Insulin sensitivity and obstructive sleep apnea in adolescents with polycystic ovary syndrome.

BACKGROUND: Polycystic ovary syndrome (PCOS) in adults is linked with insulin resistance (IR) and obstructive sleep apnea (OSA). However, less is known about these associations in adolescents. METHODS: We studied 3 groups of adolescents: 27 obese PCOS (OPCOS) (ages 13-21)11 normal-weight PCOS (NPCOS) (ages 13-21 years), and 8 healthy controls (ages 18-21 years). A hyperinsulinemic euglycemic clamp study was performed in all groups to determine IR by insulin sensitivity (M/I). Polysomnography was performed to assess for OSA in OPCOS and NPCOS groups. We compared indices of IR among all groups and OSA among OPCOS, and NPCOS. RESULTS: We noted that OPCOS and NPCOS and controls differed significantly in their IR. M/I was significantly lower in OPCOS vs. controls (p=0.0061), and also lower for NPCOS vs control but this approached but did not reach statistical significance (p=0.084). In addition, none of the NPCOS subjects had OSA compared to 42% of OPCOS (p=0.03). CONCLUSIONS: Our study suggests OPCOS adolescents have increased IR compared to controls and NPCOS subjects. Higher IR for NPCOS vs controls approached but did not reach statistical significance. Larger studies are needed. In addition, adolescents with OPCOS are at a high risk for OSA.

The Impact of Dopamine on Insulin Secretion in Healthy Controls.

OBJECTIVE: Dopamine is very commonly used in the critical care setting and impacts glucose homeostasis. In some studies, it is noted to increase insulin resistance or decrease insulin secretion. The role of insulin secretion in response to dopamine is incompletely understood. METHODS: Eight individuals underwent a hyperglycemic clamp with a dopamine infusion, and eight controls underwent hyperglycemic clamp alone. Insulin, C-peptide, glucagon, cortisol, and norepinephrine (NE) concentrations were measured at various time points. An index of insulin sensitivity (M/I) was calculated. Statistical comparison between the control and treatment arm was done using repeated measures ANOVA. The data is expressed as mean ± standard deviation. Paired t-test was used to compare pre- and post-dopamine infusion time points in the study individuals only. Data was considered to be statistically significant at P < 0.05. RESULTS: On assessing the treatment group before and during dopamine infusion, insulin and C-peptide concentrations were higher at the time of the infusion (P = 0.02 and P = 0.003, respectively). The index of insulin sensitivity was not statistically different. There was a significant decrease in insulin (P = 0.002), C-peptide (P = 0.005), and NE (P < 0.0001) concentrations in the treatment group, compared to the controls. Glucagon concentration was higher in the treatment group (P = 0.02). CONCLUSION: In this study, dopamine infusion did not adversely impact insulin secretion.

Predictors of Loss to Follow-Up among Children with Type 2 Diabetes.

BACKGROUND/AIMS: Youth with type 2 diabetes (T2D) have poor compliance with medical care. This study aimed to determine which demographic and clinical factors differ between youth with T2D who receive care in a pediatric diabetes center versus youth lost to follow-up for >18 months. METHODS: Data were analyzed from 496 subjects in the Pe-diatric Diabetes Consortium registry. Enrollment variables were selected a priori and analyzed with univariable and multivariable logistic regression models. RESULTS: After a median of 1.3 years from enrollment, 55% of patients were lost to follow-up. The final model included age, race/ethnicity, parent education, and estimated distance to study site. The odds ratio (99% confidence interval) of loss to follow-up was 2.87 (1.34, 6.16) for those aged 15 to <18 years versus those aged 10 to <13 years and 6.57 (2.67, 16.15) for those aged ≥18 years versus those aged 10 to <13 years. Among patients living more than 50 miles from the clinic, the odds ra tio of loss to follow-up was 3.11 (1.14, 8.49) versus those living within 5 miles of the site. CONCLUSION: Older adolescents with T2D are more likely to be lost to follow-up, but other socioeconomic factors were not significant predictors of clinic follow-up.

