. P279
Schober E. P144
Skrivarhaug T. O10, O16, P013, P148, P215
Sutherland J. O14, P156
Schoenle E. O10
Slavcheva O. P321
Suzuki J. P100
Schulze-Neick I. P234
Slegtenhorst S. P253
Svensson A.-M. P013
Schuster T. O05
Slover R. O03, O04, P209
Svensson J. INV9, O10, P013, P073,
Schwab K.O. P283
Smart C.E. O57
P215, P235
Schwandt A. O47, P081, P203
Śmigiel R. O35
Svetlova G. P107
Schwantzer G. P279
Smit A. P074
Swenne I. P056
Schwartz D. P050, P193
Smith A. P145
Swiercz A. P219, P224
Schwitzgebel V. O39
Smith G. O46
Szadkowska A. O35, P058
Seagrave V. P022
Smith G.J. P153
Szalecki M. P219, P224, P096, P157,
Sedlacek P. O38
Snoek F. P332, P345
Seeley B. P141
Sobngwi E. P027, P308
Szyda K. P015
Seid M. P146
Söderström U. P088, P254
Szylaj O. O08
Semedo P. P289
Soenens B. P167
ska K. P318
Szyman
Semple R.K. P012
Soesanti F. P028
Szynkarczuk A. P216
Senniappan S. P180
Sokołowska M. P015
Szypowska A. P065, P096, P125, P157,
Sepúlveda C. P138
Soliman A. P251
Shafat A. O57
Soltesz G. O10
Shah G.S. P306
Songini M. P140
Shah K. P076
Soppe C. O45
T
Shah L. P306
Southern K. P180
Tabor A. O08
Shah S. P212
Spaggiari V. P078
Taccetti G. P111
Shah T. P076
Spehar Uroic A. P258
Tachikawa E. P103
Shaha S.K. O64
Speight J. P122
Tahir B. P257
Shaikh S. P076
Spiliotis B.E. O58
Tajima N. P175
Shalaby S. P278
Srikanta S. P032, P041, P106, P348
Takubo N. P100
Sharda A. P032, P041, P106, P348
Stahl-Pehe A. P123, P160, P297
Tallone R. O40
P088, P215, P254
P175, P296
P225, P241
P229, P241, P288, P318
175
AUTHOR INDEX
Talvard M. P223
Tzifi F. P067, P092
Vigouroux C. INV2
Tamborlane W. O03, O04, O50, P034,
Tzitzika G. P347
Villoro R. O44, P014
P053, P194
Virgone A. P181
Tansey M. P329
Virmani A. P343
Tapia J. O19
U
Vivanco M. P138
Tarazona I. P344, P351
Umar F. P251
Vogel C. P081
Tasevska A. P327
Upadhyaya K.C. P303
Vogel P. P283
Tauschmann M. P047
Urakami T. P061, P100, P296
Volkening L.K. P314
Tavira B. O33
Ushijima K. P061
Von Sengbusch S. O18, P019, P293
Tayyeb S. P120
Voutetakis A. P067
Teles M.G. P062
Vries, de M. O41
Ten Kate Q.J. P009, P246
V
Vukovic R. P038
Tezier A. P119
Vainilovich Y. P228
Vuleva N. P252
Tezlaff W. O56
Valaulikar R. P206
Thabit H. P047
Valdivia N. P188
Thalange N. P189
Valera P. P140
W
Tham E. O29
Vamvakis A. P142
Wadhwa N. O06, P026, P076, P212
Theis F. O13
Van Aken S. O23, P336
Wadien T. P313
Thomas J. O17, P146
Van Albada M. P074
Wadwa R.P. P209
Thomas J.F. P209
Van Alfen-van der Velden J. P174
Wägner A. P158
Thomas K. O17
Van Broeck N. P167, P198
Wahlberg J. O33
Thornton H. P022
Van Casteren V. P162
Wajda-Cuszlag M. P225
Thorsson A. P215
Van Cauwenberge G. O23
Waldhör T. P154
Thyagaraj B.D. P032, P041, P106
Van Gampelaere C. O23, P337
Waldman B. P295
Tillman M. P128
Van Herzeele C. P336
Waldron S. O48, P020
Tillmann V. O37
Van Hoecke E. O23, P336
Walenkamp M.-J. P152
Timpanaro T. P331
