Introduction La variabilité glycémique (VG) est un paramètre important du contrôle glycémique chez les patients diabétiques de type 1 (DT1) : facteur de risque d’excursions glycémiques extrêmes et en ...particulier d’hypoglycémie sévère ; suspectée dans la genèse des complications vasculaires ou neurocognitives. Cependant, malgré l’existence de très nombreux indicateurs de VG, il n’existe aucun consensus pour son évaluation. Notre objectif est d’identifier les indicateurs les plus pertinents pour l’évaluation de la VG, tant en pratique qu’en recherche clinique. Patients et méthodes Les données de mesure continue du glucose (MCG) sont issues d’un essai clinique randomisé français (Start-In !) dont l’objectif était d’évaluer l’impact de la MCG sur l’HbA1c en diabétologie pédiatrique. Pendant les 3 premiers mois, 141 sujets ont porté le dispositif plus de 90% du temps. 15 indicateurs de VG ont été évalués de façon hebdomadaire (moyenne ; SD ; coefficient de variation-CV; Mean Amplitude of Glycemic Excursion- MAGE ; Mean Of Daily Difference-MODD ; Continuous Overall Net Glycemic Action-CONGA 1, 2, 4 et 24 ; J-index ; M-Value ; GRADE ; Low Blood Glucose Index – LBGI ; High Blood Glucose Index – HBGI ; Average Daily Risk Ratio-ADRR). Une analyse en composante principale (ACP) et une étude de corrélation de Spearman ont été réalisées. Résultats L’ACP met en exergue 3 composantes de VG expliquant au total 89% de la variance et pouvant représenter : 1) la variabilité en soi, 2) la magnitude (hypo vs hyperglycémie), 3) la temporalité (intra vs interjournalière) des excursions glycémiques. L’analyse de corrélation de Spearman renforce ces résultats avec un coefficient > 0,70 au sein des groupes d’indicateurs définis par l’ACP. Conclusion Six indicateurs semblent suffisants pour évaluer les 3 dimensions de la VG : 3 paramètres descriptifs (CV, MAGE, MODD) et 3 indicateurs de risque (LBGI, HBGI, ADRR). Ces indicateurs pourraient être utilisés comme critères standardisés, tant pour la recherche que pour la pratique clinique.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Insulin pumps are booming in pediatric diabetology. The objective of this study was to assess changes for children and adolescents with type 1 diabetes using a pump in terms of quality of life (QOL), ...satisfaction, and glycosylated hemoglobin. A retrospective self-evaluation questionnaire was distributed to 41 patients. It focused on general QOL, diabetes-specific QOL supplemented by specific questions on the pump, and satisfaction. Clinical and biological parameters (glycated hemoglobin: HbA1c) were compared before and after pump use. The score for QOL with the pump was positive, more so if started early after diagnosis of diabetes (P=0.03) and with children under the age of 8 years (P<0.02). These positive results are mainly related to the characteristics of the pump, "insulin management" and "injections," as well as "diabetes management," "behavior," "school," "family life," "daily life," and "physical activities." On the other hand, the improvement was not significant for the item "life in society, friends and family." A decrease in the number of injections and the flexibility of meals were the most positive points. HbA1c improved as soon as the pump was indicated before its use was begun (P=0.005) and remained constant for 4 years (P≤0.05). Forgotten injections, comments on diabetes, and technical problems appeared to be exceptional. The pump changed the patient's body image because of ambivalent feelings between being normal (greater freedom) and different (visibility and a reminder of the disease). The benefits in terms of QOL and glycemic control with the pump cannot be dissociated and can only be considered accompanied by paramedical and medical assistance. Improving QOL over the short and long term by reducing the risk of further complications is the daily challenge of families and diabetologists.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Les pompes à insuline sont en plein essor en diabétologie pédiatrique. L’objectif de cette étude était d’évaluer la qualité de vie (QV) et la satisfaction des enfants et adolescents diabétiques de ...type 1 sous pompe à insuline. Un auto-questionnaire rétrospectif a été distribué à 41 enfants. Il portait sur la QV générale et la QV spécifique au diabète et était complété par des éléments spécifiques à la pompe et sur la satisfaction. Des paramètres cliniques et biologiques dont l’hémoglobine glyquée (HbA1c) ont été comparés avant et après la mise en place de la pompe. Le score de QV sous pompe était positif, d’autant plus qu’elle était mise en place précocement après le diagnostic de diabète (p=0,03) et chez l’enfant de moins de 8ans (p<0,02). Cet effet positif concernait surtout les spécificités de la pompe : « gestion de l’insuline » et « injections » mais aussi la gestion du diabète, les émotions et comportement, la scolarité, la vie en famille, la vie quotidienne et les activités physiques. En revanche, le score pour l’item « vie en société, entourage » n’était pas significatif. La baisse du nombre de piqûres et la souplesse des repas étaient les points les plus positifs. L’HbA1c s’améliorait dès l’indication de la pompe avant sa mise en route (p=0,005) et était stable pendant 4ans (p≤0,05). Les oublis des injections, les remarques sur le diabète et les problèmes techniques semblaient faire exception. La pompe modifiait l’image du corps par un sentiment ambivalent de normalité (libertés engendrées) et de différence (visibilité, rappel de la maladie). Les bénéfices de QV et d’équilibre glycémique sous pompe sont indissociables et ne peuvent s’envisager qu’entourés d’un accompagnement médical et paramédical. Améliorer la QV à court et à long terme en diminuant le risque de complications ultérieures constitue le défi quotidien des familles et des diabétologues.