Use of Sitagliptin With Closed-Loop Technology to Decrease Postprandial Blood Glucose in Type 1 Diabetes.

BACKGROUND: Postprandial hyperglycemia poses a challenge to closed-loop systems. Dipeptidyl peptidase-4 (DPP-4) inhibitors, like sitagliptin, reduce postprandial glucose concentrations in patients with type 2 diabetes. The objective of this study was to assess sitagliptin's role in type 1 diabetes (T1DM) as an adjunct therapy in reducing postprandial blood glucose with an insulin-only closed-loop system. METHODS: This was a randomized, double-blinded, placebo controlled, crossover design trial. The participants were18-35 years old, had T1DM, and an HbA1c of ≤ 8.5%. A dose determination study included eight subjects with T1DM. There were three study visits. Four hours after receiving study drug (placebo, sitagliptin 50 mg, sitagliptin 100 mg), subjects underwent a mixed meal tolerance test with assessment of hormone concentrations. In a second study, 15 subjects underwent two visits receiving either placebo or 100 mg of sitagliptin plus an insulin only closed-loop system for 25 hours with timed meals. Blood glucose and other hormone concentrations were analyzed using repeated measures ANOVA. RESULTS: For the dose determination study, sitagliptin 100 mg resulted in reduced postprandial blood glucose ( P = .006). For the closed-loop study, glucose concentrations were lower in the treatment group, most prominently during the first two study meals ( P = .03). There was no difference in glucagon concentrations, but insulin concentrations and insulin delivery were lower in the treatment group. CONCLUSIONS: Sitagliptin may be considered as an adjunct therapy in a closed-loop setting. Larger studies are needed to determine the role of oral agents like sitagliptin to lower postprandial hyperglycemia with closed loop.

Effect of Marijuana Use on Thyroid Function and Autoimmunity.

BACKGROUND: Marijuana is legalized for medical use in 24 states and for recreational use in 5. However, effects of marijuana use on thyroid function and autoimmunity are unknown. METHODS: We performed a cross-sectional analysis of data from the National Health and Nutrition Examination Survey (NHANES) conducted between 2007 and 2012 to assess the effects of marijuana on thyroid function and autoimmunity in users. We included 5280 adults ages 18 to 69 years, who responded to questions related to marijuana use and had laboratory results related to thyroid parameters. Subjects were categorized as nonusers (never used), past users (used prior to 30 days ago), and recent users (used within last 30 days). Using NHANES normative cut offs for thyroid parameters, we compared recent users with nonusers and past users and calculated the odds ratios for the relative rate of clinically significant thyroid dysfunction in those groups. Multivariate logistic regression was then performed to control for confounders. RESULTS: Fifty-four percent of subjects reported lifetime cannabis use, with 15% using it recently. Univariate regression analysis showed that recent marijuana users had significantly lower frequency of elevated thyrotropin (TSH) and positive anti-thyroperoxidase antibody (TPOAb) versus nonusers/past users. After controlling for confounders, recent marijuana use remained an independent predictor for TSH <5.6 µIU/mL (odds ratio of 0.344 with 95% CI of 0.127-0.928; p = 0.04) but not for negative TPOAb. CONCLUSION: Recent marijuana use was not associated with thyroid dysfunction but was significantly associated with lower levels of TSH.

Pediatric Type 1 Diabetes: Reducing Admission Rates for Diabetes Ketoacidosis.