Van Liefferinge D. P198
Wang Y. P039
Timpanaro T.A. P220
Van Lochem E. P174
Warner J. O29, P013
Tindberg Y. P056
Van Mil E. P122, P361
Wasag D. O11
Tisch E. P084
Van Name M. P053, P194
Wasedar J.P. P282
Titovich E. P211
Van Roon A. P074
Wasserfall C. P090
Todorovic S. P038
Van Setten P. P174
Wasserman R. P050, P193
Tomasselli F. P005
Van Vreckem R. P162
Watling R. P180
Toni S. P003, P077, P105, P111
Vande Kerckhove K. P276
Wawrusiewicz-Kurylonek N. P104, P300
Torbjörnsdotter T. P056, P323
Vandoorne E. P276
Wee P.H. O53
Touhami M. P093, P320
Vanlandingham D. P269
Weets I. O10, P166, P167, P196,
Townson J. P161
Vargas Trujillo M. P016
Trettene A. P105, P115, P190,
Vasanwala R.F. O53
Weill J. O50
Vasilakis I.-A. P067, P092
Weinhandl G. P279
Triantafyllou P. P113, P165
Vautier V. O21
Weinzimer S. O03, O04
Tridjaja B. P028
Vazeou A. P037
Weissberg-Benchell J. P055, P124
Trojanowska I. P225
Vazquez L.A. P014
Weissenbacher C. P234
Trzonkowski P. O35
Vázquez L.A. O44
Welsh J. O04
Tsai M.-C. P049
Vedwal A.K. P343
Wendenburg J. O18
Tsalikian E. P329
Veeze H. O41
Wersäll J.H. P080
Tsanakas I. P142
Veeze H.J. P009, P246
Wessels M. P174
Tsang W.Y. P325
Veijola R. O36
Westra H. P074
Tsentidis C. P002
Velthuis A. P174
Wheat S. P340
Tsiroukidou K. P142
Ventrici C. P177
White B. P264, P271
Tsitsika A. P338
Verkauskiene R. O39, P263
Whitehouse A. P053, P194
Tully C. P121
Vermeulen F. P071
Whittemore R. P132
Tursunov D. P057
Verrina E. P285
Wiebe D. P163
Tuzova A. P228
Verschueren M. P197
Wieczorek P. P241, P244
Tzavara C. P338
Vervoort T. P337
Wierzba J. O35
Tziaferi V. P272
Vicinanza A. P102
Wijnands A. P131, P287
P355
P197, P333
176
Wildhardt G. P178
AUTHOR INDEX
Wysocka-Mincewicz M. P096, P157, P224,
Yu L. P099
Wilinska M.E. P047
P241, P322
Willemsen R. P145
Wysocki T. P127
Yver A. O49
Williams D. P161
X
Z
Williams M.G. P018
Xatzipsalti M. P037
Zabeen B. P090, P120
Williams P. P001
Xi L. P315
Zani F. P052
Yuen Y.P.L. P325
Willi S. O22
Zavattoni M. P115, P355
Williams R. P253
Williamson S. P275
Y
czyk B. P125
Zdun
Wilson K. P018, P245
Yagnik D. P026
Zeevaert R. P131, P236, P287
Wilson K.R.H.M. P253
Yamada A.C. P170
Zemiri F.Z. P240
Winkler C. O13
Yaneva N. P238
Zennaki A. P093, P320
Winterdijk P. P054, P122, P332, P345
Yang L. P315
Zhang M. P315
Witsch M. O47, P070, P095
Yaron M. P084
Zhang M.X. P129, P130
Witters P. P071
Yau H.C. P325
Zhang S. P129, P130
Wong W.C. P325
Yaylı S. P233
Zhao Z. P315
Wong W.K.G. P325
Ye R. P315
Zheng Z. P315
Wright N. P039
Yeste D. P110
Ziegler A.-G. O13
Wroblewski P. P058
Yokota I. P061, P100, P103, P296
Ziegler R. P019, P033, P293
Wu B. P315
Yokoya S. P175
Zielinski M. O35
Wu J. O49
Yokoyama T. P175
Zioutas M. P023
Wu T. P284
Yoshida E. P292
Zucchini S. P023, P186
Wyka K. O35, P058, P060
Youssef O. P286
Wysocka M. P225
Yu J. P255
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