Readiness for behaviour change after gestational diabetes mellitus: A prospective cohort study.

AIMS: Women with gestational diabetes mellitus (GDM) have a high risk of developing type 2 diabetes (T2D). Readiness for behaviour change to mitigate this risk may be low after pregnancy and may further decrease over time without appropriate interventions. This study aimed to evaluate readiness for behaviour change in the first and second postpartum years in women with recent GDM to determine the best timing for lifestyle interventions to prevent T2D. METHODS: This study included a subset of women with GDM between 2009 and 2013 in Ontario, Canada from a larger prospective cohort study who completed a survey in the first and second postpartum years (N = 329). The primary outcome was stage of readiness for behaviour change for diet and physical activity, compared between the first and second postpartum years. RESULTS: The mean age was 34.3 ± 4.4 standard deviation (SD) years and mean pre-pregnancy body-mass index (BMI) was 26.7 ± 6.9 kg/m2. In the first postpartum year, 86% of women reported a pre-action stage of change, which was 87% by the second postpartum year (p = 0.646). Non-Caucasian ethnicity was associated with lower odds of being in the action stage of readiness for behaviour change overall and for physical activity in both time periods. CONCLUSIONS: Most postpartum women with recent GDM are in a pre-action stage of change after delivery, which does not increase by the second postpartum year. Behavioural interventions should continue to be prioritized in postpartum women with GDM to optimize this slim window of opportunity for T2D prevention.

Service use and glycaemic control of young people with type 1 diabetes transitioning from paediatric to adult care: a 5-year study.

BACKGROUND: Regular contact with specialist care has been linked to better diabetes outcomes for young people with type 1 diabetes (YPwT1D), but evidence is limited to population-based service usage and outcomes. AIMS: This observational 5-year study sought to capture YPwT1D living in the study catchment area (covering metropolitan, regional and rural Australia) as they transitioned to adult-based diabetes healthcare services and to describe their glycaemic control and complication rates, service usage and associated factors. METHODS: Records between 2010 and 2014 in a public healthcare specialist diabetes database were extracted, care processes and outcomes were described, and associations were sought between episodes of care (EOC) and potentially predictive variables. RESULTS: Annual cohort numbers increased yearly, but without significant differences in demographic characteristics. Each year around 40% had no reported planned specialist care, and the average number of planned EOC decreased significantly year on year. Overall, mean HbA1c levels also reduced significantly, but with higher values recorded for those living in non-metropolitan than metropolitan areas (achieving significance in 3 out of 5 years). Diabetes complication assessments were only reported in 37-46%, indicating one in five with retinopathy and hypertension affecting one in three to five young people. CONCLUSIONS: Findings highlight the importance of investment to address the specific needs of adolescents and young adults and demonstrate the need for better support during these vulnerable early years, particularly for non-metropolitan residents. This will entail changes to funding mechanisms, the health workforce and infrastructure, and new models of care to provide equity of access and quality of specialist care.

Suboptimal glycemic control in adolescents and young adults with type 1 diabetes from 2011 to 2020 across Australia and New Zealand: Data from the Australasian Diabetes Data Network registry.

BACKGROUND: Competing challenges in adolescence and young adulthood can distract from optimal type 1 diabetes (T1D) self-management, and increase risks of premature morbidity and mortality. There are limited data mapping the glycemic control of people with T1D in this age group, across Australasia. RESEARCH DESIGN AND METHODS: Clinical data were extracted from the Australasian Diabetes Data Network, a prospective clinical diabetes registry. Inclusion criteria were individuals with T1D aged 16-25 years at their last recorded T1D healthcare visit (from 1st January 2011 to 31st December 2020), with T1D duration of at least 1 year. Data were stratified by two last recorded T1D healthcare visit ranges, while generalized estimated equation (GEE) modeling was used to examine factors associated with HbA1c across visits during the 10 year period. RESULTS: Data from 6329 young people (52.6% male) attending 24 diabetes centers across Australasia were included. At the last visit within the most recent 5 years, mean ± SD age was 18.5 ± 2.3 years, T1D duration was 8.8 ± 4.7 years and HbA1c was 8.8 ± 1.8% (72.2 ± 19.9 mmol/mol); only 12.3% had an HbA1c below the international target of <7.0% (53 mmol/mol). Across all T1D healthcare visits, in GEE modeling, higher HbA1c was associated with female sex (B = 0.20; 95% CI 0.12 to 0.29, p < 0.001), longer T1D duration (B = 0.04, 0.03 to 0.05, p < 0.001). Lower HbA1c was associated with attendance at a pediatric T1D healthcare setting (B = -0.33, -0.45 to -0.21, p < 0.001) and use of CSII versus BD/MDI therapy (B = -0.49, -0.59 to 0.40, p < 0.001). CONCLUSIONS: This Australasian study demonstrates widespread and persistent sub-optimal glycemic control in young people with T1D, highlighting the urgent need to better understand how healthcare services can support improved glycemic control in this population.