BACKGROUND: Diabetes ketoacidosis (DKA) is a life-threatening complication of type 1 diabetes mellitus (T1DM). Reducing DKA admissions in children with T1DM requires a coordinated, comprehensive management plan. We aimed to decrease DKA admissions, 30-day readmissions, and length of stay (LOS) for DKA admissions. METHODS: A multipronged intervention was designed in 2011 to reach all patients: (1) increase insulin pump use and basal-bolus regimen versus sliding scales, (2) transform educational program, (3) increased access to medical providers, and (4) support for patients and families. A before-after study was conducted comparing performance outcomes in years 2007-2010 (preintervention) to 2012-2014 (postintervention) using administrative data and Wilcoxon rank sum and Fischer exact tests. RESULTS: DKA admissions decreased by 44% postintervention (16.7 vs 9.3 per 100 followed patient-years; P = .006), unique patient 30-day readmissions decreased from 20% to 5% postintervention (P = .001), and median LOS significantly decreased postintervention (P < .0001). Although not an original goal of the study, median hemoglobin A1C of a subset of the population transitioned from sliding scale decreased, 10.3% to 8.9% (P < .02). CONCLUSIONS: When clinical and widespread program interventions were used, significant reductions in DKA hospitalizations, 30-day readmissions, and LOS occurred for pediatric T1DM. Continuous performance improvement efforts are needed for improving DKA outcomes.

Adjuvant Liraglutide and Insulin Versus Insulin Monotherapy in the Closed-Loop System in Type 1 Diabetes: A Randomized Open-Labeled Crossover Design Trial.

BACKGROUND: The closed-loop (CL) system delivers insulin in a glucose-responsive manner and optimal postprandial glycemic control is difficult to achieve with the algorithm and insulin available. We hypothesized that adjunctive therapy with liraglutide, a once-daily glucagon-like peptide-1 agonist, would be more effective in normalizing postprandial hyperglycemia versus insulin monotherapy in the CL system, in patients with type 1 diabetes. METHODS: This was a randomized, controlled, open-label, crossover design trial comparing insulin monotherapy versus adjuvant subcutaneous liraglutide 1.2 mg and insulin, using the CL system in 15 patients. Blood glucose (BG), insulin, and glucagon concentrations were analyzed. RESULTS: The liraglutide arm was associated with overall decreased mean BG levels (P = .0002). The average BG levels from 8:00 pm (day 1) to 9:00 pm (day 2) were lower in the liraglutide arm (144.6 ± 36.31 vs 159.7 ± 50.88 mg/dl respectively; P = .0002). Two-hour postbreakfast and lunch BG profiles were better in the liraglutide arm (P < .05) and the insulin and glucagon assay values were lower (P < .0001). Postprandially, the area under the curve (AUC) for 2-hour postbreakfast and lunch BG levels were significant (P = .01, P = .03) and the AUC for glucagon, postbreakfast (P < .0001) and lunch (P < .05), was also significant. The incidence of hypoglycemia did not differ between arms (P = .83, Fisher's exact test). Overall, adjunct liraglutide therapy plus CL was well tolerated even with expected side effects. CONCLUSION: This is a proof-of-concept study showing liraglutide can be a potential adjunctive therapy in addition to CL with insulin to reduce postprandial hyperglycemia in type 1 diabetes.

Developing a Personal and Social Identity With Type 1 Diabetes During Adolescence: A Hypothesis Generative Study.

This study explored the incorporation of type 1 diabetes mellitus (T1DM) into self-identity among adolescents. Guided interviews explored 40 adolescents' views of T1DM in relation to their sense of self and relationships with others. Responses were analyzed using thematic analysis. Results revealed that the entire sample described T1DM as a significant burden; many described how T1DM made them feel less "normal." Adolescents described both positive and negative aspects of self-management in social relationships, though most reported benefits in sharing T1DM with friends. Females were more likely to share information about T1DM and to describe positive changes in self-perception as a result of T1DM. The psychosocial processes related to integration of T1DM into self-identity described in these qualitative data provide hypothesis-generating findings that can guide future quantitative research examining incorporation of T1DM into adolescent self-identity in relation to measures of self-esteem, peer orientation, self-management, and glycemic control.

Evaluating emergency preparedness and impact of a hurricane sandy in pediatric patients with diabetes.

