A Multi-Intervention Campaign Lowers Pediatric and Young Adult Diabetic Ketoacidosis Hospitalizations in a Canadian Province.

OBJECTIVES: The Newfoundland and Labrador diabetic ketoacidosis Project (NLdkaP) is a multi-intervention, province-wide project aimed at lowering rates of diabetic ketoacidosis (DKA) within the pediatric and young adult populations. METHODS: The NLdkaP interventions were first selected, developed and implemented. We then conducted a retrospective study of hospitalization data over three 2-year periods: pre-, during and post-NLdkaP. Data included demographic factors, DKA hospitalizations and length of hospital stay. RESULTS: There were 412 DKA hospitalizations over the study period. Before the NLdkaP, the provincial hospitalization rate of DKA for patients <25 years of age was 55.61 per 100,000. During the NLdkaP, the rate dropped to 38.48 per 100,000 (p<0.001). After the NLdkaP, the rate rose to 54.53 per 100,000 (p<0.001). Hospitalization rates were highest for females (p<0.001) and for those in the 19- to 24-year age group (p<0.001). CONCLUSIONS: The NLdkaP was associated with decreased rates of DKA hospitalizations, but the rates remained relatively stable in both the pre- and postintervention periods. Although the approach and resources developed in the NLdkaP appear effective, continuous preventive efforts are needed to sustain reductions in DKA hospitalizations.

Reducing episodes of diabetic ketoacidosis within a youth population: a focus group study with patients and families.

BACKGROUND: Diabetic ketoacidosis (DKA) is the most common cause of morbidity and mortality for youth with type 1 diabetes mellitus (T1DM). This article reports qualitative data from focus groups with youth and parents of youth with T1DM on the barriers that they identify to DKA prevention and resources that may aid youth better manage their diabetes. METHODS: Four focus groups were held in three communities, two rural and one urban, in the Canadian province of Newfoundland and Labrador (NL) with adolescents and parents of youth with diabetes. Open-ended questions focused on knowledge of DKA, diabetes education, personal experiences with DKA, barriers to diabetes self-management, situations which put them at risk for DKA and resources that could be developed to aid youth in preventing DKA. RESULTS: There were 19 participants (14 parents and 5 youth). Participants identified factors which increased their risk of DKA as difficulty in distinguishing cases of DKA from other illnesses; variations in diabetes education received; information overload about their condition; the long period from initial diagnosis, when most education about the condition was received; and stress regarding situations where youth are not in the direct care of their parents. Participants from rural areas reported geographical isolation and lack of regular access to specialist health care personnel as additional barriers to better diabetes management. CONCLUSIONS: The project identified barriers to DKA prevention for youth which were not previously identified in the medical literature, e.g., the stress associated with temporary guardians, risk of information overload at initial diagnosis and the long period from initial diagnosis when most diabetes education is received. Families from rural areas do report additional burdens, but in some cases these families have developed community supports to help offset some of these problems. Mobile and online resources, educational refreshers about DKA, concise resources for teachers and other temporary guardians, and DKA treatment kits for parents may help improve diabetes management and prevent future episodes of DKA.

Plasma advanced glycation endproduct, methylglyoxal-derived hydroimidazolone is elevated in young, complication-free patients with Type 1 diabetes.

OBJECTIVES: Elevated advanced glycation endproducts (AGEs) are implicated in diabetic complications. Methylglyoxal-derived hydroimidazolone (MG-H) is one of the most abundant AGEs in vivo. Our objective was to develop a time-saving, specific method to measure free MG-H in plasma and determine its levels in complication-free young individuals with Type 1 diabetes (T1DM). The relationship of plasma free MG-H to hemoglobin A1C (A1C) and plasma methylglyoxal levels was also determined. DESIGN AND METHODS: A solid phase extraction and liquid chromatography-tandem mass spectrometry (LC-MS/MS) method was developed, and free plasma MG-H levels were measured in 40 T1DM patients (DM group), aged 6-21 years, and 11 non-diabetics (ND group), 6-22 years. Methylglyoxal was measured using LC-MS/MS and A1C by a Tosoh G7 high-performance liquid chromatograph. RESULTS: Our method showed high recovery, sensitivity and short run-time. Plasma free MG-H (nmol/L) was higher (p<0.001) in the DM group (1318+/-569; mean+/-standard deviation) as compared to the ND group (583+/-419). Within the DM group, plasma free MG-H did not correlate with plasma methylglyoxal or A1C. CONCLUSIONS: Our LC-MS/MS method to measure free MG-H in plasma may be useful for future clinical application. The increased levels of free MG-H observed in individuals with TIDM are not merely the result of short term changes in glucose or methylglyoxal, but may reflect long-term alterations to tissue proteins.

