Evaluation of 1,5-anhydroglucitol, hemoglobin A1c, and glucose levels in youth and young adults with type 1 diabetes and healthy controls.

BACKGROUND AND OBJECTIVE: Serum 1,5-anhydroglucitol (1,5-AG) is a marker of hyperglycemic excursions in adults with diabetes and hemoglobin A1c (HbA1c) < 8%. We compared 1,5-AG levels among youth and young adults with and without type 1 diabetes (T1D) and investigated the utility of 1,5-AG in the assessment of glycemic status in pediatric T1D. METHODS: We compared 1,5-AG, HbA1c, and plasma glucose levels in 138 patients with T1D (duration ≥1 yr) and 136 healthy controls, aged 10-30 yr. Within each group, we investigated associations between 1,5-AG and clinical characteristics, HbA1c and random plasma glucose. For patients with T1D, 1,5-AG was further analyzed according to HbA1c strata: <8, 8-9, and >9%. RESULTS: Compared to controls, patients with T1D had higher HbA1c (8.5 ± 1.6 vs. 5.1 ± 0.4%, p < 0.0001), lower 1,5-AG (4.0 ± 2.0 vs. 24.7 ± 6.4 µg/mL, p < 0.0001), and higher glucose (11.1 ± 5.2 vs. 5.1 ± 0.9 mmol/L, p < 0.0001). Males had higher 1,5-AG than females within patients (4.5 ± 2.3 vs. 3.4 ± 1.6 µg/mL, p = 0.003) and controls (26.0 ± 6.6 vs. 23.5 ± 6.0 µg/mL, p = 0.02). 1,5-AG was not correlated with glucose in either group. 1,5-AG was significantly correlated to HbA1c in patients, but not controls. For patients with HbA1c < 8%, 1,5-AG demonstrated the widest range and was not predicted by HbA1c; 1,5-AG levels were narrowly distributed among patients with HbA1c ≥ 8%. CONCLUSIONS: Youth and young adults with T1D demonstrate similar 1,5-AG levels which are distinct from controls. 1,5-AG assessment may provide unique information beyond that provided by HbA1c in the mid-term assessment of glycemic control in young patients with T1D and HbA1c < 8%.

Significant vitamin D deficiency in youth with type 1 diabetes mellitus.

Serum 25-hydroxyvitamin D was measured in 128 youth with type 1 diabetes mellitus. Less than 25% of the patients were vitamin D sufficient. Because individuals with type 1 diabetes mellitus possess multiple risk factors for skeletal fragility, ensuring vitamin D sufficiency throughout childhood and adolescence in this population seems especially warranted.

Temporal trends in the treatment of pediatric type 1 diabetes and impact on acute outcomes.

OBJECTIVE: To evaluate temporal trends in pediatric type 1 diabetes (T1DM) management and resultant effects on outcomes. STUDY DESIGN: Two pediatric T1DM cohorts were followed prospectively for 2 years and compared; Cohort 1 (N = 299) was enrolled in 1997 and Cohort 2 (N = 152) was enrolled in 2002. In both cohorts, eligible participants were identified and sequentially approached at regularly scheduled clinic visits until the target number of participants was reached. Main outcome measures were hemoglobin A1c (A1c), body mass index Z score (Z-BMI), and incidence rate (IR; per 100 patient-years) of hypoglycemia, hospitalizations, and emergency room (ER) visits. RESULTS: At baseline, Cohort 2 monitored blood glucose more frequently than Cohort 1 (> or = 4 times/day: 72% vs 39%, P < .001) and was prescribed more intensive therapy than Cohort 1 (> or = 3 injections/day or pump: 85% vs 65%, P < .001). A1c was lower in Cohort 2 than Cohort 1 at baseline (8.4% vs 8.7%, P = .03) and study's end (8.7% vs 9.0%, P = .04). The cohorts did not differ in Z-BMI (0.83 vs 0.79, P = .57) or IR of hospitalizations (11.2 vs 12.9, P = .38). Cohort 2 had lower IR of total severe hypoglycemic events (29.4 vs 55.4, P < .001) and ER visits (22.0 vs 29.3, P = .02). CONCLUSIONS: T1DM management intensified during the 5 years between cohorts and was accompanied by improved A1c and stable Z-BMI. Along with improved control, IR of severe hypoglycemia and ER visits decreased by almost 50% and 25%, respectively.

Durability of insulin pump use in pediatric patients with type 1 diabetes.