BACKGROUND: Natural disasters have always been associated with significant adverse events including medical and mental health problems. Children with chronic disease such has diabetes have also been believed to be affected to a greater extent by any natural disaster. The purpose of this study was to assess and compare emergency preparedness post-disaster and post-traumatic stress effects of Hurricane Sandy in affected and relatively unaffected populations. METHODS: The study was conducted between February and July 2013. A total of 142 families caring for children with Type 1 Diabetes Mellitus (T1DM) who attended clinics were recruited from hospitals in Bronx, NY (control) and in NJ (affected) by Hurricane Sandy. Subjects were recruited to participate in a survey 3-6 months after the hurricane. Data on demographics, glycemic control and insulin regimens were collected. Families were surveyed for socio-economic status (SES), using Hollingshead questionnaire, general and diabetes preparedness and the Hurricane Related Traumatic Experiences (HURTE) questionnaire was used to evaluate for symptoms of post-traumatic stress. RESULTS: Ninety-five percent of families reported to be generally well to moderately prepared for the hurricane and 83 % reported to be very well prepared with regards to their child's diabetes during the disaster. There was no difference between the sites for preparedness for the disaster, age or gender. There was a trend toward significance (p < 0.06) in New Jersey subjects as to a greater psychological impact from the hurricane. Poor glycemic control was significantly associated with lower SES (p < 0.008). Most importantly, SES was unrelated to preparedness for diabetes management during the hurricane. CONCLUSIONS: Despite low SES, families were generally well to moderately prepared for hurricane. In children with diabetes, interventional studies should be designed and implemented so that glycemic control remains unaffected, following any major disaster.

Clinical utility of magnetic resonance imaging and ultrasonography for diagnosis of polycystic ovary syndrome in adolescent girls.

OBJECTIVE: To evaluate ovarian morphology using three-dimensional magnetic resonance imaging (MRI) in adolescent girls with and without polycystic ovary syndrome (PCOS). Also compare the utility of MRI versus ultrasonography (US) for diagnosis of PCOS. DESIGN: Cross-sectional study. SETTING: Urban academic tertiary-care children's hospital. PATIENT(S): Thirty-nine adolescent girls with untreated PCOS and 22 age/body mass index (BMI)-matched controls. INTERVENTION(S): Magnetic resonance imaging and/or transvaginal/transabdominal US. MAIN OUTCOME MEASURE(S): Ovarian volume (OV); follicle number per section (FNPS); correlation between OV on MRI and US; proportion of subjects with features of polycystic ovaries (PCOs) on MRI and US. RESULT(S): Magnetic resonance imaging demonstrated larger OV and higher FNPS in subjects with PCOS compared with controls. Within the PCOS group, median OV was 11.9 (7.7) cm(3) by MRI compared with 8.8 (7.8) cm(3) by US. Correlation coefficient between OV by MRI and US was 0.701. Due to poor resolution, FNPS could not be determined by US or compared with MRI. The receiver operating characteristic curve analysis for MRI demonstrated that increasing volume cutoffs for PCOs from 10-14 cm(3) increased specificity from 77%-95%. For FNPS on MRI, specificity increased from 82%-98% by increasing cutoffs from ≥ 12 to ≥ 17. Using Rotterdam cutoffs, 91% of subjects with PCOS met PCO criteria on MRI, whereas only 52% met criteria by US. CONCLUSION(S): Ultrasonography measures smaller OV than MRI, cannot accurately detect follicle number, and is a poor imaging modality for characterizing PCOs in adolescents with suspected PCOS. For adolescents in whom diagnosis of PCOS remains uncertain after clinical and laboratory evaluation, MRI should be considered as a diagnostic imaging modality.

Sotagliflozin, a Dual SGLT1 and SGLT2 Inhibitor, as Adjunct Therapy to Insulin in Type 1 Diabetes.