Do variations in insulin sensitivity and insulin secretion in pregnancy predict differences in obstetric and neonatal outcomes?

AIMS/HYPOTHESIS: Gestational diabetes mellitus (GDM) is generally defined based on glycaemia during an OGTT, but aetiologically includes women with defects in insulin secretion, insulin sensitivity or a combination of both. In this observational study, we aimed to determine if underlying pathophysiological defects evaluated as continuous variables predict the risk of important obstetric and neonatal outcomes better than the previously used dichotomised or categorical approaches. METHODS: Using data from blinded OGTTs at mean gestational week 28 from five Hyperglycemia and Adverse Pregnancy Outcome study centres, we estimated insulin secretion (Stumvoll first phase) and sensitivity (Matsuda index) and their product (oral disposition index [DI]) in 6337 untreated women (1090 [17.2%] with GDM as defined by the International Association of Diabetes and Pregnancy Study Groups). Rather than dichotomising these variables (i.e. GDM yes/no) or subtyping by insulin impairment, we related insulin secretion and sensitivity as continuous variables, along with other maternal characteristics, to obstetric and neonatal outcomes using multiple regression and receiver operating characteristic curve analysis. RESULTS: Stratifying by GDM subtype offered superior prediction to GDM yes/no only for neonatal hyperinsulinaemia and pregnancy-related hypertension. Including the DI and the Matsuda score significantly increased the area under the receiver operating characteristic curve (AUROC) and improved prediction for multiple outcomes (large for gestational age [AUROC 0.632], neonatal adiposity [AUROC 0.630], pregnancy-related hypertension [AUROC 0.669] and neonatal hyperinsulinaemia [AUROC 0.688]). Neonatal hypoglycaemia was poorly predicted by all models. Combining the DI and the Matsuda score with maternal characteristics substantially improved the predictive power of the model for large for gestational age, neonatal adiposity and pregnancy-related hypertension. CONCLUSION/INTERPRETATION: Continuous measurement of insulin secretion and insulin sensitivity combined with basic clinical variables appeared to be superior to GDM (yes/no) or subtyping by insulin secretion and/or sensitivity impairment in predicting obstetric and neonatal outcomes in a multi-ethnic cohort. Graphical abstract.

Role of maternal glucose metabolism in the association between maternal BMI and neonatal size and adiposity.