Plasma methylglyoxal and glyoxal are elevated and related to early membrane alteration in young, complication-free patients with Type 1 diabetes.

The reactive aldehydes methylglyoxal and glyoxal, arise from enzymatic and non-enzymatic degradation of glucose, lipid and protein catabolism, and lipid peroxidation. In Type 1 diabetes mellitus (T1DM) where hyperglycemia, oxidative stress, and lipid peroxidation are common, these aldehydes may be elevated. These aldehydes form advanced glycation end products (AGEs) with proteins that are implicated in diabetic complications. We measured plasma methylglyoxal and glyoxal in young, complication-free T1DM patients and assessed activity of the ubiquitous membrane enzyme, Na+/K+ ATPase. A total of 56 patients with TIDM (DM group), 6-22 years, and 18 non-diabetics (ND group), 6-21 years, were enrolled. Mean plasma A1C (%) was higher in the DM group (8.5+/-1.3) as compared to the ND group (5.0+/-0.3). Using a novel liquid chromatography-mass spectrophotometry method, we found that mean plasma methylglyoxal (nmol/l) and glyoxal levels (nmol/l), respectively, were higher in the DM group (841.7+/-237.7, 1051.8+/-515.2) versus the ND group (439.2+/-90.1, 328.2+/-207.5). Erythrocyte membrane Na+/K+ ATPase activity (nmol NADH oxidized/min/mg protein) was elevated in the DM group (4.47+/-0.98) compared to the ND group (2.16+/-0.59). A1C correlated with plasma methylglyoxal and glyoxal, and both aldehydes correlated with each other. A high correlation of A1C with Na+/K+ ATPase activity, and a regression analysis showing A1C as a good predictor of activity of this enzyme, point to a role for glucose in membrane alteration. In complication-free patients, increased plasma methylglyoxal, plasma glyoxal, and erythrocyte Na+/K+ ATPase activity may foretell future diabetic complications, and emphasize a need for aggressive management.

High incidence of childhood type 1 diabetes in the Avalon Peninsula, Newfoundland, Canada.

OBJECTIVE: The aim of this study was to determine the incidence of type 1 diabetes among children aged 0-14 years in the Avalon Peninsula in the Canadian Province of Newfoundland. RESEARCH DESIGN AND METHODS: This was a prospective cohort study of the incidence of childhood type 1 diabetes in children aged 0-14 years who were diagnosed with type 1 diabetes from 1987 to 2002 on the Avalon Peninsula. Identified case subjects during this time period were ascertained from several sources and verified using the capture-recapture technique. Data were obtained from the only pediatric diabetes treatment center for children living on the Avalon Peninsula. RESULTS: Over the study period, 294 children aged 0-14 years from the Avalon Peninsula were diagnosed with type 1 diabetes. The incidence of type 1 diabetes in this population over the period 1987-2002 inclusive was 35.93 with a 95% CI of 31.82-40.03. The incidence over this period increased linearly at the rate of 1.25 per 100,000 individuals per year. CONCLUSIONS: The Avalon Peninsula of Newfoundland has one of the highest incidences of type 1 diabetes reported worldwide. The incidence increased over the 16-year study period.

Managing diabetes in childhood and adolescence.

OBJECTIVE: To describe management of children's and adolescents' diabetes outlining standards of care compatible with current clinical practice. QUALITY OF EVIDENCE: MEDLINE was searched using specified MeSH headings. Bibliographies of selected articles were used to find additional pertinent articles. Preference was given to randomized controlled trials, clinical practice guidelines, consensus statements, and task force recommendations. We also cite reviews of current practice regarding pediatric diabetes. MAIN MESSAGE: Managing children with diabetes presents a difficult challenge to parents and their advisors. Achieving good diabetic control is impossible unless parents are properly instructed in practical management of the disease. Children with diabetes should be managed quite differently from adults in several respects. Avoiding hypoglycemia is most important, particularly for preschool children. Higher target blood glucose levels than would be accepted for adults are both justifiable and necessary for preschool children. Controlling children's diabetes depends as much on personal factors and family adjustment as it does on insulin, food plans, and exercise. CONCLUSION: Diabetes mellitus is difficult to manage at any age. Managing children's diabetes successfully requires continuous education and encouragement of parents and children. Pediatric diabetes care teams and family physicians play a vital role in encouraging children to control their disease while participating fully in normal childhood activities.