OBJECTIVE: To assess the safety and efficacy of dual sodium-glucose cotransporter (SGLT) 1 and SGLT2 inhibition with sotagliflozin as adjunct therapy to insulin in type 1 diabetes. RESEARCH DESIGN AND METHODS: We treated 33 patients with sotagliflozin, an oral dual SGLT1 and SGLT2 inhibitor, or placebo in a randomized, double-blind trial assessing safety, insulin dose, glycemic control, and other metabolic parameters over 29 days of treatment. RESULTS: In the sotagliflozin-treated group, the percent reduction from baseline in the primary end point of bolus insulin dose was 32.1% (P = 0.007), accompanied by lower mean daily glucose measured by continuous glucose monitoring (CGM) of 148.8 mg/dL (8.3 mmol/L) (P = 0.010) and a reduction of 0.55% (5.9 mmol/mol) (P = 0.002) in HbA1c compared with the placebo group that showed 6.4% reduction in bolus insulin dose, a mean daily glucose of 170.3 mg/dL (9.5 mmol/L), and a decrease of 0.06% (0.65 mmol/mol) in HbA1c. The percentage of time in target glucose range 70-180 mg/dL (3.9-10.0 mmol/L) increased from baseline with sotagliflozin compared with placebo, to 68.2% vs. 54.0% (P = 0.003), while the percentage of time in hyperglycemic range >180 mg/dL (10.0 mmol/L) decreased from baseline, to 25.0% vs. 40.2% (P = 0.002), for sotagliflozin and placebo, respectively. Body weight decreased (1.7 kg) with sotagliflozin compared with a 0.5 kg gain (P = 0.005) in the placebo group. CONCLUSIONS: As adjunct to insulin, dual SGLT1 and SGLT2 inhibition with sotagliflozin improved glycemic control and the CGM profile with bolus insulin dose reduction, weight loss, and no increased hypoglycemia in type 1 diabetes.

Role of glucagon-like peptide-1 analogue versus amylin as an adjuvant therapy in type 1 diabetes in a closed loop setting with ePID algorithm.

Postprandial hyperglycemia due to paradoxical hyperglucagonemia is a major challenge of diabetes treatment despite the use of the artificial pancreas. We postulated that adjunctive therapy with pramlintide or exenatide would attenuate hyperglycemia in the postprandial phase through glucagon suppression, thereby optimizing the functioning of the closed-loop (CL) system. Subjects with type 1 diabetes (T1DM) on insulin pump therapy were recruited to participate in a 27-hour hospitalized admission on 3 occasions (2-4 weeks apart) and placed on the insulin delivery via CL system in random order to receive (1) insulin alone (control), (2) exenatide 2.5 µg + insulin, (3) pramlintide 30 µg + insulin. Medications were given prior to lunch and dinner, which was a standardized meal of 60 grams of carbohydrates. Insulin delivery was as per the ePID algorithm via the Medtronic CL system and continuous subcutaneous glucose monitoring via Medtronic Sof-sensors. Ten subjects age 23 ± 1 years with a HbA1c of 7.29 ± 0.3% (56 ± 1 mmol/mol) and duration of T1DM 10.6 ± 2.0 years participated in the 3-part study. Exenatide was found to be significantly better in attenuating postprandial hyperglycemia as compared to insulin monotherapy (P < .03) and pramlintide (P > .05). Glucagon suppression was statistically significant with exenatide (P < .03) as compared to pramlintide. Insulin requirements were lower with adjunctive therapy, but statistically insignificant. Insulin monotherapy results in postprandial hyperglycemia in T1DM in the CL setting and adjunctive therapy with exenatide reduces postprandial hyperglycemia effectively and should be considered as adjunctive therapy in T1DM.

Permanent neonatal diabetes mellitus in monozygotic twins achieving low-dose sulfonylurea therapy.