BACKGROUND/OBJECTIVE: One potential mechanism by which maternal obesity impacts fetal growth is through hyperglycemia below the threshold for gestational diabetes. Data regarding which measures of maternal glucose metabolism mediate this association is sparse. The objectives of this study were to (i) quantify the associations of maternal pre-pregnancy body mass index (BMI) with neonatal size and adiposity and (ii) examine the role of markers of maternal glucose metabolism as mediators in these associations. SUBJECTS/METHODS: This is a secondary analysis of 6,379 mother-infant dyads from the Hyperglycemia and Adverse Pregnancy Outcome cohort. Markers of glucose metabolism, including plasma glucose and c-peptide values, Stumvoll first-phase estimate, modified Matsuda index, and oral disposition index were measured and calculated from an oral glucose tolerance test (OGTT) between 24- and 32-weeks' gestation. We calculated the direct effect of maternal BMI category, measured at the time of the OGTT and regressed to estimate pre-pregnancy BMI, on neonatal (1) birth weight (BW), (2) fat mass (FM), (3) % body fat (BF%), and (4) sum of skinfold thickness (sSFT). We then calculated the indirect effect of BMI category on these measures through markers of glucose metabolism. RESULTS: Maternal BMI category was positively associated with neonatal BW, FM, BF%, and sSFT. Additionally, mothers who were overweight or obese had higher odds of delivering an infant with BW, FM, BF%, or sSFT >90th percentile. Fasting glucose and c-peptide values were the strongest mediators in the linear associations between maternal BMI category and neonatal size and adiposity. CONCLUSIONS: Maternal overweight and obesity were associated with higher odds of neonatal BW and adiposity >90th percentile. Fasting measures of glucose metabolism were the strongest mediators of these associations, suggesting that future studies should investigate whether incorporation of these markers in pregnant women with obesity may improve prediction of neonatal size and adiposity.

Diabetic ketoacidosis presentations in a low socio-economic area: are services suitable?

BACKGROUND: Diabetic ketoacidosis causes a significant number of hospitalisations worldwide, with rates tending to increase with remoteness and socioeconomic disadvantage. Our study aimed to explore healthcare professionals' perceptions of factors affecting presentation of people with type 1 diabetes in a low socioeconomic area of Queensland, Australia. METHODS: This was a qualitative study. Individual semi-structured face-to-face or telephone interviews were completed with patients with type 1 diabetes who had presented in diabetic ketoacidosis, and healthcare professionals who have experience in related care. Data were analysed using Gibbs's framework of thematic analysis. RESULTS: Four patients with type 1 diabetes and 18 healthcare professionals were interviewed. Restricted access was identified as a factor contributing to diabetic ketoacidosis and delayed presentation, with ketone testing supplies, continuous glucose monitoring technology and transport considered barriers. Many of these factors were arguably preventable. Opportunities to improve the care available to patients with type 1 diabetes were detailed, with particularly strong support for dedicated out of hours telephone help lines for adults with type 1 diabetes. CONCLUSIONS: Gaps in support for patient self-care to avoid diabetic ketoacidosis presentations and prevent late presentation of diabetic ketoacidosis revealed by this study require service reconfiguration to support care delivery. Until change is made, people with type 1 diabetes will continue to make both avoidable and delayed, acutely unwell, presentations to Emergency Departments.

Exploring women's priorities for the potential consequences of a gestational diabetes diagnosis: A pilot community jury.

BACKGROUND: There is no international diagnostic agreement for gestational diabetes mellitus (GDM). In 2014, Australia adopted a new definition and testing procedure. Since then, significantly more women have been diagnosed with GDM but with little difference in health outcomes. We explored the priorities and preferences of women potentially impacted by a GDM diagnosis. METHOD: We recruited 15 women from the Gold Coast, Australia, to participate in a pilot community jury (CJ). Over two days, the women deliberated on the following: (a) which important consequences of a diagnosis of GDM should be considered when defining GDM?; (b) what should Australian health practitioners call the condition known as GDM? RESULTS: Eight women attended the pilot CJ, and their recommendations were a consensus. Women were surprised that the level of risk for physical harms was low but emotional harms were high. The final ranking of important consequences (high to low) was as follows: women's negative emotions; management burden of GDM; overmedicalized pregnancy; minimizing infant risks; improving lifestyle; and macrosomia. To describe the four different clinical states of GDM, the women chose three different labels. One was GDM. CONCLUSIONS: The women from this pilot CJ prioritized the consequences of a diagnosis of GDM differently from clinicians. The current glucose threshold for GDM in Australia is set at a cut-point for adverse risks including macrosomia and neonatal hyperinsulinaemia. Definitions and guideline panels often fail to ask the affected public about their values and preferences. Community voices impacted by health policies should be embedded in the decision-making process.

A discussion of healthcare support for adolescents and young adults with long-term conditions: Current policy and practice and future opportunities.

