The establishment of a new national network leads to quality improvement in childhood diabetes: implementation of the ISPAD Guidelines.

AIMS: To investigate whether implementation of International Society for Pediatric and Adolescent Diabetes (ISPAD) Guidelines and the establishment of a system for nationwide anonymous comparison, between treatment centres, of quality indicators for childhood diabetes could lead to improvement in diabetes care. METHODS: Children and adolescents with type-1 diabetes in Norway are treated at the public hospitals. Data were collected prospectively yearly according to standardized written instructions. Quality indicators were defined and benchmarked. HbA1c was measured at a central national Diabetes Control and Complications Trial (DCCT) standardized laboratory. RESULTS: The participation increased with 454 type-1 diabetes patients from eight clinics included in 2001 and 1658 patients from 25 clinics in 2005. The adherence rate in 2005 was 85% of all eligible patients from 25 of 26 pediatric clinics. The mean HbA1c of all clinics improved (8.6% in 2001 and 8.1% in 2005) and this was statistically significant (p < 0.01). The use of intensive insulin treatment increased from 56% to 78% (p < 0.01) and pumps from 8% to 37% (p < 0.01). The incidence of diabetes ketoacidosis (DKA) remained constant. The incidence of severe hypoglycemia declined insignificantly. The proportion of patients not screened yearly for microalbuminuria and retinopathy, according to ISPAD guidelines, decreased from 12% to 2% (p < 0.01) and from 42% to 27% (p < 0.01), respectively. All changes occurred gradually from 2001 to 2005. CONCLUSIONS: During the establishment of a system for benchmarking of diabetes treatment in Norway the outcomes showed significant improvements associated with changes in management and the quality of screening assessments. Benchmarking combined with organized quality meetings and discussions was effective to improve outcome on a national level.

LV systolic impairment in patients with asymptomatic coronary heart disease and type 1 diabetes is related to coronary atherosclerosis, glycaemic control and advanced glycation endproducts.

AIMS: To evaluate whether heart failure in type 1 diabetes is linked to poor glycaemic control, coronary atherosclerosis or advanced glycation endproducts (AGEs). METHODS: Twenty six patients with type 1 diabetes (mean duration 32+/-5 years), and 16 age matched controls were recruited. Mean HbA(1c) through 18 years (HbA(1c)18), serum levels of AGEs and coronary atherosclerotic burden (CAB) were determined by IVUS. Peak tissue velocities and strain by tissue Doppler imaging were measured in 12 LV regions as an evaluation of LV function. RESULTS: Systolic tissue velocity was inversely correlated to CAB (r=0.53, p<0.01), to HbA(1c)18 (r=0.46, p<0.05) and to the duration of diabetes (r=0.46, p<0.05). Systolic strain was inversely correlated to HbA(1c)18 (r=0.45, p<0.05), to duration of diabetes (r=0.41, p<0.05), and tended to correlate with AGEs (r=0.37, p=0.07). In multiple regression analyses, CAB and HbA(1c)18 were significant independent predictors for systolic velocity, while AGEs and duration of diabetes were significant predictors of systolic strain. CONCLUSION: LV systolic function was impaired by increasing coronary atherosclerosis and worsening of glycaemic control. AGEs might be another mechanism for the increased risk of heart failure in type 1 diabetes.

Intracoronary ultrasound examinations reveal significantly more advanced coronary atherosclerosis in people with type 1 diabetes than in age- and sex-matched non-diabetic controls.

AIMS/HYPOTHESIS: The extent of coronary atherosclerosis is significantly more advanced in symptomatic type 1 diabetes patients than in symptomatic non-diabetic patients. Whether this difference exists between asymptomatic individuals with diabetes and controls is not documented. In vivo imaging techniques allow quantification of the difference at a preclinical stage. METHODS: The degree of coronary atherosclerosis in early onset type 1 diabetes patients without symptoms of cardiovascular disease was compared with that of age- and sex-matched controls. Intracoronary ultrasound (IVUS) examinations were performed to determine the degree of atherosclerosis. The mean age of the patients was 43 years (35-58), they had a mean duration of disease of 30 (23-39) years and the diagnosis of type 1 diabetes was made at a mean age of 12.5 years. The controls were people with transplanted hearts; donors were sex- and age-matched and had a mean age of 43 (35-58) years. RESULTS: The degree of subclinical coronary atherosclerosis was significantly more severe in type 1 diabetes patients than in controls. This was the case for all parameters measured. The mean plaque area was >or= 40% in 71% (54/76) of diabetic arteries as opposed to 33% (25/76) of arteries from controls (p<0.0001). The mean plaque thickness was 0.59+/-0.38 mm vs. 0.44+/-0.30 mm in controls (p<0.0001). The mean lumen area was 8.6+/-3.8 mm2 in type 1 diabetes and 12.1+/-4.3 mm2 in controls (p<0.0001). CONCLUSIONS/INTERPRETATION: Asymptomatic individuals with type 1 diabetes have significantly more advanced subclinical coronary atherosclerosis than controls. Coronary atherosclerosis in type 1 diabetes develops at an early age.