Insulin pumps are booming in pediatric diabetology. The objective of this study was to assess changes for children and adolescents with type 1 diabetes using a pump in terms of quality of life (QOL), satisfaction, and glycosylated hemoglobin. A retrospective self-evaluation questionnaire was distributed to 41 patients. It focused on general QOL, diabetes-specific QOL supplemented by specific questions on the pump, and satisfaction. Clinical and biological parameters (glycated hemoglobin: HbA1c) were compared before and after pump use. The score for QOL with the pump was positive, more so if started early after diagnosis of diabetes (P=0.03) and with children under the age of 8 years (P<0.02). These positive results are mainly related to the characteristics of the pump, “insulin management” and “injections,” as well as “diabetes management,” “behavior,” “school,” “family life,” “daily life,” and “physical activities.” On the other hand, the improvement was not significant for the item “life in society, friends and family.” A decrease in the number of injections and the flexibility of meals were the most positive points. HbA1c improved as soon as the pump was indicated before its use was begun (P=0.005) and remained constant for 4 years (P≤0.05). Forgotten injections, comments on diabetes, and technical problems appeared to be exceptional. The pump changed the patient's body image because of ambivalent feelings between being normal (greater freedom) and different (visibility and a reminder of the disease). The benefits in terms of QOL and glycemic control with the pump cannot be dissociated and can only be considered accompanied by paramedical and medical assistance. Improving QOL over the short and long term by reducing the risk of further complications is the daily challenge of families and diabetologists.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Context:
Drug-based therapy is usually the initial treatment for Graves' disease (GD) hyperthyroidism in children, but there is some debate about treatment duration.
Objective:
Our objective was to ...assess the effect of long-term carbimazole therapy on GD remission in children and its determinants.
Design and Setting:
This was an observational prospective multicenter follow-up cohort study.
Participants:
Participants included 154 children newly diagnosed with GD between 1997 and 2002. The intention was to treat patients with three consecutive courses of carbimazole, each lasting 2 yr. Definitive treatment was performed in cases of poor compliance with antithyroid drug (ATD) treatment, thyrotoxicosis relapse, or major adverse effects of ATD treatment.
Main Outcome Measure:
The main outcome measure was remission for at least 18 months after the completion of each course of ATD treatment.
Results:
The median duration of follow-up was 10.4 (9.0–12.1) yr. Overall estimated remission rates (95% confidence interval) 18 months after the withdrawal of ATD treatment increased with time and were 20 (13–26), 37 (29–45), 45 (35–54), and 49 (40–57)% after 4, 6, 8, and 10 yr follow-up, respectively. A multivariate competing risk model revealed an independent positive effect of less severe forms of hyperthyroidism at diagnosis subhazard ratio of 1 for patients with free T4 <35 pmol/liter vs. 0.4 (0.20–0.80) for free T4 ≥ 35 pmol/liter; P = 0.01 and of the presence of other autoimmune conditions subhazard ratio of 2.23 (1.19–4.18); P = 0.01 on remission rate after medical treatment.
Conclusion:
About half the patients achieved remission after carbimazole discontinuation, and there seems to be a plateau in the incidence of remission achieved after 8–10 yr ATD therapy.
La phase rémission partielle (RP) dans le diabète de type 1 (DT1) est caractérisée par une diminution transitoire des besoins en insuline.
Évaluer les facteurs associés à la RP dans le DT1 chez ...l’enfant.
Nous avons réalisé une étude rétrospective monocentrique au CHU d’Amiens. La RP a été définie par des besoins en insuline≤0,5 UI/kg/j et une HbA1c≤7,5 %.
