Targets and teamwork: Understanding differences in pediatric diabetes centers treatment outcomes.

OBJECTIVE: The reason for center differences in metabolic control of childhood diabetes is still unknown. We sought to determine to what extent the targets, expectations, and goals that diabetes care professionals have for their patients is a determinant of center differences in metabolic outcomes. RESEARCH DESIGN AND METHODS: Children, under the age of 11 with type 1 diabetes and their parents treated at the study centers participated. Clinical, medical, and demographic data were obtained, along with blood sample for centralized assay. Parents and all members of the diabetes care team completed questionnaires on treatment targets for hemoglobin A1c (HbA1c) and recommended frequency of blood glucose monitoring. RESULTS: Totally 1113 (53% male) children (mean age 8.0 ± 2.1 years) from 18 centers in 17 countries, along with parents and 113 health-care professionals, participated. There were substantial differences in mean HbA1c between centers ranging from 7.3 ± 0.8% (53 mmol/mol ± 8.7) to 8.9 ± 1.1% (74 mmol/mol ± 12.0). Centers with lower mean HbA1c had (1) parents who reported lower targets for their children, (2) health-care professionals that reported lower targets and more frequent testing, and (3) teams with less disagreement about recommended targets. Multiple regression analysis indicated that teams reporting higher HbA1c targets and more target disagreement had parents reporting higher treatment targets. This seemed to partially account for center differences in Hb1Ac. CONCLUSIONS: The diabetes care teams' cohesiveness and perspectives on treatment targets, expectations, and recommendations have an influence on parental targets, contributing to the differences in pediatric diabetes center outcomes.

Children with type 1-diabetes from ethnic minorities: vulnerable patients needing a tailored medical support.

BACKGROUND AND AIM: Newly diagnosed children with type 1 diabetes from ethnic minorities are a growing presence in outpatient pediatric clinics, and are reported as a group at risk of poor metabolic control. In the present study we investigated the barriers affecting chances of minority diabetic children to achieve the same metabolic targets of native peers with type 1 diabetes. MATERIALS AND METHODS: The study investigated 35 children from ethnic minorities (group 1) admitted to the Children University Hospital of Parma, Italy, from 1st January 2000 to December 31st, 2011, and data concerning current age, gender, ethnicity, age at diabetes onset, HbA1c, DKA severity degree at diagnosis, insulin therapy, annual number of out patient clinic visits, number of admissions for acute decompensation, and treatment cost. A short questionnaire on background, family situation, difficulties in diabetes monitoring, and outpatient clinic procedures completed the study. The results were compared with data collected from 30 matched native peers (group 2). RESULTS: Mean HbA1c level at admittance was higher in Group 1 (11.8 +/- 1.0%) than in Group 2 (9.0 +/- 2.2%; p=0.000). The differences were confirmed when HbAlc mean cumulative values (8.6 +/- 2.1 vs 7.6 +/- 1.1; p=0.022) were calculated. Group 1 children at admission showed poorer metabolic conditions and longer stay at hospital (16 +/- 3 days) than Group 2 patients (8 +/- 2 days; p=0.000). The total costs for DKA treatment and family education resulted higher in group 1 (+54%) than in group 2 patients. Discontinuous capillary blood glucose monitoring and outpatient clinic visits missed were more frequent in Group 1 than in group 2 patients. Thirteen patients in group 1 needed a re-admittance to hospital because of a hypoglycemia (5 cases) or a hyperglycemia (8 cases). The same episodes were not recorded in group 2 patients. Most of parents expressed the wish to be supported with educational material in their own language. CONCLUSIONS: Children with TDM belonging to an ethnic minority had poorer metabolic control compared with native patients. This results from several cultural, educational, economic deficiencies which influence their family life and probably reduced their chances to obtain a better control.

Sulfonylurea-responsive neonatal diabetes mellitus diagnosed through molecular genetics in two children and in one adult after a long period of insulin treatment.