Although KCNJ11 mutations of the KATP channel within the ß cell are known to prevent insulin secretion and cause permanent neonatal diabetes mellitus, the genotype-phenotype correlation continues to be of clinical interest. We report the clinical outcomes in monozygotic twins with neonatal diabetes due to heterozygous mutations in KCNJ11 at R201H. The twins demonstrated concordant clinical outcomes after transitioning from insulin to oral sulfonylurea therapy at 4 months of age. Both twins remained on sulfonylurea therapy while achieving similar growth, development, and metabolic goals. They exhibit marked sensitivity to sulfonylurea therapy with current dosing at 0.05 and 0.06 mg/kg per day at age 5 years which deviates from the approximate maintenance dose of 0.4 mg/kg per day at the time of transition and subsequent follow-up. Metabolic control provided by low-dose sulfonylurea therapy is likely due to early age at transition from insulin to sulfonylurea therapy and possible preservation of endogenous insulin secretion.

Obesity, hyperglycemia and endothelial function in inner city Bronx adolescents: a cross-sectional study.

BACKGROUND: Along with the rise in obesity, cardiovascular disease (CVD) has become the major cause of death in developed countries. Although overt coronary heart disease rarely manifests during childhood, atherosclerosis can begin by the second decade of life. Therefore, identifying reliable risk markers of early vascular disease in childhood could be important. Alteration in endothelial function (EF) is an early preclinical marker of the atherosclerotic process and can be assessed non-invasively using reactive hyperemia peripheral arterial tonometry (RH-PAT). The purpose of this study was to investigate if obesity in children is associated with lower EF as measured with RH-PAT, and if obese children with impaired glucose regulation have further impairment in RH-PAT measured EF compared to obese children with normal glucose tolerance. METHODS: Cardiovascular risk factors, adipocytokines and EF using RH-PAT were evaluated in lean (n = 14) and obese (n = 37) adolescents (age 12-18 years). Based on an oral glucose tolerance test, the obese group was subdivided into: obese with normal (NGT, n = 22) and obese with impaired glucose regulation (IGR, n = 15). RESULTS: RH-PAT score was lower in obese subjects compared to lean controls (1.70 ± 0.02 vs. 1.98 ± 0.09, P = 0.02), indicating worse EF. This difference remained significant when adjusted for age, sex and ethnicity (P = 0.02). We observed a pattern of worsening EF with increasing metabolic burden, with RH-PAT scores of 1.98 ± 0.09,1.73 ± 0.08 and 1.65 ± 0.12 in the lean, obese-NGT and obese-IGR groups, respectively, ptrend = 0.03. Obese subjects were more insulin resistant [higher HOMA] (p = 0.03), and had higher levels of leptin (p = 0.004), hsCRP (p = 0.0004), and TNF-α (p = 0.03) compared to lean subjects. Adjusting for insulin resistance and adipocytokines substantially attenuated the obesity association with RH-PAT, suggesting that insulin resistance and inflammation may mediate the association of EF with obesity. CONCLUSIONS: Risk factors for adult cardiovascular disease, including impaired EF, insulin resistance and inflammation, are evident in obese adolescents. Whether early detection of these cardiovascular risk factors will be useful for informing interventions to prevent disease progression needs further study. TRIAL REGISTRATION: Clinical Trials Identifier: NCT01879033.

National study of continuity clinic satisfaction in pediatric fellowship training.

BACKGROUND: A national online survey was conducted to evaluate pediatric subspecialty fellow satisfaction regarding continuity clinic experience. METHODS: An anonymous online survey (SurveyMonkey™) was developed to evaluate demographics of the program, clinic organization, and patient and preceptor characteristics, and to compare fellow satisfaction when fellows were the primary providers with faculty supervision versus attending-run clinics assisted by fellows or a combination of the two models. Pediatric subspecialty fellows in a 3-year Accreditation Council for Graduate Medical Education accredited program in the United States (excluding emergency medicine, neonatology, and critical care) were invited to participate. RESULTS: There were 644 respondents and nearly half (54%) of these had fellow-run clinics. Eighty-six percent of fellows responded that they would prefer to have their own continuity clinics. Higher satisfaction ratings on maintaining continuity of care, being perceived as the primary provider, and feeling that they had greater autonomy in patient management were associated with being part of a fellow-run clinic experience (all P < 0.001). Additionally, fellow-run clinics were associated with a feeling of increased involvement in designing a treatment plan based on their differential diagnosis (P < 0.001). There were no significant associations with patient or preceptor characteristics. CONCLUSION: Fellow-run continuity clinics provide fellows with a greater sense of satisfaction and independence in management plans.