Les dossiers de 149 enfants âgés de 1 à 18 ans ont été analysés. Parmi les patients, 53,4 % ont présenté une phase de RP durant en moyenne 9 mois±7,6 (56,2 % de garçons). La RP est associée significativement à une acidocétose inaugurale (42 %), un syndrome polyuro-polydipsique court, une HbA1c initiale basse et une glycémie initiale haute. La présence d’antécédents familiaux d’auto-immunité est liée à une plus grande fréquence de RP, ainsi que des besoins en insuline et des doses de sortie plus faibles. L’HbA1c initiale haute est corrélée à une durée de RP courte.
La RP est associée aux paramètres reflétant la fonction β résiduelle. Elle apparaît comme une fenêtre opportune pour les thérapeutiques futures ciblant cette fonction β résiduelle. Connaître les facteurs associés à la RP permettrait une sélection des patients éligibles pour les essais thérapeutiques.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Les adolescentes diabétiques de type 1 (DT1) semblent être sujettes à une prise de poids excessive pendant la puberté. L’objectif était d’évaluer le risque de surpoids chez des adolescents DT1 à la ...puberté.
une cohorte d’enfants DT1 a été classée et comparée selon le sexe et l’IMC en catégories (maigreur à obésité) pendant leur année de 6ème et de 2nde, puis comparée à des adolescents témoins picards scolarisés en 6ème et en 2nde en 2008–2009, répartis à l’identique. Chez un sous-groupe d’enfants prépubères de notre cohorte, nous avons suivi l’évolution de leur corpulence exprimée en Z-score IMC durant la puberté.
Notre cohorte comportait 112 enfants (46G/66F). Le surpoids était chez les filles DT1, significativement plus important en 2nde qu’en 6ème (25,8% vs 15,2%, p=0,048), que chez les garçons DT1 en 2nde (25,8% vs 10,9%, p=0,02) et que chez les filles témoins en 2nde (25,8% vs 14,8%, p=0,01). Chez les filles DT1 en fin de puberté, le Z-score IMC moyen était 2,5 fois plus élevé (1,1DS vs 0,43DS, p<0,0001). En fin de puberté, le Z-score IMC des filles DT1 était supérieur à celui des garçons DT1 (1,1DS vs 0,6DS, p=0,03).
A la puberté, les adolescentes DT1 étaient plus à risque de surpoids.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
OBJECTIVE
To determine on a large scale the multiple medical and nonmedical factors that influence glycemic control in the general population of children with diabetes, we performed a nationwide ...French cross-sectional study.
RESEARCH DESIGN AND METHODS
We enrolled 2,579 patients aged 1–19 years with type 1 diabetes of > 1 year's duration. The study was center based: 270 centers were identified, 206 agreed to participate, and 147 included at least 90% of their patients. Questionnaires were completed by physicians interviewing patients and family, and HbA1c measurements were centralized. To identify explanatory variables for HbA1c level and frequency of severe hypoglycemia, we performed multiple regression analysis using all the quantitative variables collected and stepwise logistic regression for the qualitative variables.
RESULTS
Mean HbA1c value for the whole population was 8.97 ± 1.98% (normal 4.7 ± 0.7% SD). Only 19 children (0.7%) had ketoacidosis during the 6 months before the study, whereas 593 severe hypoglycemia events occurred in 338 children (13.8%). Control was better in university-affiliated hospitals and centers following > 50 patients, reflecting the importance of access to experienced diabetologists. Children had a mean of 2.3 injections, allegedly performed 2.8 glucose measurements per day, and were seen an average of 4.6 times per year at the center. In the multiple regression analysis, 94% of the variance of HbA1c was explained by our pool of selected variables, with the highest regression coefficient between HbA1c and age (Rc = 0.43, P < 0.0001), then with daily insulin dosage per kilogram (Rc = 0.28, P < 0.0001), mother's age (Rc = 0.26, P < 0.0001), frequency of glucose measurements (Rc = 0.21, P < 0.0001), and diabetes duration (Rc = 0.14, P < 0.0001). Logistic regression identified quality of family support and dietary compliance, two related qualitative and possibly subjective variables, as additional explanatory determinants of HbA1c. The frequency of severe hypoglycemia was 45 per 100 patient-years and correlated with diabetes duration, but not with HbA1c levels or other variables.
CONCLUSIONS
Although overall results remain unsatisfactory, 33% of studied French children with type 1 diabetes had HbA1c <8%, the value obtained in Diabetes Control and Complications Trial adolescents treated intensively. Diabetes management in specialized centers should be encouraged.