A permanent neonatal diabetes mellitus has finally been diagnosed through molecular genetics in two children and one adult after 9 to 35 years of uninterrupted insulin treatment. These patients developed diabetes before 6 months of age and were autoantibody negative. In one boy, a mutation in the KCNJ11 gene was identified at 9 years of age. In the other two patients (daughter and father, 12.6 and 25 years old respectively) the new gene variant (ABCC8/L213P) was found. Switching from insulin to sulfonylurea treatment leads to the definitive discontinuance of insulin therapy, improving metabolic control as well as the amelioration of the associated neurodevelopmental disabilities in the young girl in which an intermediate Development Delay, Epilepsy, Neonatal Diabetes syndrome was diagnosed.

Celiac disease in children with type 1 diabetes: impact of gluten free diet on diabetes management.

UNLABELLED: Background and aim of the work the coexistence of Type 1 Diabetes (T1D) and celiac disease (CD) has been long established. METHODS: Between January 2000 and December 2009, biopsy-proven CD was diagnosed in 12 children with T1D, giving a prevalence of 4.8 % in our out-patient clinic population. For each patient with coexisting T1D and CD, two control subjects with T1D and without CD who matched for age, sex and duration of diabetes were chosen. Prospective study follow up lasted 24 months. At the enrolment time, and at 2-month intervals, time from diagnosis of T1D to diagnosis of CD, presence of gastrointestinal symptoms, HbA1c value, body mass index (BMI), Height and Weight SDS were collected by a single observer. Daily insulin requirements were also retained. RESULTS: In 3 children, CD predated the onset of T1D and these children were excluded from the analysis. The 9 children who subsequently developed CD became earlier diabetic than control group (p=0.002). Eight of these children had CD diagnosis within 1 year after T1D onset. Seven out of 9 children were positive for TTG antibodies and all were positive for EMA. A significant increase in insulin requirement was found in CD children after 1 year of GFD (p= 0.02). The mean HbAlc value in CD children was higher than in the control subjects (p<0.01).A significant increase in the insulin requirement after 1 year in the GFD compliant children was found. There was a significant improvement in height-SDS after institution of GFD in the GFD-compliant children. Families of children with both T1D and CD reported higher burden than those affected by T1D only (p=0.001). The health care providers perceived family burden to increase with CD appearance (p<0.05). CONCLUSION: Our study supports the importance of screening for CD in children with T1D 1. The early treatment with GFD of biopsy-confirmed CD children promotes a significant catch-up growth and prevents a growth failure during the follow-up.

Type 1 diabetes (T1DM) in children and adolescents of immigrated families in Emilia-Romagna (Italy).

BACKGROUND AND AIM OF THE WORK: The etiology and natural history of T1DM are still unknown but certainly both genetics and environmental factors contribute to the development of the disease. Migration studies are an important tool to better understand the role of the environment. The aim of this study was to investigate some variables in diabetic children of immigrant families living in Emilia-Romagna compared with Italian diabetic children living in the same region. METHODS: We recruited 73 diabetic children from immigrant families and 707 Italian diabetic children. All children were cared by Pediatric Diabetes Units of Emilia-Romagna (10 centers). The investigated variables were: gender, current age, place of birth, parents' country of origin, age at diagnosis, HbA1c and insulin regimen. RESULTS: No significant difference with reference to gender neither among the two ethnic groups, nor in the current mean age was observed. Mean age at diagnosis in the Italian children was lower than in immigrant patients born outside Italy--group A- (7.4 vs. 9.6, p < 0.000) and higher compared to those born in Italy--group B- (7.4 vs. 5.7 p < 0.003; A vs. B p < 0.000). The immigrant patients showed higher mean HbA1c than Italian patients (8.8 vs. 8.2, p < 0.009). CONCLUSIONS: A younger age at diagnosis of T1DM in immigrant children, born in Italy compared with those born in the country of origin, and with Italian patients, suggests the existence of some environmental determinants acquired with a more westernised lifestyle. Immigrant children have significantly poorer metabolic control compared with western patients. (www.actabiomedica.it)

Haemolysis during diabetic ketoacidosis treatment in two girls with incomplete glucose-6-phosphate dehydrogenase deficiency.

