Survey of Australian general paediatricians regarding insulin initiation practices in children with new onset of type 1 diabetes.

AIM: Australian and New Zealand (NZ) paediatric endocrinologists' and NZ general paediatricians' insulin initiation strategies for children with type 1 diabetes (T1D) was recently described. The aim of this study was to document the insulin initiation practices of Australian general paediatricians in newly diagnosed children with T1D. METHODS: An online survey was sent to Australian general paediatricians identified through the Australian Paediatric Society diabetes database. RESULTS: Twenty four general paediatricians participated on behalf of their Australian regional and metropolitan diabetes units managing 2059 patients. The diabetes units averaged 86 patients and all practices were multidisciplinary models of care. Intensive insulin therapy regimens were initiated at diagnosis for children age 2-10 years by 93% respondents compared with 73% Australian endocrinologists, 17% NZ endocrinologists and 36% NZ general paediatricians. Carbohydrate counting as part of flexible bolus dosing was usual practice for 83% of respondents, which was substantially more than Australian endocrinologists (63%), NZ endocrinologists (64%) and NZ general paediatricians (33%). CONCLUSION: Almost all Australian general paediatricians who completed the survey initiate intensive insulin therapy regimes with carbohydrate counting in newly diagnosed children with T1D, consistent with the 2018 evidence-based recommendations of the International Society of Pediatric and Adolescent Diabetes. A substantial proportion of children with T1D within Australia are managed by general paediatricians who tend to align with international peak body guidelines.

Glycemic Outcome Associated With Insulin Pump and Glucose Sensor Use in Children and Adolescents With Type 1 Diabetes. Data From the International Pediatric Registry SWEET.

OBJECTIVE: Insulin delivery methods, glucose-monitoring modalities, and related outcomes were examined in a large, international, diverse cohort of children and adolescents with type 1 diabetes from the Better Control in Pediatric and Adolescent Diabetes: Working to Create Centers of Reference (SWEET) -Registry. RESEARCH DESIGN AND METHODS: Participants with type 1 diabetes of ≥1 year, aged ≤18 years, and who had documented pump or sensor usage during the period August 2017-July 2019 were stratified into four categories: injections-no sensor (referent); injections + sensor; pump-no sensor; and pump + sensor. HbA1c and proportion of patients with diabetic ketoacidosis (DKA) or severe hypoglycemia (SH) were analyzed; linear and logistic regression models adjusted for demographics, region, and gross domestic product per capita were applied. RESULTS: Data of 25,654 participants were analyzed. The proportions of participants (adjusted HbA1c data) by study group were as follows: injections-no sensor group, 37.44% (8.72; 95% CI 8.68-8.75); injections + sensor group, 14.98% (8.30; 95% CI 8.25-8.35); pump-no sensor group, 17.22% (8.07; 95% CI 8.03-8.12); and pump + sensor group, 30.35% (7.81; 95% CI 7.77-7.84). HbA1c was lower in all categories of participants who used a pump and/or sensor compared with the injections-no sensor treatment method (P < 0.001). The proportion of DKA episodes was lower in participants in the pump + sensor (1.98%; 95% CI 1.64-2.48; P < 0.001) and the pump-no sensor (2.02%; 95% CI 1.64-2.48; P < 0.05) groups when compared with those in the injections-no sensor group (2.91%; 95% CI 2.59-3.31). The proportion of participants experiencing SH was lower in pump-no sensor group (1.10%; 95% CI 0.85-1.43; P < 0.001) but higher in the injections + sensor group (4.25%; 95% CI 3.65-4.95; P < 0.001) compared with the injections-no sensor group (2.35%; 95% CI 2.04-2.71). CONCLUSIONS: Lower HbA1c and fewer DKA episodes were observed in participants using either a pump or continuous glucose monitoring (CGM) or both. Pump use was associated with a lower rate of SH. Across SWEET centers, use of pumps and CGM is increasing. The concomitant use of pump and CGM was associated with an additive benefit.

Bubble formation occurs in insulin pumps in response to changes in ambient temperature and atmospheric pressure but not as a result of vibration.