Le but de cette étude est de déterminer la prévalence des marqueurs biologiques de la maladie cœliaque (MC) dans une cohorte française de 84 enfants diabétiques de type 1. La détection des anticorps ...antitransglutaminase (AtTG), antiendomysium (AAE) et antigliadine (AAG) a été réalisée. Le groupe 1 inclut 81 patients (96,4 %) diabétiques avec des marqueurs sérologiques négatifs pour la maladie cœliaque. Le groupe 2 inclut 3 patients (3,6 %) présentant des anticorps positifs : 1 AAG-AAE-AtTG et 1 AAE-AtTG avec une confirmation histologique du diagnostic de maladie cœliaque et 1 AAG avec une biopsie négative. Aucune différence statistique n’est observée entre les deux groupes concernant l’âge, la durée du diabète, la taille cible familiale, les ratios taille/âge et poids/taille. En ce qui concerne l’équilibre du diabète, un niveau moins élevé d’HbA1c (hémoglobine glyquée) est retrouvé chez les patients présentant des marqueurs sérologiques de la MC. Les anticorps anti-thyroperoxidase et anti-thyroglobuline ont été recherchés comme un marqueur d’auto-immunité. La prévalence des thyroïdites est identique à celle retrouvée dans d’autres études semblables mais n’est pas associée à la MC. La prévalence des marqueurs sérologiques de la MC est importante dans cette cohorte d’enfants diabétiques français mais moindre que celle décrite dans d’autres pays.
The aim of this study was to determine the prevalence of celiac disease (CD) markers in a French cohort of 84 children type 1 diabetics. Detection of antitransglutaminase (AtTG), antiendomysium (AEA) and antigliadin (AGA) antibodies was performed. Group 1 included 81 (96.4%) diabetic patients with negative antibodies. Group 2 included 3 patients (3.6%) with positive serological markers: 1 AGA-AEA-AtTG and 1 AEA-AtTG with proved histological diagnosis and 1 AGA positive with negative histology. No statistically significant difference was observed between the groups with regard to age, duration of diabetes, familial target stature, and ratios Height/Âge and Weight/Height. Presence of CD serological markers was related to a lower level of HbA1c. Prevalence of CD serological markers is important in this French cohort but lower than other countries.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Factors associated with glycemic control. A cross-sectional nationwide study in 2,579 French children with type 1 diabetes.
The French Pediatric Diabetes Group.
M Rosilio ,
J B Cotton ,
M C Wieliczko ...,
B Gendrault ,
J C Carel ,
O Couvaras ,
N Ser ,
P F Bougnères ,
P Gillet ,
S Soskin ,
P Garandeau ,
C Stuckens ,
B Le luyer ,
J Jos ,
H Bony-Trifunovic ,
A M Bertrand ,
F Leturcq and
A Lafuma
Hôpital Saint Vincent de Paul, Service d'Endocrinologie, Paris, France.
Abstract
OBJECTIVE: To determine on a large scale the multiple medical and nonmedical factors that influence glycemic control in the
general population of children with diabetes, we performed a nationwide French cross-sectional study. RESEARCH DESIGN AND
METHODS: We enrolled 2,579 patients aged 1-19 years with type 1 diabetes of > 1 year's duration. The study was center based:
270 centers were identified, 206 agreed to participate, and 147 included at least 90% of their patients. Questionnaires were
completed by physicians interviewing patients and family, and HbA1c measurements were centralized. To identify explanatory
variables for HbA1c level and frequency of severe hypoglycemia, we performed multiple regression analysis using all the quantitative
variables collected and stepwise logistic regression for the qualitative variables. RESULTS: Mean HbA1c value for the whole
population was 8.97 +/- 1.98% (normal 4.7 +/- 0.7% SD). Only 19 children (0.7%) had ketoacidosis during the 6 months before
the study, whereas 593 severe hypoglycemia events occurred in 338 children (13.8%). Control was better in university-affiliated
hospitals and centers following > 50 patients, reflecting the importance of access to experienced diabetologists. Children
had a mean of 2.3 injections, allegedly performed 2.8 glucose measurements per day, and were seen an average of 4.6 times
per year at the center. In the multiple regression analysis, 94% of the variance of HbA1c was explained by our pool of selected
variables, with the highest regression coefficient between HbA1c and age (Rc = 0.43, P < 0.0001), then with daily insulin
dosage per kilogram (Rc = 0.28, P < 0.0001), mother's age (Rc = 0.26, P < 0.0001), frequency of glucose measurements (Rc =
0.21, P < 0.0001), and diabetes duration (Rc = 0.14, P < 0.0001). Logistic regression identified quality of family support
and dietary compliance, two related qualitative and possibly subjective variables, as additional explanatory determinants
of HbA1c. The frequency of severe hypoglycemia was 45 per 100 patient-years and correlated with diabetes duration, but not
with HbA1c levels or other variables. CONCLUSIONS: Although overall results remain unsatisfactory, 33% of studied French children
with type 1 diabetes had HbA1c < 8%, the value obtained in Diabetes Control and Complications Trial adolescents treated intensively.
Diabetes management in specialized centers should be encouraged.
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