Glucose-6-phosphate dehydrogenase (G6PD) deficiency is a typical X-linked enzymopathy causing severe haemolytic anaemia in males, and mild to moderate anaemia in homozygous females. Haemolysis due to G6PD deficiency in patients with type 1 diabetes mellitus (T1DM) has been principally reported in males, but is uncommon. During the last 10 years 2 girls with an unknown incomplete G-6-PD deficiency showed haemolysis during the treatment of DKA at the onset of T1DM. We speculate that the patients here described showed haemolytic anaemia as a phenotypic expression of the lyonization process and/or an uncommon penetrance of the defective gene. Haemolysis occurred when blood glucose levels were returning to normal values. In normal red blood cells, G6PD provides a source of reducing power for maintaining sulphydryl groups (SH) and facilitating the detoxification of free radicals and peroxides. During insulin i.v. infusion the copious glucose available due to the hyperglycaemia progressively decreased and affected the old red blood cells to generate nicotinamide adenine dinucleotide (NADPH), a crucial source for energy-dependent functions. This NADPH loss could have enhanced the rate of all factors such as methaemoglobin generation, Heinz body formation, and lipid peroxidation, which occur in G6PD deficient cells in response to both endogenous and exogenous oxidants. The direct consequence of this phenomenon is an increased erytrocyte oxidant sensitivity and a loss of sulphydryl group availability causing premature red blood cell destruction.

Sedentary lifestyle in active children admitted to a summer sport school.

Aim of this study was to investigate the sedentary patterns of school-aged active children admitted to a summer sport school. One hundred-twelve children aged 9-11 years were interviewed through a questionnaire about sedentary behaviours and nutrition habits. Seventy-one per cent of children reported they watch TV seven days a week, girls less than boys (84 +/- 45 minutes vs. 110 +/- 75 minutes) (t = 2.056; p = 0.042). The habit of TV viewing during meals was widespread (38% breakfast, 31% lunch, 62% dinner, 18% every meal). The prevalence of overweight or obesity (58.5%) was significantly higher among boys watching TV at dinner compared to the boys viewing TV only in the afternoon (35%) (chi2 = 4.976; p = 0.026). Fifty-seven per cent of children (65% boys) were accustomed to nibble snacks during TV viewing, and this habit was widespread in overweight or obese boys (chi2 = 4.546; p = 0.033). The dietary patterns of children watching TV include more snack foods and fewer fruits than the dietary patterns of the same children exercising (chi2 = 4.199 p = 0.040). Also in active children the habit to watch television is widespread and, in spite of the tendency to physical activity, 46% of them were overweight or obese; in fact the time spent looking at a TV may be associated to overweight/obesity and this relationship could be explained by the amount of high-density foods consumption during inactivity. Playing video games, read a book and listening to music are sedentary lifestyle patterns but these seem not to represent a risk factor for an increased BMI.

Effectiveness of a tailored medical support to overcome the barriers to education, treatment and good metabolic control in children with type-1 diabetes from ethnic minorities.

AIM: To analyze the effectiveness of a tailored medical support to help children from ethnic minorities to achieve the same good metabolic control of autochthonous peers with type-1 diabetes (T1D). METHODS: Children <10 years of age belonging to ethnic minority (EM) families (Group 1) were compared with autochthonous peers (Group 2) who received the diagnosis of T1D in 2014-2016. The Protocol for minorities included other than the standard protocol: booklets translated in ethnic minority languages; weekly visits at home or at school; family-guides; clinic visits supported by professional interpreters. After twelve months of this approach, parents of ethnic minority children answered a short questionnaire concerning satisfaction about educational tools for diabetes management. RESULTS: From 1st January 2014 to December 31st 2016, 72 children received the diagnosis of T1D at the University Children Hospital of Parma, Italy. Nineteen children belonged to an EM family (26.38%), and were included in the Group 1. Twenty-one autochthonous peers were randomly recruited for the Group 2. T1D was diagnosed at the same mean age in Group 1 (5.2±2.2) and in Group 2 patients (5.7±2.4). Metabolic derangements at diagnosis were more severe in Group 1 than in Group 2 patients. However, patients of both Groups showed a similar decrease in HbA1c levels during the first 3 and 6 months post diagnosis. Patients did not differ in mean insulin doses at discharge and at follow up. The calls to the emergency toll-free telephone number were more numerous from the parents from Group 1 than from the parents of Group 2. Total cost to implement the tailored protocol in Group 1 was higher of 87% compared with the standard protocol used for Group 2 patients. Great majority of parents reported to be satisfied with the provided diabetes education program. CONCLUSIONS: The results of this study suggested that children from EM families can achieve the same good metabolic control of autochthonous peers with T1D, providing a cost-effective tailored support to their family members.