BACKGROUND: Adolescence and young adulthood can be a period of significant and unique life changes in which competing demands and challenges distract from disease self-management. Specific challenges related to the way individual services are configured can also limit the support available. This paper presents a discussion of healthcare service support for adolescents and young adults, using type 1 diabetes as an exemplar. DESIGN: Discussion paper. RESULTS: A wide variety of issues at the biopsychosocial level of the individual, health services policy and practice pose challenges to effective health support for adolescents and young adults. Intersectoral, multilevel and multicomponent opportunities are available to engage and empower young people to be part of change and accountability mechanisms and to transform the support available and outcomes achievable. A priority research agenda can benefit patients, families and their communities. CONCLUSION: Future policy and practice development may assist clinicians, service providers and managers, policymakers, non-governmental organizations and community groups to deliver more effective and efficient support to vulnerable adolescent and young adult populations.

Seasonality, temperature and pregnancy oral glucose tolerance test results in Australia.

BACKGROUND: The oral glucose-tolerance test (OGTT) is currently the standard method for diagnosis of gestational diabetes (GDM). We conducted a post hoc analysis using the Australian Hyperglycemia and Adverse Pregnancy Outcome (HAPO) data to determine seasonal variations in OGTT results, the consequent prevalence of GDM, and association with select perinatal parameters. METHOD: Women enrolled in the Australian HAPO study sites (Brisbane and Newcastle) from 2001 to 2006 were included if OGTT results between 24 to 32 weeks gestation were available (n = 2120). Fasting plasma glucose, 1-h plasma glucose, 2-h plasma glucose, HbA1c, HOMA-IR, and umbilical cord C-peptide and glucose values were categorized by season and correlated to monthly temperature records from the Australian Bureau of Meteorology for Brisbane and Newcastle. GDM was defined post hoc using the IADPSG/WHO criteria. RESULTS: Small but significant (p <  0.01 on ANOVA) elevations in fasting glucose (+ 0.12 mM), HbA1c (+ 0.09%), and HOMA-IR (+ 0.88 units) were observed during the winter months. Conversely, higher 1-h (+ 0.19 mM) and 2-h (+ 0.33 mM) post-load glucose values (both p <  0.01) were observed during the summer months. The correlations between fasting glucose, 1-h glucose, 2-h glucose, and HbA1c with average monthly temperatures confirmed this trend, with positive Pearson's correlations between 1-h and 2-h glucose with increasing average monthly temperatures, and negative correlations with fasting glucose and HbA1c. Further, umbilical cord C-peptide and glucose displayed negative Pearson's correlation with average monthly temperature, aligned with trends seen in the fasting plasma glucose. Overall prevalence of GDM did not display significant seasonal variations due to the opposing trends seen in the fasting versus 1-h and 2-h post-load values. CONCLUSION: A significant winter increase was observed for fasting plasma glucose, HbA1c, and HOMA-IR, which contrasted with changes in 1-h and 2-h post-load venous plasma glucose values. Interestingly, umbilical cord C-peptide and glucose displayed similar trends to that of the fasting plasma glucose. While overall prevalence of GDM did not vary significantly by seasons, this study illustrates that seasonality is indeed an additional factor when interpreting OGTT results for the diagnosis of GDM and provides new direction for future research into the seasonal adjustment of OGTT results.

The Effects of Glucose Therapy Agents-Apple Juice, Orange Juice, and Cola-on Enteral Tube Flow and Patency.

To develop evidence-based hypoglycemia treatment protocols in patients receiving total enteral nutrition, this study determined the effect on enteral tube flow of glucose therapy agents: apple juice, orange juice, and cola, and it also examined the effects of tube type and feed type with these glucose therapy agents. For this study, 12 gastrostomy tubes (6 polyethylene and 6 silicone) were set at 50 mL/h. Each feeding set was filled with Isosource HN with fibre or Novasource Renal. Each tube was irrigated with 1 glucose therapy agent, providing approximately 20 g of carbohydrate every 4 h. Flow-rate measurements were collected at 2 h intervals. The results showed that the glucose therapy agent choice affected flow rates: apple juice and cola had higher average flow rates than orange juice (P = 0.01). A significant difference was found between tube type and enteral formula: polyethylene tubes had higher average flow rates than silicone tubes (P < 0.0001), and Isosource HN with fibre had higher flow rates than Novasource Renal (P = 0.01). We concluded that apple juice and cola have less tube clogging potential than orange juice, and thus may be considered as primary treatment options for hypoglycemia in enterally fed patients. Polyethylene tubes and Isosource HN with fibre were less likely to clog than silicone tubes and Novasource Renal.