INTRODUCTION: Bubble formation in insulin pump giving sets is a common problem. We studied change in temperature, change in atmospheric pressure, and vibration as potential mechanisms of bubble formation. METHODS: 5 Animas 2020 pumps with 2 mL cartridges and Inset II infusion systems, 5 Medtronic Paradigm pumps with 1.8 mL cartridge and Quickset and 3 Roche Accu-chek pumps with 3.15 mL cartridges were used. Temperature study: insulin pumps were exposed to a temperature change from 4°C to 37°C. Pressure study: insulin pumps were taken to an altitude of 300 m. Vibration study: insulin pumps were vigorously shaken. All were observed for bubble formation. RESULTS: Bubble formation was observed with changes in temperature and atmospheric pressure. Bubble formation did not occur with vibration. DISCUSSION: Changes in insulin temperature and atmospheric pressure are common and may result in bubble formation. Vibration may distribute bubbles but does not cause bubble formation.

Changes in altitude cause unintended insulin delivery from insulin pumps: mechanisms and implications.

OBJECTIVE: Children and adults with type 1 diabetes who receive insulin pump therapy have reported hypoglycemia during air travel. We studied the effects of atmospheric pressure on insulin pump delivery. RESEARCH DESIGN AND METHODS: Ten insulin pumps were connected to capillary tubes. The effects of changes in ambient pressure on insulin delivery, bubble formation, bubble size, and cartridge plunger movement were analyzed. RESULTS: During a flight (200 mmHg pressure decrease), excess insulin delivery of 0.623% of the cartridge volume occurred (P < 0.001, Student t test). In hypobaric chamber studies, bubbles developed in the insulin when the pressure decreased and displaced the insulin out of the cartridge. Pre-existing bubbles changed in size consistent with Boyle law. Cartridge plunger movement did not occur in normal flight conditions but did occur when catastrophic plane depressurization was mimicked. CONCLUSIONS: Atmospheric pressure reduction causes predictable, unintended insulin delivery in pumps by bubble formation and expansion of existing bubbles.

A 'radical' new rural model for pediatric diabetes care.

OBJECTIVE: The purpose of the study was to evaluate a new rural Australian multidisciplinary model of pediatric diabetes care. METHODS: In 2007, in response to insurmountable obstructions to establish an effective multidisciplinary team within the public health system, an Australian rural pediatric practice created a private multidisciplinary diabetes care model. The 'Rural Australian Diabetes -Inspiring Control Activity & Lifestyle' model -'RADICAL'-comprised a locally based, co-located core team of general pediatrician, diabetes educator, and mental health nurse. Regular diabetes clinics were established, including team meetings where each individual patient was discussed. Therapy included proactive child and family emotional support and promotion of insulin regimes that aimed to match patient lifestyle, especially insulin pump therapy. By 2009, 56 of 61 children and adolescents with type 1 diabetes across a broad regional area had access to the model of care. The model was evaluated in terms of metabolic control, patient satisfaction, and quality of life. RESULTS: Since the RADICAL model was established, the average HbA1c has fallen from mean 9.6% +/- 1.81 (median 9.7%) in 2006 to mean 8.1% +/- 1.25 (median 7.9%) in 2009 (p < 0.001). Patient satisfaction with the model was overwhelming. The previously demonstrated reduced quality of life of Australian rural diabetic youth compared with urban diabetic youth was eliminated. CONCLUSION: Multidisciplinary child diabetes care can be successfully achieved in rural settings using local resources with results comparable to international tertiary multidisciplinary diabetes units.

Simple, robust strategies for generating DNA-directed RNA interference constructs.

We describe two complementary strategies for preparing DNA-directed RNA interference (ddRNAi) constructs designed to express hpRNA. The first, oligonucleotide assembly (OA), uses a very simple annealing protocol to combine up to 20 short nucleotides. These are then cloned into appropriately designed restriction sites in expression vectors. OA can be used to prepare simple hairpin (hp)-expressing constructs, but we prefer to use the approach to generate longer constructs. The second strategy, long-range cloning (LRC), uses a novel adaptation of long-range PCR protocols. For LRC, entire vectors are amplified with primers that serve to introduce short sequences into plasmids at defined anchor sites during PCR. The LCR strategy has proven highly reliable in our hands for generating simple ddRNAi constructs. Moreover, LCR is likely to prove useful in many situations in which conventional cloning strategies might prove problematic. In combination, OA and LRC can greatly simplify the design and generation of many expression constructs, including constructs for ddRNAi.