Long-acting insulin allergy in a diabetic child.

Insulin allergy has been uncommon since the introduction of human recombinant insulin preparations; the prevalence is 2.4%. Insulin injection could elicit immediate reactions, which are usually induced by an IgE-mediated mechanism, within the first hour after drug administration. In the present study, we describe the case of a child who experienced immediate urticaria after long-acting insulin injection. A 9-year-old girl affected by type I diabetes mellitus referred a history of three episodes of urticaria 30 min after insulin subcutaneous injection. During the first week of insulin therapy, she developed generalized immediate urticaria twice after long-acting insulin glargine first and then once after insulin degludec administration. Symptoms resolved within a few hours after treatment with oral antihistamine. She tolerated rapid insulin lispro. Her personal allergological history was negative. Skin prick tests with degludec, glargine and detemir were performed, showing negative results. Intradermal 1:100000-diluted tests were immediately positive for both degludec and glargine but not for detemir. In light of these findings, detemir was administered without any reaction. Our results show that detemir is tolerated by patients with clinical hypersensitivity reactions to degludec and glargine. Although reactions could be attributable to additives allergy, such as zinc or metacresol, this was excluded since all three preparations contain the same components. So, insulin itself acted as offending allergen. Detemir differs from degludec and glargine in a few aminoacids. Therefore, it is possible that the conformational rather than the linear epitope may be responsible for the reaction. This result suggests integrating intradermal tests in the diagnostic flowchart for insulin allergy. Insulin allergy should always be suspected in patients with immediate symptoms after drug injection. As allergologic work-up, prick by prick test and intradermal test to insulin preparations should be performed. In case of negative results of cutaneous tests, insulin analogs may be administered.

Self-monitoring adherence to physical activity in children and adolescents with type 1 diabetes.

Monitoring blood glucose is essential for good diabetes control and even more important when participating in sports. Many variables can have an effect on blood sugar response to aerobic or anaerobic activities. A moderate exercise produces an average fall in plasma glucose of approximately 40% of baseline values. The majority of hypoglycaemia episodes occurs in children with pre-exercise plasma glucose concentrations < 120 mg/dl, therefore it is advisable to achieve a blood glucose level of at least 120 mg/dl if not higher before starting an exercise in order to prevent hypoglycaemia episodes. Since 15 g of oral glucose result in only about a 20-mg/dl rise in glucose concentrations, 30-45 g of oral glucose may be more appropriate to treat hypoglycaemia during exercise. A sufficient adherence to the physical activity prescribed by the health care professionals it easy to find in the children with Type 1 diabetes. According our experience, 60 per cent of the children report to spend on average 1 hour daily for exercise, proving so to consider physical activity beneficial in the treatment of diabetes mellitus. Glycate haemoglobin levels in these motivated patients were better than in children exercising sporadically and shortly either at school or in the spare time. Although the health care professionals effort, only half of the patients referred to monitor blood glucose levels before, after or before and after the exercise. Only one third of the patients reported to regularly adjust insulin dosage to own response to physical activity. Two third of the patients referred to consume added carbohydrate to avoid hypoglycaemia.

Outside-hospital assistance for children and adolescents with type 1 diabetes mellitus.