Neuropathic cachexia associated with type 1 diabetes in an adolescent girl.

BACKGROUND: Diabetic neuropathic cachexia is a rare and little understood variant of diabetic neuropathy. It predominantly affects men with type 2 diabetes mellitus in their sixth to seventh decades of life and is characterized by the subacute onset of a painful sensory neuropathy, rapid weight loss, and psychiatric comorbidity. METHODS: We present the only female pediatric case described to date, and one of only a handful of cases reported to affect type 1 diabetics. RESULTS: In this patient a diagnosis of diabetic neuropathic cachexia was based on the rapid onset of severe allodynic pain, polyneuropathy, and marked weight loss in the setting of poorly controlled diabetes, without evidence of end-organ disease and exclusion of other known causes of neuropathy. CONCLUSIONS: Diabetic neuropathic cachexia is a complex neuroendocrinologic disorder characterized by profound weight loss, neuropathic pain, and mood disturbance. Electrodiagnostic abnormalities were pronounced showing a moderately severe generalized sensorimotor polyneuropathy.

A quality improvement intervention to increase access to pediatric subspecialty practice.

OBJECTIVE: To improve access to new pediatric endocrinology appointments in an urban academic hospital faculty-based practice. METHODS: Three strategies were implemented to increase the number of appointment slots: new patient appointments were protected from conversion to follow-up appointments; all physicians, including senior faculty, were scheduled to see 3 to 4 new patients per session; and sessions devoted exclusively to follow-up appointments were added based on demand. The main outcomes for this quality improvement activity were waiting times for new and follow-up appointments, monthly visit volume, the per-provider visit volume, differences in the proportion of new visits, and clinic arrival rates pre- and postintervention. RESULTS: Thirteen months after the intervention, average wait for a new patient appointment decreased from 11.4 to 1.7 weeks (P < .001) and follow-up appointment wait time decreased from 8.2 to 2.9 weeks (P < .001). Mean monthly total visit volume increased from 284 to 366 patient visits (P < .01) and mean monthly visit volume per provider increased from 36.8 to 41.0 patients (P = .08). New patients were 27% of the visit volume and 35% after the intervention. CONCLUSIONS: Access to our pediatric specialty care clinic was improved without increasing the number of providers by improved scheduling.

The Relationship between Self-Management and Glycemic Control in a Cohort of Children with Type 1 and Type 2 Diabetes.

AIM: Self-management of diabetes improves glycemic control. The development of a quick, objective questionnaire in the clinic setting may provide data to the clinician caring for the patient in overall evaluation. OBJECTIVE: We developed a 23 question tool (clinic preparedness score) and administered it to type 1 and 2 (T1DM & T2DM) diabetes patients. Clinicians of patients were surveyed to determine their perception of adherence by patients. A total of 350 T1DM patients and families and 137 T2DM families were administered the questionnaire. Additionally, HbA1C was correlated to the various parameters that are related to improved glycemic control such as having a meter, carrying glucose tablets for hypoglycemia, and downloading/ writing blood sugars in log book in T1DM and T2DM. RESULTS: T1DM subjects had a lower HbA1C with better clinic preparedness (8.2 ± 1.3 vs. 9.4 ± 1.9%) However, this did not hold true for T2DM (p NS). If T1DM subjects adjusted their insulin dose and reported that their parent was involved they had better HbA1C than those that did not change insulin dose and if parent was uninvolved in the care. Clinicians of patients were able to accurately predict that appropriate dose adjustments resulted in good glycemic control. CONCLUSIONS: Pediatric T2DM adherence measures do not mirror similar characteristics of T1DM in childhood. The variability in glucose monitoring, medication and insulin administration may affect T2DM differently than T1DM.