Optimal blood glucose control during 18 years preserves peripheral nerve function in patients with 30 years' duration of type 1 diabetes.

OBJECTIVE: To assess the association between 18 years of mean HbA(1c) and nerve conduction parameters of the lower limb in patients with type 1 diabetes of 30 years' duration. RESEARCH DESIGN AND METHODS: HbA(1c) has been examined prospectively since 1982 in a group of 39 patients with type 1 diabetes. Mean age at baseline was 25 years (range 18-40) with 12 years' disease duration. The mean age at diagnosis of diabetes was 12.5 years. Nerve function of lower limbs was assessed at baseline, after 8 years, and after 18 years. RESULTS: A total of 23 men and 16 women were studied. Mean age was 43 years. Mean HbA(1c) was 8.2% (range 6.6-11.3) during 18-year follow-up. Nerve conduction velocity (NCV) and nerve action potential amplitude (NAPA) at the last examination were significantly associated with mean HbA(1c) (P < 0. 05). From 1982 to 1999, there was a significant reduction in nerve function in patients with mean HbA(1c) >or=8.4% (highest tertile). For example, the mean NCV in the tibial nerve was reduced from 47 to 31 m/s (P < 0.01). The number of nerves with NCV (P < 0.01) and NAPA (P = 0.01) reduced to below the reference level in each patient was also significantly associated to mean HbA(1c). No significant associations were found between nerve function parameters, sex, disease duration, blood pressure, serum cholesterol, microalbuminuria, or smoking. CONCLUSIONS: The present study shows that mean HbA(1c) is a strong predictor of nerve function. Mean HbA(1c) <8.4% over 18 years was associated with near-normal nerve function.

Eighteen years of fair glycemic control preserves cardiac autonomic function in type 1 diabetes.

OBJECTIVE: To study the association between 18 years of mean HbA(1c) and cardiac autonomic function in type 1 diabetic patients having used intensive insulin treatment. RESEARCH DESIGN AND METHODS: A total of 39 patients with type 1 diabetes were followed during 18 years, and HbA(1c) was measured yearly. At 18 years follow-up heart rate variability (HRV) measurements were used to assess cardiac autonomic function. Standard cardiac autonomic tests during normal breathing, deep breathing, the Valsalva maneuver, and the tilt test were performed. Maximal heart rate increase during exercise electrocardiogram and minimal heart rate during sleep were also used to describe cardiac autonomic function. RESULTS: We present the results for patients with mean HbA(1c) <8.4% (two lowest HbA(1c) tertiles) compared with those with HbA(1c) > or = 8.4% (highest HbA(1c) tertile). All of the cardiac autonomic tests were significantly different in the high- and the low-HbA(1c) groups, and the most favorable scores for all tests were seen in the low-HbA(1c) group. In the low-HbA(1c) group, the HRV was 40% during deep breathing, and in the high-HbA(1c) group, the HRV was 19.9% (P = 0.005). Minimal heart rate at night was significantly lower in the low-HbA(1c) groups than in the high-HbA(1c) group (P = 0.039). With maximal exercise, the increase in heart rate was significantly higher in the low-HbA(1c) group compared with the high-HbA(1c) group (P = 0.001). CONCLUSIONS: Mean HbA(1c) during 18 years was associated with cardiac autonomic function. Cardiac autonomic function was preserved with HbA(1c) <8.4%, whereas cardiac autonomic dysfunction was impaired in the group with HbA(1c) > or = 8.4%.

Strong association between time watching television and blood glucose control in children and adolescents with type 1 diabetes.

OBJECTIVE: To examine the relationship between blood glucose control and the time spent watching television in Norwegian children and adolescents with type 1 diabetes in a population-based study. RESEARCH DESIGN AND METHODS: A total of 538 children and adolescents from 9 hospitals in the eastern part of Norway participated in the study; 70% of eligible subjects participated. The time spent watching television and time using a computer was recorded separately by interview together with clinical data. Mean (+/-SD) age was 13.1 +/- 3.7 years, mean diabetes duration was 5.4 +/- 3.4 years, and mean A1C was 8.6 +/- 1.3% (reference range 4.1-6.4). RESULTS: Sixty-two patients (11%) watched television <1 h daily (mean A1C 8.2 +/- 0.9%), 189 patients (35%) watched television between 1 and 2 h daily (8.4 +/- 1.2%), 166 patients (31%) watched television 2-3 h daily (8.7 +/- 1.4%), 75 patients (14%) watched television 3-4 h daily (8.8 +/- 1.2%), and 46 patients (9%) watched television > or =4 h daily (9.5 +/- 1.6%). This trend was highly significant (P < 0.001). The association between television viewing and A1C remained significant, even after adjusting for age and BMI and insulin dose. No correlation between A1C and the use of a personal computer was observed. CONCLUSIONS: Extensive television watching is associated with poor blood glucose control in children and adolescents with type 1 diabetes.