Service usage and vascular complications in young adults with type 1 diabetes.

BACKGROUND: Few studies have examined young adults with type 1 diabetes use of health services and the development of vascular complications. As part of the Youth Outreach for Diabetes (YOuR-Diabetes) project, this study identified health service usage, the prevalence and factors predictive of development of vascular complications (hypertension, retinopathy and nephropathy) in a cohort of young adults (aged 16-30 years) with type 1 diabetes in Hunter New England and the Lower Mid-North Coast area of New South Wales, Australia. METHODS: A cross-sectional retrospective documentation survey was undertaken of case notes of young adults with type 1 diabetes accessing Hunter New England Local Health District public health services in 2010 and 2011, identified through ambulatory care clinic records, hospital attendances and other clinical records. Details of service usage, complications screening and evidence of vascular complications were extracted. Independent predictors were modelled using linear and logistic regression analyses. RESULTS: A cohort of 707 patients were reviewed; mean (SD) age was 23.0 (3.7) years, with mean diabetes duration of 10.2 (5.8, range 0.2 - 28.3) years; 42.4% lived/ 23.1% accessed services in non-metropolitan areas.Routine preventative service usage was low and unplanned contacts high; both deteriorated with increasing age. Low levels of complications screening were found. Where documented, hypertension, particularly, was common, affecting 48.4% across the study period. Diabetes duration was a strong predictor of vascular complications along with glycaemic control; hypertension was linked with renal dysfunction. CONCLUSION: Findings indicate a need to better understand young people's drivers and achievements when accessing services, and how services can be reconfigured or delivered differently to better meet their needs and achieve better outcomes. Regular screening is required using current best practice guidelines as this affords the greatest chance for early complication detection, treatment initiation and secondary prevention.

The Canadian Hypoglycemia During Hospitalization Score Is Externally Valid in the Australian Diabetes IN-hospital: Glucose & Outcomes (DINGO) Cohort.

OBJECTIVES: The Hypoglycemia During Hospitalization (HyDHo) score predicts hypoglycemia in a population of Canadian inpatients by assigning various weightings to 5 key clinical criteria known at the time of admission, in particular age, recent presentation to an emergency department, insulin use, use of oral hypoglycemic agents, and chronic kidney disease. Our aim in this study was to externally validate the HyDHo score by applying this risk calculator to an Australian population of inpatients with diabetes. METHODS: This study was a retrospective data analysis of a subset of the Diabetes IN-hospital: Glucose & Outcomes (DINGO) cohort. The HyDHo score was applied based on clinical information known at the time of admission to stratify risk of inpatient hypoglycemia. RESULTS: The HyDHo score was applied to 1,015 patients, generating a receiver-operating characteristic c-statistic of 0.607. A threshold of ≥9, as per the original study, generated a sensitivity of 83% and a specificity of 20%. A threshold of ≥10, to better suit this Australian population, generated a sensitivity of 90% and a specificity of 34%. The HyDHo score has been externally valid in a geographically different population; in fact, it outperformed the original study after accounting for local hypoglycemia rates. CONCLUSIONS: Our findings support the external validity of the HyDHo score in a geographically different population. Application of this simple and accessible tool can serve as an adjunct to predict an inpatient's risk of hypoglycemia and guide more appropriate glucose monitoring and diabetes management.

Preeclampsia as a risk factor for diabetes: a population-based cohort study.