Telephone care, Telemedicine, Home care and Diabetic Camps are the most useful ways for Paediatricians to transfer diabetic care outside the hospital. These provide children with diabetes and their parents with an effective and practical tool to solve directly arising therapeutic problems and improve their quality of care and life. The advantages for the National Health Care System could be macroscopic: according to some studies, the Telephone care service allows to save 85% of the hospitalisation costs for children with acute metabolic intercurrent illnesses-related derangements. Telemedicine service, based on telephone line relying on the Internet technology, is a complementary tool to follow children and adolescents with diabetes in out-patient clinic. The rare experiences in this field report a reduction in insulin doses and an improvement of metabolic control and quality of life. The Home care service has to be performed by a nurse and has to be useful for patients and parents to organize the management of diabetes at home and to improve therapeutic adherence. Diabetic camps give the opportunity to children and adolescents with diabetes to verify, outside the family and under health professionals' supervision, their ability to manage the disease, and to increase own self-esteem.

A Multicenter Retrospective Survey regarding Diabetic Ketoacidosis Management in Italian Children with Type 1 Diabetes.

We conducted a retrospective survey in pediatric centers belonging to the Italian Society for Pediatric Diabetology and Endocrinology. The following data were collected for all new-onset diabetes patients aged 0-18 years: DKA (pH < 7.30), severe DKA (pH < 7.1), DKA in preschool children, DKA treatment according to ISPAD protocol, type of rehydrating solution used, bicarbonates use, and amount of insulin infused. Records (n = 2453) of children with newly diagnosed diabetes were collected from 68/77 centers (87%), 39 of which are tertiary referral centers, the majority of whom (n = 1536, 89.4%) were diagnosed in the tertiary referral centers. DKA was observed in 38.5% and severe DKA in 10.3%. Considering preschool children, DKA was observed in 72%, and severe DKA in 16.7%. Cerebral edema following DKA treatment was observed in 5 (0.5%). DKA treatment according to ISPAD guidelines was adopted in 68% of the centers. In the first 2 hours, rehydration was started with normal saline in all centers, but with different amount. Bicarbonate was quite never been used. Insulin was infused starting from third hour at the rate of 0.05-0.1 U/kg/h in 72% of centers. Despite prevention campaign, DKA is still observed in Italian children at onset, with significant variability in DKA treatment, underlying the need to share guidelines among centers.

High frequency of diabetic ketoacidosis at diagnosis of type 1 diabetes in Italian children: a nationwide longitudinal study, 2004-2013.

This longitudinal population-based study analyses the frequency of diabetic ketoacidosis (DKA) at type 1 diabetes diagnosis in Italian children under 15 years of age, during 2004-2013. DKA was defined as absent (pH ≥ 7.30), mild/moderate (7.1 ≤ pH < 7.30) and severe (pH < 7.1). Two multiple logistic regression models were used to evaluate the time trend of DKA frequency considered as present versus absent and severe versus absent, adjusted for gender, age group and geographical area of residence at diagnosis. Overall, 9,040 cases were ascertained. DKA frequency was 40.3% (95%CI: 39.3-41.4%), with 29.1% and 11.2% for mild/moderate and severe DKA, respectively. Severe DKA increased significantly during the period (OR = 1.03, 95%CI: 1.003-1.05). Younger-age children and children living in Southern Italy compared to Central Italy were at significantly higher risk of DKA and severe DKA. Family history of type 1 diabetes and residence in Sardinia compared to Central Italy were significantly associated with a lower probability of DKA and severe DKA. The high frequency of ketoacidosis in Italy over time and high variability among age groups and geographical area of residence, strongly suggests a continuing need for nationwide healthcare strategies to increase awareness of early detection of diabetes.

Telephone and hot lines: a tool delivering clinical care.