OBJECTIVE: To examine longitudinal outcomes, rate of and reasons for discontinuation, and predictors of insulin pump success in a cohort of youth initiating pump therapy. RESEARCH DESIGN AND METHODS: We followed a cohort of youth with type 1 diabetes (n = 161) starting the pump between 1998 and 2001 and recorded natural history of treatment. RESULTS: At pump start, patients (71% female) had a mean age of 14.1 +/- 3.7 years, diabetes duration of 7.1 +/- 4.0 years, daily blood glucose monitoring (BGM) frequency of 4.0 +/- 1.2, a daily insulin dose of 1.0 +/- 0.3 units/kg, and an HbA(1c) (A1C) of 8.4 +/- 1.4%. After 1 year, mean daily BGM frequency was 4.5 +/- 1.7, daily insulin dose was 0.8 +/- 0.2 units/kg, and A1C was 8.1 +/- 1.3% (all baseline versus 1-year data, P < 0.01). As of 2005, 29 patients (18%) had resumed injection therapy at a mean age of 17.0 +/- 2.9 years after a mean duration of pump use of 2.1 +/- 1.3 years. BGM frequency at baseline and at 1 year was significantly lower in the patients who resumed injection therapy (P < 0.02). In addition, patients who remained on the pump had lower A1C than those who resumed injection therapy at both 1 year (P = 0.04) and at the most recent clinic visit (P = 0.01). CONCLUSIONS: After an average of 3.8 years, >80% of pediatric patients maintained pump therapy with preservation of baseline A1C. Patients discontinuing the pump were less adherent and did not achieve equivalent glycemic benefit compared with continued users; these patients require ongoing support aimed at improving adherence and outcomes.

Hypothyroidism in a breast-fed preterm infant resulting from maternal topical iodine exposure.

Hypothyroidism developed in a preterm infant, whose initial screening thyroid function test results were normal, at 2 weeks of life. The infant's mother was packing her Caesarian incision with iodine soaked gauze, resulting in a markedly increased breast milk iodine concentration. Treatment with oral L-thyroxine normalized thyroid function tests.

Hypopituitarism in PHACES Association.

The association consisting of posterior fossal malformations, cervicofacial, hemangiomas, arterial anomalies, cardiac defects, eye anomalies, and sternal clefting, or supraumbilical raphe, refers to the occurrence of congenital structural and vascular anomalies in the presence of a facial hemangioma. We report a patient with this association, growth retardation, and developmental delay who was found to have a partially empty sella turcica, central hypothyroidism, and growth hormone deficiency. Endocrinologic evaluation should be considered in any infant with this association.

Complications and comorbidities of type 2 diabetes.

A number of children and adolescents are at risk for complications and comorbidities of type 2 diabetes, prediabetes, or metabolic syndrome. These complications and comorbidities are likely to present significant personal burdens and societal costs. The pediatrician should be aware of screening and interventions to lessen the effect of these risks on their patients. Societal-wide lifestyle changes are needed desperately to reduce the prevalence of these largely preventable diseases.

Sexual development in a 21 month-old boy caused by testosterone contamination of a topical hydrocortisone cream.

Sexual development, including enlargement of the penis, growth acceleration, and growth of pubic hair without an increase in the size of his testes, occurred in a 21 month-old boy over a period of several months. The sexual development was caused by dermal exposure to a hydrocortisone cream, prescribed for eczema, which was contaminated by testosterone. After use of the cream was discontinued, sexual development ceased.

Reducing acute adverse outcomes in youths with type 1 diabetes: a randomized, controlled trial.

OBJECTIVE: Both acute and chronic complications of diabetes account for a disproportionate percentage of US health care expenditures. Despite improvements in diabetes care, the incidence of adverse events in children with type 1 diabetes remains high, particularly for youths with poor glycemic control. Cost-effective intervention programs designed to reduce complications are needed. This study evaluated a low-intensity, nonmedical intervention using a case manager (called a "Care Ambassador"), with and without the supplementation of psychoeducational modules, designed to monitor and encourage routine diabetes care visits to reduce short-term adverse outcomes and improve glycemic control in youths with type 1 diabetes. METHODS: We performed a 2-year prospective, randomized clinical trial in 299 youths with type 1 diabetes, aged 7 to 16 years, comparing 3 treatment programs (Care Ambassador [CA], Care Ambassador plus psychoeducational modules [CA+], and standard multidisciplinary diabetes care [SC]). The study was conducted in a large metropolitan US city from April 1997 through April 2000. Number of medical visits, frequency of hypoglycemic events, hospital/emergency department (ED) utilization, and glycosylated hemoglobin A1c were assessed during follow-up. RESULTS: During the 2-year study period, both the CA and CA+ groups had significantly more routine visits (mean [standard deviation]: 7.3 [2.06] and 7.5 [2.02], respectively) compared with the SC group (5.4 [2.62]). The CA+ intervention group had significantly reduced rates of short-term adverse outcomes compared with the other 2 groups; 25% fewer total hypoglycemic events, 60% fewer severe hypoglycemic events, and 40% fewer hospitalizations and ED visits. "High-risk" youths in the CA+ group (baseline glycosylated hemoglobin A1c > or =8.7%) were 3.4-fold (1.57-7.41) more likely to improve their glycemic control compared with those at high risk in the other 2 groups. CONCLUSIONS: For youths with type 1 diabetes, the CA and CA+ interventions increased visit frequency. Youths in the CA+ intervention had reduced rates of hypoglycemia and hospital/ED utilization with estimated annual cost savings of 80 000 dollars to 90 000 dollars. The CA+ intervention compared with the other 2 groups improved glycemic control in "high-risk" youths. Nonmedical case management incorporating psychoeducational modules seems to be a cost-effective approach to improving outcomes in youths with diabetes.