BACKGROUND: Women with preeclampsia (PEC) and gestational hypertension (GH) exhibit insulin resistance during pregnancy, independent of obesity and glucose intolerance. Our aim was to determine whether women with PEC or GH during pregnancy have an increased risk of developing diabetes after pregnancy, and whether the presence of PEC/GH in addition to gestational diabetes (GDM) increases the risk of future (postpartum) diabetes. METHODS AND FINDINGS: We performed a population-based, retrospective cohort study for 1,010,068 pregnant women who delivered in Ontario, Canada between April 1994 and March 2008. Women were categorized as having PEC alone (n=22,933), GH alone (n=27,605), GDM alone (n=30,852), GDM+PEC (n=1,476), GDM+GH (n=2,100), or none of these conditions (n=925,102). Our main outcome was a new diagnosis of diabetes postpartum in the following years, up until March 2011, based on new records in the Ontario Diabetes Database. The incidence rate of diabetes per 1,000 person-years was 6.47 for women with PEC and 5.26 for GH compared with 2.81 in women with neither of these conditions. In the multivariable analysis, both PEC alone (hazard ratio [HR]=2.08; 95% CI 1.97-2.19) and GH alone (HR=1.95; 95% CI 1.83-2.07) were risk factors for subsequent diabetes. Women with GDM alone were at elevated risk of developing diabetes postpartum (HR=12.77; 95% CI 12.44-13.10); however, the co-presence of PEC or GH in addition to GDM further elevated this risk (HR=15.75; 95% CI 14.52-17.07, and HR=18.49; 95% CI 17.12-19.96, respectively). Data on obesity were not available. CONCLUSIONS: Women with PEC/GH have a 2-fold increased risk of developing diabetes when followed up to 16.5 years after pregnancy, even in the absence of GDM. The presence of PEC/GH in the setting of GDM also raised the risk of diabetes significantly beyond that seen with GDM alone. A history of PEC/GH during pregnancy should alert clinicians to the need for preventative counseling and more vigilant screening for diabetes. Please see later in the article for the Editors' Summary.

Coexisiting type 1 diabetes and celiac disease is associated with lower Hba1c when compared to type 1 diabetes alone: data from the Australasian Diabetes Data Network (ADDN) registry.

AIM: To compare HbA1c and clinical outcomes in adolescents and young adults with type 1 diabetes (T1D), with or without celiac disease (CD). METHODS: Longitudinal data were extracted from ADDN, a prospective clinical diabetes registry. Inclusion criteria were T1D (with or without CD), ≥ 1 HbA1c measurement, age 16-25 years and diabetes duration ≥ 1 year at last measurement. Multivariable Generalised Estimated Equation models were used for longitudinal analysis of variables associated with HbA1c. RESULTS: Across all measurements, those with coexisting T1D and CD had lower HbA1c when compared to those with T1D alone (8.5 ± 1.5% (69.4 ± 16.8 mmol/mol) vs. 8.7 ± 1.8% (71.4 ± 19.8 mmol/mol); p < 0.001); lower HbA1c was associated with shorter diabetes duration (B = - 0.06; 95% CI - 0.07 to - 0.05; p < 0.001), male sex (B = - 0.24; - 0.36 to - 0.11; p < 0.001), insulin pump therapy use (B = - 0.46; - 0.58 to - 0.34; p < 0.001), coexistence of T1D and CD (B = - 0.28; - 0.48 to - 0.07; p = 0.01), blood pressure (B = - 0.16; - 0.23 to - 0.09; p < 0.001) and body mass index (B = -- 0.03; - 0.02 to - 0.04; p = 0.01) in the normal range. At last measurement, 11.7% of the total population had a HbA1c < 7.0% (53.0 mmol/mol). CONCLUSIONS: Across all measurements, coexisting T1D and CD is associated with lower HbA1c when compared to T1D alone. However, HbA1c is above target in both groups.

Blood pressure in adolescents and young adults with type 1 diabetes: data from the Australasian Diabetes Data Network registry.