Telephone lines are now a widespread way of communication between patients and physicians. Nevertheless opinions about their effectiveness and efficacy are rather inconsistent. Aim of this study is to review medical literature in order to assess how and when telephone lines have been described as a good or a bad way to help health care, looking for different experiences and opinions, reviews and guidelines about the use of telephone as a tool for delivering health care. We compared what we have found, particularly about Diabetes, with our previous experience. Medline from Pub Med from National Library of Medicine has been consulted using "telephone", "hot line" or "hotline" as key words. Among the 20 thousands references found in the literature, 2051 of them we considered relevant. The most frequently recurrent topics concern pediatrics (19.2%), while diabetes is not very frequent (0.6%). Analyzing more in details, we noticed that the application fields ofhotlines are emergency management, secretary tasks, preventive health care, acute episodes and chronic conditions. Different models of telephone help lines and guidelines in training and running help lines have been found as well. Examining diabetes help lines, we noticed that they are mainly used in case of intercurrent illness, doubts about insulin dose, hypoglycemia. Parents of the youngest patients and with the shortest duration of diabetes are the most frequent users, regardless of HbA1c. Most calls came during holy-days and weekend, especially early in the morning or during the night.

Breakfast habits of 1,202 northern Italian children admitted to a summer sport school. Breakfast skipping is associated with overweight and obesity.

Very little is known about the differences in breakfast of children performing physical activity in the morning. This paper analyzed the breakfast habits of 747 boys and 455 girls, distributed in 2 homogeneous age groups, 6-10 and 11-14 year-old, participating in a Summer Sport School. Children were asked whether, when, where, how and with whom they consumed breakfast; who prepared meals; what they ate and drank; what they did during breakfast. Weight, height and BMI were recorded. Seventy-eight percent of children usually had breakfast, but 22% reported skipping breakfast. In the non-breakfast consumer subjects, 27.5% were overweight and 9.6% obese vs 9.1 and 4.5% respectively in breakfast eaters. Bakery products (76%) and milk (71%) were the most frequently consumed foods. Only 15% of parents encouraged their children to consume additional foods at breakfast before exercising, and 42% of children believed that this extra nutrition was unnecessary. In 80% of cases, the chief decision-maker for breakfast was the mother, the father played little part (1%). During breakfast, 48% of children ate and drank in silence, 26% played with brothers and sisters, 18% watched television and only 8% talked with parents. A high prevalence of over-weight and obesity was found among non-breakfast consumer children. Breakfast omission in children exercising conflicts with their increased energy requirements and may be connected to the trend of parents and children to under-estimate the importance of breakfast for nutritional balance and for environment promotion of physical performance.

Effectiveness of a toll-free telephone hotline for children and adolescents with type 1 diabetes. A 5-year study.

In 1995 we introduced a 24-h 7-day-a-week toll-free telephone service and specific guidelines to help the patients at home to reduce the risk of diabetic ketoacidosis (DKA) progression during intercurrent illnesses. Five years later we analysed the calls received at this emergency telephone hotline service (ETHS). From 1 January 1996 to 31 December 2001 a total of 9.125 calls was recorded (5.1 +/- 4.2 calls per day), but only 24% of them were veritable hot-line calls and were received from 767 patients or parents resulting in a mean of 2.5 +/- 0.8 calls per patient or parent. Fifty-nine percent of these users called from outside Parma's area. Their mean age (7.8 +/- 4.2 years) and duration of diabetes (2.8 +/- 1.2 years) were significantly lower (p < 0.001) and shorter (p < 0.001) compared to those (12.8 +/- 2.9 and 4.9 +/- 3.2 years respectively) found in the population which called for no-emergency reasons. Twenty-two percent of the veritable hot-line calls were received on saturdays and sundays or holidays, in the morning (25%), in the evening (59%) or during the night (16%). Telephone care has been finally demonstrated to be an useful way to provide a continuous support for patients and their families in the management of diabetes in some critical situations. ETHS helps them to achieve and maintain a better metabolic control and to avoid DKA during acute intercurrent illness and consequently hospital admissions.

Relationship between metabolic control and quality of life in adolescents with type 1 diabetes. Report from two Italian centres for the management of diabetes in childhood.

This study is aimed at answering the question whether the demands of the intensified diabetes management and good metabolic control may influence the Quality of Life (QOL) of adolescents with Type 1 Diabetes (T1D), and that of their parents. Overall, 153 adolescents were involved (78 males, mean age 15.0 +/- 2.3 median age 14.6 years; average diabetes duration 6.5 +/- 3.5 years) from the Regional Centres of the Universities of Chieti and Parma. HbA1c determination was centralized and the adolescents were tested according to the adolescent version of the questionnaire developed by Ingersoll and Marrero on the impact of diabetes, worries about diabetes, satisfaction with life, and health perception. The burden on the family was assessed following a newly constructed questionnaire. The average HbA1c value was 7.7 +/- 1.4% (boys 8.0 +/- 1.4 and girls 7.5 +/- 1.2%). The impact of diabetes was similar for both boys and girls (average scores: 44.68 vs 45.00) with no effect regarding age or the duration of diabetes, but the influence of HbA1c values was significant (p < 0.001). Compared with boys, girls had an earlier (at about 12 years of age) and more significant increase in worries (p < 0.01). Lower HbA1c values were associated with fewer worries (p < 0.02). Satisfaction deterioration appeared earlier in girls than in boys and was associated with high levels of HbA1c (p < 0.01). Health perception was poorer in girls than in boys and was influenced by HbA1c values (p < 0.005) in both girls and boys. The burden on the family with diabetes decreased with the age of the adolescent. In conclusion, in our group of adolescents with T1D, lower HbA1c was also associated with better QOL and with a lower perception of a burden on the family. These findings justify the efforts to assess QOL perception in adolescents in order to facilitate achieving better metabolic control.

Adherence to physical activity in young people with type 1 diabetes.

Regular physical activity plays a key role in the management of children and adolescents with Type 1 diabetes mellitus but it is not considered as a treatment for diabetes. Aim of this study was to investigate time spent exercising, adherence to the programme for a safe exercise and ability of young people with diabetes to take appropriate measures to reduce potential risks. Ninety one Type 1 diabetes mellitus young people (aged from 10 to 18 years, duration of diabetes longer than 6 months) without associated chronic diseases were randomly enrolled in the study. Age, sex, weight, height, BMI, duration of disease, mean HbA1c value over preceding 6 months have been collected. The time weekly spent for physical activity, the type of exercise usually performed, the measures taken to reduce exercise risks have been collected by a structured questionnaire. BMI was 21.6+/-3.05 in the boys and 21.3+/-3.63 in the girls. All patients spent exercising 438+/-221 minutes/week. Boys exercised 71 minutes longer than girls in competitive sports. Children exercising less than 60 minutes weekly showed a mean HbA1c level (8,9+/-05%) higher than that found in children exercising 120-360 minutes (8,3+/-0.4 %; p=0.002) or 360-480 minutes (8,0+/-0.6 %; p< 0.01) weekly. Children attending a competitive sport (at least 360 min per week) had a better glycemic control (HbA1c=7,39+/-0.6 %; p=0.03) than other active peers. Fifty percent of patients reported to monitor blood glucose levels during exercise; 32 % changed insulin dose according to blood glucose levels; 60 % usually added carbohydrate-based foods before (35%), during (15%) or after (10%) exercise. Hypoglycemic episodes (37.7%) were reported more frequently than hyperglycemic ones (p=0.024), but only twelve percent of them were symptomatic and appeared 30 minutes to 2 hours after the end of exercise. These results must encourage health care professionals to review regularly the ability of their patients in managing physical activity and to check their adherence to the program for a safe exercise.

Voluntary discontinuance of seven years successful insulin prophylaxis produced shortly overt diabetes in a first-degree relative of a diabetic child at high risk for type 1 diabetes.

This is the story of a nondiabetic first-degree relative of a child with Type 1 Diabetes who was screened for Type 1 diabetes and was found to be at high risk being positive for genetic, immunologic and metabolic markers. He accepted to be treated with low-dose subcutaneous insulin and for 7 years he has been living in subclinical prediabetes state. At the beginning of eighth year, he voluntary discontinued the preventive insulin therapy and after 18 months clinically overt diabetes appeared.