AIM: Hypertension increases complication risk in type 1 diabetes (T1D). We examined blood pressure (BP) in adolescents and young adults with T1D from the Australasian Diabetes Data Network, a prospective clinical diabetes registry in Australia and New Zealand. METHODS: This was a longitudinal study of prospectively collected registry data. INCLUSION CRITERIA: T1D (duration ≥ 1 year) and age 16-25 years at last visit (2011-2020). Hypertension was defined as (on ≥ 3 occasions) systolic BP and/or diastolic BP > 95th percentile for age < 18 years, and systolic BP > 130 and/or diastolic BP > 80 mmHg for age ≥ 18 years. Multivariable Generalised Estimating Equations were used to examine demographic and clinical factors associated with BP in the hypertensive range across all visits. RESULTS: Data from 6338 young people (male 52.6%) attending 24 participating centres across 36,655 T1D healthcare visits were included; 2812 (44.4%) had BP recorded at last visit. Across all visits, 19.4% of youth aged < 18 years and 21.7% of those aged ≥ 18 years met criteria for hypertension. In both age groups, BP in the hypertensive range was associated with male sex, injection (vs. pump) therapy, higher HbA1c, and higher body mass index. CONCLUSIONS: There is a high proportion of adolescents and young adults reported with BP persistently in hypertensive ranges. Findings flag the additive contribution of hypertension to the well-established body of evidence indicating a need to review healthcare models for adolescents and young adults with T1D.

Hospital presentations with diabetic ketoacidosis: A retrospective review.

BACKGROUND: Diabetic ketoacidosis (DKA) is a significant source of preventable episodes of care and cost. This study aimed to describe the demographic and clinical characteristics of people with type 1 diabetes (T1D) presenting to the Emergency Department (ED) with DKA in an area of socio-economic deprivation in metropolitan Queensland, Australia, and to describe factors associated with hospital admission and re-presentation in this population. METHODS: This was a retrospective descriptive analysis of routine healthcare record data for January 2015-December 2019. People with T1D were identified through hospital discharge codes. RESULTS: More than half (n = 165) the estimated local T1D population (n = 317) experienced an index ED presentation for DKA; mean±SD age at ED presentation was 31.1 + /- 19.3 years, 126 (76.4%) were aged ≥ 16 years and 20 (12.1%) were newly diagnosed. Index DKA presentation was significantly associated with female sex (p = 0.04) but no other demographic or geographic variables. More than half the presentations (n = 92, 55.8%) occurred outside regular business hours. Twenty-three representations occurred within 90 days, associated with older age (p = 0.045) and lower residential socio-economic score (p = 0.02). CONCLUSION: Findings highlight the frequent problem of DKA and the importance of socio-economic influences. This flags the need and opportunity to improve support to people with T1D to promote diabetes self-care.

Services doing the best they can: service experiences of young adults with type 1 diabetes mellitus in rural Australia.

AIMS AND OBJECTIVES: To describe the healthcare experiences of young adults with type 1 diabetes who access diabetes services in rural areas of New South Wales, Australia. BACKGROUND: The incidence of type 1 diabetes in childhood and adolescence is increasing worldwide; internationally, difficulties are encountered in supporting young people during their transition from children to adulthood. Consumers' experiences and views will be essential to inform service redesign. DESIGN: This was a qualitative exploratory study. METHODS: Semistructured telephone interviews were conducted with 26 people aged 18-28 years living rurally, recruited through staff in four regional healthcare centres in 2008. RESULTS: Two key themes were evident: lack of access (comprised of transfer to adult services, access to health professionals and access to up-to-date information) and age-appropriate provision. The impact of place of residence and personal motivation crossed all themes. Participants contrasted unfavourably the seamless care and support received from paediatric outreach services with the shortages in specialist and general practice-based care and information and practical problems of service fragmentation and lack of coordination experienced as adults. They identified a range of issues including need for ongoing education, age-appropriate services and support networks related to developing their ability to self-manage. They valued personal service; online and electronic support was seldom volunteered as an alternative. CONCLUSION: This was a first view of rural young people's experiences with adult diabetes services. Reported experiences were in line with previous reports from other settings in that they did not perceive services in this rural area of Australia as meeting their needs; suggestions for service redesign differed. RELEVANCE TO CLINICAL PRACTICE: New models of age-appropriate service provision are required, to meet their needs for personal as well as other forms of support, whilst acknowledging the very real resource limitations of these locations.